HomeMy WebLinkAboutMassage Establishment - Top Oriental MassageINTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT: 2/27/2017
TO: ederico Rodriguez, Fire Department
�kharles Bulot, Building Commissioner
�Ayoka Paek, Building Dept.
mes Burns, Police Department
FROM: Linda M. Martin, Clerk A` �
SUBJECT: RENEWAL - MASSAGE ESTABLISHMENT LICENSE
RECOMMENDATION
LOCATION: Top Oriental Massage
DATE DUE: 03/07/17
FAX OR E-MAIL TO: 235-9171 / Imartin(cDsouthbendin.gov
RECOMMENDATIONS AND COMMENTS:
By Date
For 411 municipal business license questions,contact: City of South Bend• Department of Community Investment jw'�IVNO
227 West Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601. 574.235.5912 •rno.235.9g:a q 3 4 374N �5
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
I. APPLICATION TYPE Check One: New Renewal
II. BUSINESS DATA A. Busyness Name. b? 641 W L )-oy A".ssAGF—
B.BusinessAddress:4-4 1•:-lCKobf gokh
City: 5;00rt- F.JQ4b State: li l zip: 44bf S
C. Mailing Address (If different from above): 55&01 *Q!�" �PA/
City: r7011131- ' rl State: t. ILL Zip: 46614-
D. Busines' Teleph6de-ITffrlffber. "
E. Business Fax Number.
— F. E-M'ail Address: `alio, Q -�
G. Zoning of Business Location:
H. HaV.e you ever had a Massage Establishment license, or similar license, suspended or revoked
by any governing municipality within three (3) years prior to the date of this application:
YES % NO
1. If yes, what was the reason:
2. If yes, what was the business occupation following the suspension/revocation:
1 1. Describe the nature and scope of the business: r"6i) s-m—t< 1ME&APj
AS�LLOw Et1 11��i4-PPC te—+Bt.E GrTY I�" DEt1 11��i4-PPC tce4B-E GsTY /�" D
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I
Application Filed
Application Fee i
Sent to Dept.
FEB 2 4 2017
For Office Use Only
License Number
Board of PD161 c Works
NotApprovedi MAR 14 Nt7
Reason
all municipal business license questions,contact: City of South Bend-• Department of Community Investment
227 Westlefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 •574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
III. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship (if sole proprietorship, proceed to 1).
Partnership (if partnership, proceed to 2).
Corporation, (if corporation, proceed to 3).
1. Sole Proprietor
Name:1F/lES �BELWEI�r!/iL
Residential Address: SSA} '&449o90 WQI VE
";oil
* il 54b Zip:44G14 -
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
Name #2:
Residential Address:
City:
State:
State:
3. Corporation
Legal name of corporation:
Date and state of incorporation:
List officers and directors.who own 15% or more of stock:
Name #1:
Title:
Business Address:
City: State: _
Residential Address:
City: State
Name #2:
Business Address:
Citv:
Residential Address:
City:
State:
State:
E
Zip:
Zip:
Zip:
Zip:
2
I municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 14005 -South Bend, Indiana 46601. 574.235.5912 • P. 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
IV. PERSONAUDATA (Continued)
t pf
of
O. Please list all previous employment for three (3) years prior to the date of this application:
Company • , Address
City, State, ZIP Dates
—f6P o2rf�.Er�M�4ssa6�M?t Nu�o/ty, svvr+�>3�a�,��1.w�rS _
P2 Zoo-- S' 2D4(S'
(Attach additional sheets It necessary)
V. INCLUDE WITH APPLICATION:
Three (3) passport photos taken within 6 months of application.
VI. INCLUDE $5,00 PROCESSING FEE WITH APPLICATION
VII. AFFIRMATION
I, -hereby; certify and affirm that all of the information I -have given in this application is true -and
accurate to the best of my knowledge. I further certify that I have in no way attempted to
mislead the City in this application by omitting facts known to me. I agree to cooperate with any
review, conducted pursuant to the licensing procedures, including permission to enter and
inspect the place of business and facilities in conjunction with such review. I have read and
understand the regulations of the Massage Establishment and/or Therapist license found in the
City of'!South Bend Municipal Code, Section 4-35.
i
Zi9 i %
Signature Date
10