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For all municipal business license questions, contact: City of South Bend -Department of Community Investment <br />227 West Jefferson Blvd - Suite 1400 S -South Bend, Indiana 46601- 574.235.5912 - F: 574.2 5.9021 <br />t�ec.t�o.�7(0389 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 / <br />I. APPLICATION TYPE Check One: New Renewal �f <br />II. BUSINESS DATA <br />A. Business Name: <br />B. Business Address: (DIV 5. 64AYa hwUP <br />City: South &"A State: :1N Zip: 46611 <br />C. Mailing Address (If different from above): (Dtb E /1X �Y't <br />City: SDA &VIJ State:. Z!J Zip: 'IV(Q11 <br />D. Business Telephone Number: 04) 394-31ota4 <br />E. Business Fax Number: <br />F. E-Mail Address: rq(%Igt_�iIYlA55grkC, eoilsa�amail .cnrn <br />G. Zoning of Business Location: <br />H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked <br />by any governing municipality 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 />L Describe the nature and scope of the business: Fhoyldl� YDp rfic- rnas oge 414PAa/ <br />For Office Use Only <br />Application Filed FEB 2 0 2017 / <br />Application Fee Paid d 0 2017 <br />Sent to Dept. FER 2 0 2017 <br />Not Approved <br />Reason <br />Fee Paid <br />APPj3>�VE� <br />Ooard Of Puiplip Works <br />