Fillable POOLROOM PERMIT APPLICATION (City of Riverside, California)

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POOLROOM PERMIT APPLICATION (City of Riverside, California)

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The POOLROOM PERMIT APPLICATION (City of Riverside, California) form is 8 pages long and contains:

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  • 12 check-boxes
  • 178 other fields

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BROWSE CITY OF RIVERSIDE, CALIFORNIA (CA) FORMS

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Applicant Name:
Type of Business:
License/Permit Type:
Proposed Business Site:
City Planning Approval: Zoning Approved
Zoning Not Approved
City of Riverside Planning Approver:
Staff Name: __________________________________________
Title: __________________________________________
Telephone: _______________________________________
The undersigned acknowledges and understands that the approval set forth on this form in no way
represents that the business proposed to be conducted on the site listed above, complies with
applicable zoning laws, planning requirements or use permits, and that additional conditions may
need to be met prior to conducting business on the site.
Contact the Planning Department directly prior to beginning your business.
__________________________________________
(Applicant Signature)
__________________________________________
(Print or Type Name)
Page 1 PRA_5.28_RPD-Vice 2/2020
RIVERSIDE POLICE DEPARTMENT
POOLROOM PERMIT APPLICATION
PRE-APPLICATION ZONING APPROVAL
Poolroom Permit Application
What are you applying for? Poolroom Permit
Renewal Poolroom Permit
Page 2 PRA_5.28_RPD-Vice 2/2020
First Name Middle Name Last Name
1. OWNER'S PERSONAL INFORMATION
City
Country
State
Place of Birth:
Height:
Weight:
SSN:
Street Address City State Zip
Current Residence Address:
Current Business Address:
Cell Phone Number:
Day Time Telephone Number:
2. List all the places you have lived for the past 5 years, if different from your current address:
Dates Street Address City State
List any and all names, nicknames or aliases you have used in the past:
State of Issuance:
Driver's License or Identification Number:
Date of Birth:
Hair Color:
Eye Color:
Street Address City State Zip
3. Employment History for the past 5 years (if different from current employment):
Dates Employer Address Reason for Leaving
4. If Owner is a Corporation or Partnership or will have on-sight Manager, complete the following
information:
Name of Business:
Page 3 PRA_5.28_RPD-Vice 2/2020
State of
Incorporation:
Incorporation
Date:
State Corporate
No.:
Title:
Business Address:
Street City State Zip
Address:
First Middle Last
6. Provide the following information for managers, partners, directors, and officers:
Name:
Street City State Zip
Height:
Weight:
SSN:
State of Issuance:
Driver's License or Identification Number:
Date of Birth:
Hair Color:
Eye Color:
Cell Phone Number:
Business Phone Number:
Title:
Business Address:
Street City State Zip
Address:
Name:
Street City State Zip
Height:
Weight:
SSN:
State of Issuance:
Driver's License or Identification Number:
Date of Birth:
Hair Color:
Eye Color:
Cell Phone Number:
Business Phone Number:
First Middle Last
5. Attach copies of articles of Incorporation and Bylaws, if applicable.
Page 4 PRA_5.28_RPD-Vice 2/2020
Title:
Business Address:
Street City State Zip
Address:
Name:
Street City State Zip
Height:
Weight:
SSN:
State of Issuance:
Driver's License or Identification Number:
Date of Birth:
Hair Color:
Eye Color:
Cell Phone Number:
Business Phone Number:
continued.....Provide the following information for managers, partners, directors, and officers:
First Middle Last
Title:
Business Address:
Street City State Zip
Address:
Name:
Street City State Zip
Height:
Weight:
SSN:
State of Issuance:
Driver's License or Identification Number:
Date of Birth:
Hair Color:
Eye Color:
Cell Phone Number:
Business Phone Number:
First Middle Last
NoYes
7. In the past 10 years, have you been convicted of a crime?
If "Yes," list convictions:
Offense
Date of
Conviction Location Parole or Probation?
Page 5 PRA_5.28_RPD-Vice 2/2020
NoYes
8. Have you ever been arrested of a crime?
If "Yes," list arrest:
Offense
Date of
Arrest Location
9. In case of an emergency, provide a name, address, and 24-hour emergency contact number.
First Middle Last
Name:
Address:
Street City State Zip
10. How many pool tables at the location:
24-Hour Telephone Number for Emergencies:
NoYes
11. Will alcohol be served?
If yes, provide alcohol license number:
Type:
NoYes
12. Will live entertainment ever be provided?
If "Yes," YOU MUST also obtain an Entertainment Permit.
13. HOURS OF OPERATION
Hours Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Open
Close
Page 6 PRA_5.28_RPD-Vice 2/2020
Riverside Police Department shall complete an investigation of the qualifications and moral
character of the applicant and either grant or deny the permit within ninety (90) days after the
submission of the completed application; provided, however, if good cause exists, the
Riverside Police Department may extend the period of investigation for an additional thirty (30)
days, provided the applicant is mailed notification or verbally notified that the investigation
has not been completed.
1. I have read the provisions of Chapter 5.28.010 through 5.28.150 of the Riverside
Municipal Code governing the operation of poolrooms within the city of Riverside.
2. I understand that I am required to comply with all laws related to poolrooms. If this
application is approved, I agree to abide by applicable laws and ordinances.
3. I understand that I must apply for renewal of my permit or certificate before it expires. I
also understand that if I do not apply for my renewal before the expiration date, I will be
required to re-apply and pay all application fees.
4. I have read this entire application and all of the answers provided above. I understand
that any material misrepresentation or omission, intentional or not, may result in the
denial of this application or revocation of any license, permit or certificate issued
pursuant to this application.
5.
I hereby declare that I am authorized to submit this application on behalf of the entity or
individual listed on the application because I am an owner of the entity, I have authority
