License - Massage Establishment Renewal - Summer Spa Massage

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For all municipal business license questions, contact: City of south Rend - Department of Community Investment 227 West Jefferson Blvd - Suite 1400 5 -South Bend, Indiana 46601 - 574.235.5912 - F: 574,235.9021 'sec . 7 ! 911 U,65. LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT Ctgp-b MUNICIPAL CODE SECTION - 4-35 I. APPLICATION TYPE Check One II, BUSINESS DATA New Renewal XX A. Business Name: Summer Spa Massage B. Business Address: 3601 E. Jefferson Blvd City: South Bend State: IN Zip: C. Mailing Address (If different from above): City: State: Zip: D. Business Telephone Number: 574-383-5035 E. Business Fax Number: F. E-Mail Address: 1726065950@QQ.com 46615 G. Zoning of Business Location: Neighborhood center — personal care and services H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked by any governing municipality within three (3) years prior to the date of this application: YES NO Xx 1. If yes, what was the reason: 2. If yes, what was the business occupation following the suspension/revocation: I. Describe the nature and scope of the business: To provide therapeutic massage J. Include a list of massage therapist employed at this location: (include a separate sheet if necessary) MeiLi Sun - For Office Use Only Application FileciFER 2 12023 Public Safety Approval Application Fee Pajdttb Z I 7U7T License Fee Paid EFR Sent to Dept._ � � 7f19? License Number �5+�[ �a 3 Gila,} CJfllR 2 3 2023 Aeo i d� d/ 1jQ4_ F B 2 2023 Not ve Reason CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS I Elizabeth A. Maradik, President Gary A. Gilot, Member �/ VT L Jose-pphl�R.. Molnar, Vice President U Y/ Jordan V. Gathers, Member � "/� Murray L. Miller, Member Attest: Theresa M. Heffner, Clerk Date: