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For all munIdpal business license questions, contact: City of South Bend • Department of Community Investment <br />227 West Jefferson Bivd • Suite 1400S •South Bend, Indiana 45601 • 574.235.5912 • F: 574.23a 21 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT TjLf.fV <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One <br />II. BUSINESS DATA <br />A. Business Name: <br />New Renewal <br />B. Business Address: ` L—lN f <br />City:_ 5tate:Zi p: fir* P v_ r <br />C. Mailing Address (If different from above): <br />City: State: Zip: <br />U. Business Telephone Number: [ — 5-7Y~-9 23 753Z <br />E. Business Fax Nu <br />F. E-Mail Address: <br />G. Zoning of Busin <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 NQ <br />I. If yes, what was the reason: <br />2. If yes, what was the business occupation foilowing the suspension/revocation: <br />i. Describe the nature and scope of the Business: <br />J. Include a list of massage therapist employed at this location: (include a separate sheet if necessary) <br />Q I �E <br />For Office Use Only <br />Application Filed Eph h 2ng Public Safety Approval <br />Application Fee Paid License Fee Paid FEB <br />Sent to Dept,. FEE 2 8.2D72 License Number MSEaoAZ-al1 <br />b� i C Q- rl l)-E. 7—O Ir� i <br />Ap <br />proved pproved <br />Not CITY OF SOUTH BEND, INDIANA <br />ReaBOARD OF PUBLIC WORKS <br />Elizabeth A. Maradik, President <br />Qs�il�.t <br />Gary A. Gilot, Member <br />JY/�.w K yi2�g <br />��, 1 <br />Joseph R. Molnar, Vice President <br />619, <br />Jordan V. Gathers, Member <br />Y, <br />Murray L. Miller, Member <br />Attest: Theresa M. Heffner. Clerk <br />Date: March 28, 2023 <br />