from the owner or am the owner.
6. I acknowledge that any false, misleading, or fraudulent statement of material fact in
this application by an
agent of an owner, or an owner, will be held against the owner
and is grounds for denial of this application,
or suspension or revocation of the permit
associated with this application.
Initials: ____
Initials:_____
Initials: ____
Initials: ____
Initials: ____
Initials: ____
7. I hereby declare that I have read and understand all the laws, rules and regulations,
and policies and procedures associated with this application; and that I fully
understand the nature, meaning, and content of such laws, rules, and policies. I
warrant and represent that I will adhere to all laws, rules, and policies, during the
application process and after a permit is issued by the City.
11. I acknowledge that this application does not confer an entitlement or a vested right to
receive a permit, and I acknowledge that I must follow all rules and procedures to
obtain a permit prior to operating or otherwise claiming that I have any such right to a
permit or to operate.
10. I acknowledge the City will review this application for compliance with applicable laws,
regulations, and ordinances, and that this application may be denied as allowed by
laws, rule, or policies of the City.
9. I acknowledge that any promise, representation, or any other statement made to me
by any agent or employee of the City that is not contained within this application is
null, void, and unenforceable and that I am not relying on any such promise,
representation, or statement.
8. I hereby declare that I have conducted my own research and investigation regarding
the compliance of the proposed location with state and local laws, including, but not
limited to, location requirements, zoning regulations, and address requirements. I
further declare that the proposed location of the poolroom fully complies with
applicable state and local law.
Initials: ____
Initials: ____
Initials: ____
Initials: ____
Initials: ____
Page 7 PRA_5.28_RPD-Vice 2/2020
12. I hereby declare that I have read this acknowledgement and advisement, that I have
had the opportunity
to consult with, and be represented by, legal counsel of my own
choice prior to the execution and submission of this application, and that I am knowingly
and voluntarily submitting this application in compliance with this acknowledgement
and advisement and all applicable laws.
13. I acknowledge that I am jointly and severally liable for any and all taxes, fees, and
charges associated with the permit.
14. I consent for the city of Riverside, by and through its appropriate officers, agents, and
employees to verify and confirm the information contained in this application, and to
conduct such other investigations as may be reasonably required by the City of
Riverside, its officers, agents, and employees for the purpose of determining the
capability, fitness, and capacity of the applicant to obtain a Poolroom Permit.
15. Whenever there is a change in information that was required to be submitted in the
application. Such notification shall be in writing to the Riverside Police Department
within ten (10) business days of the change.
Initials: ____
Initials: ____
Initials: ____
Initials: ____
I declare under penalty of perjury under the laws of the State of California
that the foregoing is true and correct.
Applicant's Signature Date
Print Name
PROPERTY OWNER CONSENT AND AUTHORIZATION
OF POOLROOM ACTIVITIES
I, , declare under penalty of perjury that
1. I am the Property Owner of record, or the duly authorized representative of the Property
Owner, for the real Property located at (“the
Property”)
2. The Property Owner acknowledges and consents to the business, ,
, conducting the proposed
poolroom activities at the Property.
3. No person shall engage in any massage activities on the proposed Property without all
licenses and permits required by the Riverside Municipal Code (RMC) while a poolroom
application is pending.
4. The city of Riverside may enter the property to conduct inspections of the Property during the
application process in order to thoroughly investigate whether a massage permit should be
granted.
5. I have read, understand,and will ensure compliance with the terms in RMC Section 5.28
(Poolrooms), as applicable. I further understand that as the legal owner of the property, I am
responsible for any violation and nuisance activity which may occur at the above-mentioned
property.
I certify
under penalty of perjury under the laws of the State of California that the foregoing is
true and correct.
*This authorization form will not be valid without notarization. The authorization form automatically expires
upon sale or transfer of the property to a new legal owner. If sale or transfer of the property occurs prior to the
applicant obtaining a massage permit, the applicant must resubmit this notarized form with approval of the
new legal owner of the property.
(Date)
(Printed Name & Title)
(Authorized Representative Business Name)
Page 8 PRA_5.28_RPD-Vice 2/2020
(Name of Property Owner/Authorized Representative)
(Address)
(Business Name)
Tenant Applicant Name (Corporation/LLC/Partnership/Sole Owner)
(Signature of legal owner/owner representative)
(Authorized Representative Business Address)
(Business Telephone)
Riverside Police Department
PERMIT APPLICATION
NOTARY ACKNOWLEDGMENT
CALIFORNIA ACKNOWLEDGMENT CIVIL CODE § 1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
)State of California
County of ______________________________
On _________________________ before me, _____________________________________________,
Date Here Insert Name and Title of the Officer
personally appeared __________________________________________________________________
Name(s) of Signer(s)
__________________________________________________________________________________,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/
her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the
laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature _________________________________
Place Notary Seal and/or Stamp Above
Signature of Notary Public
)
Page 9 PRA_5.28_RPD-Vice 2/2020
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Completed 25 February 2021

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