HomeMy WebLinkAboutMassage Establishment - Top Oriental MassageINTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT: 3/1/2018
TO:
Federico Rodriguez, Fire Department
Larry Magliozzi, Area Plan Commission
7C Angela Smith, Area Plan Commission
James Burns, Police Department
FROM:
Linda M. Martin, Clerk
SUBJECT:
RENEWAL - MASSAGE ESTABLISHMENT LICENSE
RECOMMENDATION
Top Oriental Massage
LOCATION:
421 Hickory Rd
DATE DUE: 03/06/2018
FAX OR E-MAIL TO: 235-9171 1 Imartin southbendin. o�
RECOMMENDATIONS AND COMMENTS:
By Date
For all municipal business license questions, contact: City ofSouth Bend - Department 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
I. APPLICATION TYPE Checl(One: New Renewal XXX
II. BUSINESS DATA
A. Business Name: TOP ORIENTAL MASSAGE
B. Business Address: 421 HICKORY RD.
City: SOUTH BEND
C. Mailing Address (if different from above):
City: SOUTH BEND
D. Business Telephone Number: —
E. Business Fax Number:
State: IN
5569 BUCKHORN DR.
F. E-Mail Address: ia.6e_(6twrt;k (A-
State: IN
Zip: 46615
Zip: 46614
G. Zoning of Business Location: CB -
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 NO X.
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: m A ss- A6.r=. -f -4e 44P V
ALLO W F—b (ND F—P-- A UPPLA CA517�—A--T—�, Ctl_Ys
UqTq Affl) ()PT'>jAA 7 to 5.
For Office Use Only
Application Filed FEB 2 7 2018 Public Safety Approval TEB 2 7 ZU1,1
Application Fee Paid FEB 2 7 2013 License Fee Paid
Sent to Dept. FEB 2 7 2013 License Number Ze— -7 17 44
Not Approved
Reason IAR P 7
1
For all municipal business Ilcense questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd o Suite 1400 5 -South Send, 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: JAMEZ,5
Residential Address:!i�kb
City: >O.� F_ A State: Zip: �b6 14-
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City'. Stater Zip:
Name #2:
Residential Address:
City, State: 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:
Titip-
Business Address:
City: State: _
Residential Address:
City: State:.__
Name #2:
Title:
Business Address:
City:
Residential Address:
City:
is
Zip:
Zip:
State: Zip:
State:
Zip:
For all municipal business license questions, contact: City of South Bend -Department of Community Investment
M 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
IV. PERSONAL DATA (Continued)
N. Photographs:
ph
em
of the
o the
Company Address City, State, ZIP Dates
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
4
Date