HomeMy WebLinkAbout06- City Clerk RECE!V I
'88 FEB -3 P,^ :09
Date Submitted: 1/15/88
Please return this memo to the City Clerk' s Office as
soon as possible.
SHAUNA CLARK
City Clerk
By: C. Buechter
Application Of Games of Amusement
BARBARA JEAN CLARK dba GRINDER SLOP
1607 PI. "E" Street (Business Address)
{ San Bernardino, CA 92405
To the Honorable Mayor and Common Council :
I, , Chief of Police
of the City of San Bernardino, have heretofore made a thorough
investigation. I hereby recommend that your honorable body
said application.
(grant/deny)
Date grante enied Chief of Police of the
City of San Bernardino
The above foregoing application was
(granted/denied)
by the City Council on the day of
�1 Q hd rat wll NEI
CITY OF SAN 3ERNARDINO
OFFICE USE ONLY
LICATION FOR BUSINESS LICENSE OR PERMIT POLICE DEPARTMENT
CK ONE:) (FACE PAGE) Date
❑ Dine and Dance ❑ Theater ❑ Solicitation ❑ I.D.No.
Special Officer
❑ Massage Parlor ❑ Armored Car ❑ City Mall ❑ School Employee Print/Photo Fee: $
Games/Amusement ❑ Guard Service ❑ Burglar Alarm ❑ Taxi Driver Other Fee: $
Live Entertain ❑ Dot.Agency ❑ Police App. ❑ Ambulance Driver Total Fees: $
❑ Poolroom ❑ Private Patrol ❑ Police Reserve ❑ valley College Receipt No.
❑ Other ❑ Security Guard ❑ Message Tech By
❑ Parade Permit (Location)
❑ Weapon Permit CITY HALL
Date Submitted:
GENERAL INFORMATION (Type or print in ink) _
Name hone Lfl p New ❑ Renewal
—81{7 Business LiC.Fee: S
Address City Zip
-?Ze O U //1�/ / /l vim, /O�/ Invest.Fee: a
Occupation Ct�T Employer Total: a
DO a 3 Receipt No. —
Address
t� n Phone
Dot of irth Place off Birth d/- o E)/� Are YOU a U.S.Citizen? Length of i ce in
L-1146/79 Yes ❑ No County 41 )'�&— City
$ex Height Weight Color of Eyes Colo f Hair Complexion Nationality
7 v E Col
)
Driver':License No. rate Social Security No. Scars,Marks,Tetoos I'l
7 a65 eR- - I
Ns t of Kin Relationship Address
Zt-
Have You Ever Been Found Guilty Or Plead Guilty To Any Crime? ❑ No Yes (if yes please explain•Exclude Minor Traffic Offenses)
- _X -- / iekV 1T#/tiI�
Have you over used another name? If Yes • Please list the O names / /X x'841'-
❑ No t9 Yes &7 VjEW I
E�
PLEASE READ AND SISIGN. /®
1 CERTIFY THAT ALL STATEMENTS IN THIS APPLICATION ARE TRUE,ACCURATE AND COMPLETE.FALSIFICATION OF ANY STATEMENT MAY
RESULT IN THE CANCELLATION OF THIS APPLICATION
Signature
Date:
REFERENCES (Business License Applicants Only)
Name Address e
Vic, 1440 0
PhonO 0 l Y O V
Business/P ofession Address Phone Years Known
Name Address Phone
Businesj/ rofession Address Phone Years Known
i��Mh� Xg
Name
fe'a Phone
Businass/Profession Address Phone Years Known
I I r ur 4AIV t$tMWNr%Uil
BUS_IN._ i LICENSE/PERMIT SU_P1 ._MENT
Applicant , Tyodol Bus-moss or P�rmh �(ffE� / / Dare
�f1ME5--
osed Name of Busin DBAI 4.Address 5.Pho
I Plan to start Business on (Date) I will be operating(Oat's of the Week)
Between the hours)f—ow�s�— and —49'10&—• Manor'Supervisor Name ,T,4 �e��9x;bar-
7.Have you ever had a Business License revoked,suspended or cancelled for any reason? Yes �i No
If yes please explain (Use additional pages if necessary) r
S.Are you now or have you ever been engaged in any Business as a Partner or Corporate Owner Yes �91 No
If yes please list firm/s name/s and officers of each corporation. (Use additional pages if necessary)
9.Live Entertainment Detailed Description of the Enterta+nment.
Applica Only
Location of the Entertainment How many people will be engaged Admission Fee
in the Entertainment? S
RESIDENCES (List Addresses for the last five years with current at the top)
1.Fr m To Address s Zip
- 7 _v�E�r- 1 40 E, i vE /oa i 1 N x) �3
ndlorci Address Phone No.
fly &0/,/,
2 From To Add Zip
�� - - 8� � 1 ,�til dF ,vv pro�/
Landlord Address Phone No.
3.From To Addres h r, Zip
Landlord Address Phone No.
4.From To Address Zip
Landlord Address Phone No.
5.From To Address Zip
Landlord Address Phone No.
EMPLOYMENT OR BUSINESS HISTORY (List Employers for the last five years with current at the top)
1.From To e! Address O n • ll``N nA �4 O Supe-
_ tJ✓' I N� L— /�
2 ro To ) Addr r R U� �09 �T/QT/� Su isor /e�
.� G ,2-
3.From To j Address Supervisor
4.From — To ! Address Supervisor
i
5.From To Address Supervisor
1
certify that the above information is true and correct. Signed --- ---
Investigated By Date
1 Recommend this License/Permit be :D Granted ! Denied