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For all municipal business license questions, contact: City of South Bend • Department of Community Investment U96 ov <br />227 WestJefferson Blvd • Suite 1400S -South Bend, Indiana 46601 • 574.235.5912 • F: 574.235,5021 Mv. 000 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />L APPLICATION TYPE Check One: New Renewal <br />II. BUSINESS DATA <br />A. Business Name: <br />B. Business Address: <br />City: �ioa444 U4* State: rC /1Z Zip:.V) 1�'lY— <br />C. Mailing Address (If different from above):-4& a�yp, <br />City: State: Zip: <br />D. Business Telephone Number: �=� <br />C72Y 2— <br />E. Business Fax Number: <br />F. E-Mail Address: <br />G. Zoning of Business Locatic <br />H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked <br />by any governing municip ity within three (3) years prior to the date of this application: <br />YES NO <br />1. If yes, what was the reason: <br />2. If yes, what was the business occupation following the suspension/revocation: <br />I. Describe the nature and scope of the business: prfiVI-1 � /�C/� lqe / <br />b2 dot <br />For Office Use Only <br />Application Filed FE13' 1 LUl/ PublicSa"Ap <br />Application Fee PaicFEB 2 1 2017 License ee ai <br />Sent to Dept. FEB 21 2017 License Number <br />Not Approved <br />Reason <br />4 N11 <br />NJ <br />