HomeMy WebLinkAboutMassage Establishment - Hair CraftersINTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT: 311/2018
TO:
ederico 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
Hair Crafters
LOCATION:
602 Lincoln Way East
DATE DUE: 03/06/2018
FAX OR E-MAIL TO: 236-9171 1 Imartin apsouthbendin.gov
RECOMMENDATIONS AND COMMENTS:
By Date
For all 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 - R 574,235.9021
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LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
1. APPLICATION TYPE Check One:
11, BUSINESS DATA
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A. Business Name: HAIR GRAFTERS
B. Business Address: 602 LINCOLN WAY E.
City: SOUTH BEND
C. Mailing Address (if different from above): _
City:
State: IN
State:
D. Business Telephone Number: 574-288-2448
E. Business Fax Number: 574-233-8370 ___
F. E-Mail Address: E,DEWINTER@SBCGLOBAL. NET
Renewal XXX
Zip: 46601
Zip:
G. Zoning of Business Location: LB
H. Have 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 N 0
1, If yes, what was the reason:
2. If yes, what was the business occupation following the suspension/revocation:
I. Describe the nature and scope of the business: FUZZ 5 -e-[^ 0 ;C e -Sak,
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For Office Use Only
FEB 2 6 2018
Application Filed Public Safety royal
AppB 2 6 2,018
Application Fee Paid FEB 2 6._jjfla_ License Fee Paid
Sent to Dept, E L-B 9 License Number
Not Approved
Reason
1
For all municipal business license questions, contact, City of South Bend • Department of Community investment
227 West Jefferson Blvd • Suite 1400 5 -South Bend, Indiana 46601 • 574.235.5912 • P 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
III. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship (If sale proprietorship, proceed to 1).
Partnership (If partnership, proceed to 2).
Corporation (If corporation, proceed to 3),
1. Sole Proprietor
Name:
Residential Address:
City: State:
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
Name #2:
Residential Address:
City:
State:
State:
Zip:
Zip:
Zip:
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: pre-_'; `el e'vi'-
Business Address: 6, 0;2- L,`A,. e-e) /fu Gv/v' �Fq 5f
City: 1r6/11_1) i, State: /, oO Zip: q& & o l
Residential Address: L/V,'-Ofn
City: It t! 'Imel'vk State:b, Zip:
Name#2: AA-2 _,,.��sAs'+''
Title:
Business Address: &0,'� 4- c_e,%0 W11", S
City: rani` d State: 0 /� Zip: �1-&6 6) %
Residential Address: A3/{���/
City:State: j Iy Zip:��
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 west Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.735,5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
IV. PERSONAL DATA (Continued)
N. Photographs:
Attach below (3) Passport photos, 1"x1", taken within 6 months of the date of this application.
O. Please list all previous employment for three (3) years prior to the date of this application:
Company Address City, State, ZIP
Aa1,P'G'yaY-��►5
r C. r6_k .(e 6-S S to 1,476
(Attach additional sheets if necessary)
V. INCLUDE WITH APPLICATION:
Three (3) passport photos taken within 6 months of application.
VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
VII. AFFIRMATION
Dates
jt�Ja� E V 5--a$
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
4