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HomeMy WebLinkAboutMassage Establishment - Chinese Massage SpaINTER -OFFICE MEMORANDUM BOARD OF PUBLIC WORKS DATE SENT: 3/1/2018 TO: Federico Rodriguez, Fire Department Larry Magliozzi, Area Plan Commission Angela Smith, Area Plan Commission James Burns, Police Department FROM: << Linda M. Martin, Clerk SUBJECT: RENEWAL - MASSAGE ESTABLISHMENT LICENSE RECOMMENDATION Chinese Massage_Spa LOCATION: 2614 S. Mich_igan_St DATE DUE: 03/06/2018 FAX OR E-MAIL TO: 235-9171 1 Imartin@southhendin.go� RECOMMENDATIONS AND COMMENTS: By Date For a I I municipal business license questions, contact: City of South Bend ® Department of Community Investment 227 West Jefferson Blvd -Suite 1400 S -South Bend, Indiana 46601 - 574.235.5912 - F: 574,235.9021 r), K62KO, 990 166 LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT MUNICIPAL CODE SECTION - 4-35 I. APPLICATION TYPE Check One: II. BUSINESS DATA lm A. Business Name: CHINESE MASSAGE SPA B. Business Address: 2614 S, MICHIGAN ST. City: SOUTH BEND C. Mailing Address (if different from above): City: D. Business Telephone Number: 574-514-0242 E, Business Fax Number: State: IN State: Renewal XXX Zip: 46614 Zip: G. Zoning of Business Location: MIXED USE H. Have you ever had a Massage Establishment l'icense, 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, e the nature and scope of the business: W 0 � i Jk 'row 1C-A 4- A0 'I For Office Use Only Application Filed FEB 2 7 2018 Public Safety Approval _R 2-7— FEB 2 7 2018 Application Fee PaidT —2018 License Fee Paid Sent to Dept. FEB 17 2.018 License Number 61UX(I Of Not Approved Reason I W For all municipal business license questions, contact: City of South Bend -Department of Community Investment 227 West Jefferson Blvd o Suite 1400 S -South Bend, Indiana 46601 • 574.235.5912 o r: 574.235.9021 LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT MUNICIPAL CODE SECTION - 4-35 ill. OWNERSHIP A. Type of ownershi (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 e Name: wow Residential Address: �(� [i�j �ro o'it, City: --State: _ Zip: 2. Partnership (List at least two (2) partners) Name #1: Residential Address: City: Name #2: Residential Address: City: 3. Corporation State: State: 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: Title: Business Address: City: Residential Address: City: N Zip: M Zip: State: Zip: State: Zip: For 0 municipal business license questions, contact: City of South Bend a nepartmeat of Community Investment 227 West Jefferson Blvd - Suite 1400S -South Bend, Indiana 46601 • 574.235.5912 . F: 574.235.9021 LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT MUNICIPAL CODE SECTION - 4-35 W rlt=©Cnntfl[ nATn ICnnfinli-4) )hc O. Please list all previous employment for three (3) years prior to the date of this application: Company Address 5o�-e,-, )m ed (Attach additional sheets if necessary) City, State, ZIP Dates 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. Signature Date