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Forallmunicipal business license questions, contact: CityofSouth Bend -Department Of Communitylrvestment <br />227 West Jef*erso n Blvd ■ Suite 1400 S -South Bend, Indiana 46601 6 574.235-5412 • F: 574.235.9n2 t <br />_Ree. 7Ug7R7 ` <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One: New Renewal. ]� <br />II. BUSINESS DATA <br />A. Business Name:�:fl <br />B. Business Address: rr _2 17 -L��'L .J <br />City: G% /V6� It _ State/I <br />C. MailingAdd ress (if differentfrom above): <br />City: State Zip: <br />D. Business Telephone Number: ,� 1344421�L2L_ <br />E. Business Fax Number: <br />F. E-Mail Address: - 13 <br />G. Zoning of Business Location, <br />t <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 X _ <br />I. 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: m1 <br />c <br />mass%% thera t employecLat this location: (include a separate sheet if necessary) <br />YV S O -. A n — <br />ror orrice use Only <br />Application Filed FEB Q 3 2023 Public Safety Approval <br />Application Fee Paid FEB 0 3 7023 License Fee Paid <br />Sent to Dept. FE. 0 3 2023-License Number � L <br />CITY OF SOUTH BEND, INDIANA <br />Not Approved^ BOARD OF PUBLIC WORKS <br />Reason <br />Elizabeth A. Maradik, President <br />V' A. <br />Gary A. Gilot, Member <br />Joseph R. Molnar, Vice President <br />Jordan V. <br />Gathers, Member <br />Y'% <br />Murray L. Miller, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: February 28, 2023 <br />