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rnra;l muncipal business I cense questions, contact: Cityof South Bend • 6epartmentofCommunityInvestment <br />22.7 west lcfferson Blvn • Sul*,e 1400 5 •5Duth Bend, Indiana 46601 • 574.235.5912 • F' 5a4, 235.9W 1 <br />Rey 71 OQ� 5, <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />I. APPLICATI0N TYPE Check One: New Renewal <br />II. BUSINESS DATA <br />A. Business Name: A.E <br />B. Business Address: 9a <br />City:5grrtA �t�4 _ State: X�­ zip: fy <br />C. Mailing Address (If different from above) - <br />City: State: Zip: <br />D. Business Telephone Number: Z -- 2,2 y <br />E. Business Fax Number: <br />F. E-Mail Address: J*le Co' lzw_z,�crag. mas",,' <br />G. Zoning of Business Location:11�X' <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 thisapplicati❑n: <br />YES NO X <br />1. If yes, what was the reason: <br />2. It yes, what was the business occupation fallowing the suspension/revocation: <br />I. Describe the nature and scope of the business: 1,f ZrGTI t L&&A&--js5 5,,W <br />J. Include a list of massage therapist employed at this location. (include a separate 5heetif necessary) <br />S <br />For Office Use Only <br />Application Filed FEB a 8 202,1 Public Safety Approval <br />Application Fee Paid FAR 9 R 7M3 License Fee Paid <br />Sent to Dept. 82023 License Number MSEA0113~00L� <br />�tice-lR� _ Zoni:) <br />Not Approved CITY OF SOUTH BEND, INDIANA <br />Beason BOARD OF PUBLIC WORKS <br />l2 <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />�/ VT t <br />Joseph R. Molnar, Vice President <br />Jordan V. Gathers, Member <br />i„ / <br />Murray L. Miller, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: March 28, 2023 <br />