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For all municipal business license questions, ronIact: Clty of south Bend • Department of Community Imrestment <br />227 West Jefferson Blvd - Su to 1400 S -5L;uth Bend, Indiana 46601 • 574,235.5912 • F:574.235.9021 +j <br />L-1%j T <br />LICENSE APPLICATION FOR -MASSAGE ESTABLISHMENT 27je�q 5'OW <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One: New Renewal V <br />li. BUSINESS DATA <br />A. Business <br />Business Address: nu_5 -Tr-- ,_�D' 1 \1r✓D <br />City. '�'1� State:_ Zip: <br />C. Mailing Address (If different from above): <br />City: State: <br />D. Business Telephone Number: _ ] - k <br />E. Business Fax Number: <br />F. E-Mail Address:�A7_ vV_ uAc �N ift tLL-t� C <br />Zip: <br />G. Zoning of Business Location: <br />H. Have you ever had a Massage EstabliAment license, or similar license, suspended or revolted <br />by any governing municipal* ithin 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 />1. Describe the nature and scope of the business: <br />J. Include a list of massage therapist employed at this location: (Includr� separate sheet if necessary) <br />, <br />LIL I <br />For Office Use Only <br />Application riled FEB 2 8 2023 Public Safety Approval <br />Application Fee Paid_ License Fee Paid . EEB 2 R 9071 _ <br />Sent to Dept. F EH L K 2021 License NumberC)SEA A3~ <br />Not Approved <br />Reason CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />Joseph R. Molnar, Vice President <br />8191 <br />Jordan V. Gathers, Member <br />�4 <br />Murray L. Miller, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: April 11, 2023 <br />