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For ail municipal business I Icense questions, contact: City of South Bend - IDLpartme (it of Community Investment <br />227 West Jefferson Blvd -Suite 1400 S -South Bend, Indiana 46601 - 574,235.5912 - F: 574,235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check Crone: <br />11. BUSINESS DATA <br />A. Business Name: <br />B. Business Addres <br />L <br />City: State: 3_ zZip:O <br />C. Mailing Address (If different from above): k5_0 (A� Aue . . ...... <br />City: State: 5 1 Zip: 0 6a t <br />D. Business Telephone Number: S <br />New <br />Renewal <br />Business Fax Number: <br />F. E-Mail Address: C VVt c1f, '>e a <br />AJVIC�\c (60 o A/ <br />C. Zoning of Business Location: (n Q <br />H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked <br />by any governing municipality 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: MCA-'-'-'CLeV <br />0 <br />For Office Use Only <br />Application Filed MAP 1 2018 Public Safety Approval <br />Application Fee PaidUAR-1n L License Fee Paid <br />Sent to Dept. 41, -- <br />License Number <br />AVVU0VjWj) <br />Not Approved 119aird of INN 16lici, WQj.'kq <br />Reason <br />1 <br />