1. Name and Address of Business:
NAME: ___________________________
ADDRESS: _____________________________________________________________
OWNER OF PREMISES: ________________________
2. a. If applicant is a person, the name, residence address and telephone number of the person:
NAME: ___________________________
ADDRESS: _____________________________________________________________
TELEPHONE: ___________________________
b. Is the applicant a partnership, corporation or association? YES ____ NO ____
IF YES, ATTACH LIST SHOWING THE TYPE OF ORGANIZATION, NAME AND ADDRESS OF ORGANIZATION, AND THE NAME, RESIDENCE ADDRESS TELEPHONE NUMBER OF EACH PERSON HAVING ANY LEGAL OR BENEFICIAL INTEREST IN SUCH APPLICANT.
3. Has any person whose name is listed in 2(a) or 2(b) above ever been convicted of any felony prostitution or any violation of the law relative to prostitution? (This includes any crime sexual misconduct, including but not limited to Sections 14-177 through 14-202.1 (Article 26), 14-203 through 14-208 (article 27) of the North Carolina General Statutes or any section of the town’s Code of Ordinance (Chapter J, Article VI) or of any federal statutes relating to prostitution or any violation of any law or ordinance of any governmental unit concerning or related to the business or profession of massage).
YES ___ NO ____
IF YES, ATTACH A COMPLETE STATEMENT ON EACH PERSON SHOWING SUCH CONVICTIONS.
10. Has any license held by any person whose name is listed in 2 (a) or 2 (b) above ever been revoked by any governmental unit to operate a massage business or to engage in the business or profession of massage?
YES ___ NO ____
IF YES, ATTACH A COMPLETE STATEMENT ON EACH REVOCATION SHOWING THE NAME OF THE PERSON AND EACH BUSINESSES NAME AND ADDRESS AND WHICH GOVERNMENTAL UNIT REVOKED SAID LICENSE INCLUDES DATE OF REVOCATION.
11. Does any of the above listed in 2 (a) or 2 (b) own or operate any other massage business or other establishment?
YES ___ NO ____
IF YES, ATTACH LIST SHOWING NAME AND ADDRESS OF EACH BUSINESS AND GIVE A DESCRIPTION OF BUSINESS.
12. Does any of the above listed in 2(a) or 2(b) plan to operate any other business on the premise listed in I above or on adjoining premises?
IF YES, ATTACH LIST SHOWING THE NAME, ADDRESS AND NATURE OF THE BUSINESS(ES).
13. Does the premise of the applicant comply with all zoning, building and fire prevention codes?
YES ___ NO ___
14. The Town of Dallas, North Carolina will not consider any application if the applicant does not complete this form or provides all the information requested. Allow forty-five (45) days for processing.
9. If your application is approved, the following will be required.
a. An annual operator’s privilege license, as prescribed by the Board of Aldermen will have to be paid.
b. Each massagist will have to obtain a privilege license and pay an annual privilege license, as prescribed by the Board of Aldermen.
10. If you application is disapproved, the applicant may appeal to the Board of Aldermen by filing written notice of the appeal with the Town Clerk within ten (10) days from the date of disapproval. Applicant must state reason for appeal.
IF APPLICANT IS A PERSON:
I, _____________________ (print applicant’s name), affirm or swear that the information, which I have provided, on the application and the attached is true and accurate and contains no misstatement of facts. I understand, if any of the information is found to be untrue, the application will be disapproved.
DATE: ____________________ _____________________________________
Applicant’s Signature
IF APPLICANT IS A PARTNERSHIP, CORPORATION OR ASSOCIATION:
I, _______________________, am an officer of ________________________________________ affirm or swear that the information, which I have provided, on the application and the attached is true and accurate ad contains no misstatement of facts. I understand, if any of the information is found to be untrue, the application will be disapproved.
__________________________________ ____________________________________
Signature Title
(Seal, if applicable)
DATE: ________________________
______________________________________________________________________________
TOWN USE: DATES
TOWN CLERK: Received____ Approved/Disapproved: _____
POLICE CHIEF: Received____ Returned____ Approved/Disapproved: _____
FIRE CHIEF: Received____ Returned____ Approved/Disapproved: _____
INSPECTOR: Received____ Returned____ Approved/Disapproved: _____
(Prior Code, § J-IV-4)