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For all municipal business license questions, contact: City of South Bend - Department of Community Investment <br />227 West Jefferson Blvd - Suite 14005 -South Bend, Indiana 46601 - 574,235.5912 - F; 574.235.9402J. <br />aK` 0a'-5 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT Rtv-- L� <br />MUNICIPAL CODE SECTION - 4-35�" <br />I. APPLICATION TYPE Check One <br />II. BUSINESS DATA <br />A. Business Name: <br />B. Business Address: <br />New Renewal <br />City: ht A <br />C. Mailing Address (If different from above): <br />City: <br />D. Business Telephone Number: <br />.State: zip, <br />te: Zip: <br />F. Business Fax Humber: <br />F. E-Mall Address:.[`i1��G Q <br />G. Zoning of Business Location: <br />H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked <br />by any governing munieipa within three (3) years prior to the date of thisapplication: <br />YES NO <br />1. If yes, what was the reason: <br />2. If yes, what was the business oc ation following the suspension/revocation; <br />I. Describe the nature and scope of the business: -1Lw]1 > <br />Far Office Use Only <br />Application Filed �EB 2 S nn Public Safety Approval <br />Application Fee Paid FEB z 6 2023 License Fee Paid <br />Sent tc Dept._ FEB G 8 2023 License Number. <br />Po I t C' e- RACL 7Dni I15 <br />Not Approved_ CITY OF SOUTH BEND, INDIANA <br />Reason BOARD OF PUBLIC WORKS <br />A. Maradik, President <br />Gary A. Gilot, