HomeMy WebLinkAboutMassage Establishment - Pura Vida MassageArli� 114:1gja IL I - & I
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DATE SENT: 3120/20,118
TO: Federico Rodriguez, Fire Department
Larry Magliozzi, Area Plan
Angela Smith, Area Plan
games Burns, Police Department
Gene Eyster, Police Department
,YChris Dressel, Communi Investment
FROM. Linda M. Martin,
rtin, Clerk
BLIS
SUBJECT® NEW- MASSAGE ES7A HMENT LICENSE
RECOMMENDATION -Pura Vida Massage
LOCATION: 904 E Jefferson Blvd
J. DUE: April 3, 2018
FAX OR E-MAIL TO: 236-9171 / l�ml:artini@_southibendin.gov
RECOMMENDATIONS AND COMMENTS:
By Date
For ail municipal business I Icense questions, contact: City of South Bend - IDLpartme (it 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
I. APPLICATION TYPE Check Crone:
11. BUSINESS DATA
A. Business Name:
B. Business Addres
L
City: State: 3_ zZip:O
C. Mailing Address (If different from above): k5_0 (A� Aue . . ......
City: State: 5 1 Zip: 0 6a t
D. Business Telephone Number: S
New
Renewal
Business Fax Number:
F. E-Mail Address: C VVt c1f, '>e a
AJVIC�\c (60 o A/
C. Zoning of Business Location: (n Q
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
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: MCA-'-'-'CLeV
0
For Office Use Only
Application Filed MAP 1 2018 Public Safety Approval
Application Fee PaidUAR-1n L License Fee Paid
Sent to Dept. 41, --
License Number
AVVU0VjWj)
Not Approved 119aird of INN 16lici, WQj.'kq
Reason
1
ES. l
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
111. OWNLRSHIP
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 5
Name:
Residential Address:
City: i✓�� �c� State: �~ 1
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
State:
..................
Name #2:
Residential Address:
City:
3, Corporation
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:
2
Zip: L)& t -7
Zip:
M.
0
State: zip:
State:
Zip:
For all municipal business license questions, contact: City of South Bend -Department of Community Investment
227 West Jefferson Blvd a Suite 1400 5 -South Bend, Indiana 46601 e 574.235,5912 • F: 574,235,9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
IV. PERSONAL DATA (Continued)
:port
ontl
O. Please list all previous employment for three (3) years prior to the date,of this application:
Company Address City, State, ZIP
CU,L
e qol L�-' COWL& /�L)e' Sdirl Ev, ad
(Attach additional sheet 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
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.
U'�' %1&
Signature .
4
MAR 15 2018
Date