HomeMy WebLinkAboutMassage Establishment - Southside Massage RetreatINTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT: 3/1/2018
TO: KFederico Rodriguez, Fire Department
,Larry Magliozzi, Area Plan Commission
/�iAngela Smith, Area Plan Commission
7(James Burns, Police Department
FROM: Linda M. Martin, Clerk
SUBJECT: RENEWAL - MASSAGE ESTABLISHMENT LICENSE
RECOMMENDATION
Southside Massage Retreat
LOCATION: 411 E. -Ireland Rd Ste 300
DATE DUE: 03/06/2018
FAX OR E-MAIL TO: 236-9171 1 Imartin(c�southbendin.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 14005 -South Bend, Indiana 46601 574�235'5912 - R 574.235'9021
R
t-ec" �fv. ",?M'c)o
LICENSE APPLICATION FOR — MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION — 4-35
I. APPLICATION TYPE Check One:
11. BUSINESS DATA
V M-1 j
A. Business Name: SOUTHSID'E MASSAGE RETREAT
B. Business Address: 411 E. lRELAND RD. SUITE 300
City: SOUTH BEND
C. Mailing Address (If different from above):
City:
D'. Business Telephone Number: 574-8'5'5-1836
State: IN
State:
E. Business Fax Number:
F. E-Mail Address. SMRETREAT@HOTMAIL.COM
G. Zoning of Business Location.. CB
Renewal XXX
Zip: 46,614
Zip:
H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked
by any governing muniO, litywithin 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:
OPAI. Describe the nature and scope of the business: akXV-Q,
For Office Use Only
Application Filed FEB 2 6 2018 Public Safety Approval
Application Fee Paid FEB 2 6 Z018 License Fee Paid I-- E,13 2 6 20 18
Sent to Dept. EER_2_6_?0j License Number _IjL/-0:2g
I a -
T; 'JGIs
Not Approved
Reason
1.
For ali 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 o F: 574.23M021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
Ill. OWNERSHIP
A. Type of owners ip (check one):
Sale Proprietorship (If sole proprietorship, proceed to 1).
Partnership (If partnership, proceed to 2).
Corporation (if corporation, proceed to 3).
1. Sole Proprietor
Name:
Residential Address: \�c
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:
State: _
State:
2
Zip:
Zip:
Zip:
Zip:
Zip:
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 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
IV. PERSONAL DATA (Continued)
N. Photographs:
AtfP� h holn r 01 D.-..- 'l—t ru„ ru s_L_ ...L•L:,_ / .____�L �SaL I s LtL:_ __-1:__a:_
Company Address
(Attach additional sheets if necessary)
City, State, ZIP Dates
g° it
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. 1 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.
Signatur
4
7) 2a— �; -
Date
5
A
'k."urtificate of Insurance
OCCURRENCE COVERAGE
- ABNIP In -Dines Liability Program
ABMP MAILING ADDRESS: MASTER POLICY HOLDER
.Associated Bodywork & Massage Professionals
25188 Genesee Trait Road
Suite 200
Golden, CO 80401
Allied Professionals Insurance Services
ISSUED BY:
AI'I A]BMP x7..:- Allied Professionals Insurance Company, A
=.: Risk Retention Group, Inc.
Allied Professionals Insurance RPG
AGENT/BROKER
LIABILITY f,TS
ANNUAL AGGREGATE
$6,000,000
PER OCCURRENCE LIMIT ...........................................
$2,000,000
COMMERCIAL GENERAL )I,IAI3ILI TX
.:-.
PRODUCTS-COMP/4.....................
Included
PROFESSIONA ,LIABILITY ........................................
Included
GENERAL LIABILITY ....: % ........................................
Included
FIRE LIABILITY LIMIT' .........................................
$100,000
Tolvefify< formation, contact ABMP. Tel:
This Policy is issued by your risl<sgtention group. Your risk retention;gi
regulations of your Mate. State4nsuiance insolvency guaranty funds, aze
afforded to person(s) named hereilras. Named Insureds according to `the i
refers, subject to limitatfbri by. any applic9liler-64ate 6icensing It w _No;ol
herein, are granted or inferred.
COVERAGES -_
THIS IS TO CERTIFY THAT THE POLICY OF INSURANCET.I$TED ABOVE B'AS BL•EN ISSUED,TO--
TEE INSURED NAMED BELOW. THE INSURED ACTIVE DATEL1WP:QE0—W-APPLIES ONLY T0=
ELEMENTS OF COVERAGE CONTINUOUSLY IN PLACE SINCU THE INCSPIT(W.!OP THE NAMED
INSURED'SPOLICY. CHANGES TO COVERAGE ARE EFFECTIVE RETROACTIVELY ONLY TOTHE
DATE THE CHANGE WAS MADE. REPORT IN WRITINGIVITHIN 48 ,NOURS ANY & ALL CLAIMS,
OR INCIDENTS THATYOU BELIEW MAY RESULT IN A CLAIM, EVEN IF UROUNDLESS.
This Certificate, along mth the Policy to which it refers, is valid evidence oftoverage extended to 16e
Certificate Holder listed Wow.
CERTIFICATE HOLDER
(Aclive Registered Members are on file whit the RIBA P Membership Director)
Member/Named Insured: Sara Cozort
Membership I.D. #: 796294
Member/Policy Term Active: Jun-27-2017
Member/Policy Term Expires: Jun-26-2018
Total Member Cost: $ 199 (ADM?Membetstup,including
Member Liability Coverage)
0
t
Authorized Representative
CANCELLATION: Should any oftlie above described policies be cancelled before the
expiration date thereof, the issuing company will endeavor to mail 10 days written notice for
non-payment or 90 days written notice for any other reason to the certificate holder named
above, but failure to mail such notice shall impose no obligation or liability of any kind upon the
company, its agents or representatives.
4-8478 Fax: 343-674-0859
not be subject to all of the insurance laws and
able for your risk retention group. Coverage is
I conditions of the Policy to which this Certificate
> or conditions, except as specifically stated
ADDITIONAL INSURED: (with inception date)
State of hhdiana Jun 27, 2017
402 W Washington St
Indianapolis, IN 46204-2243
The Trustees of Indiana University, its Jun 27, 2017
officers, Agents, and employees are named
as additional insured.
St. Joseph County 4H Fair, Inc. Jun 27, 2017
Coverage is extended subject to all lerms and conditions of the Policy.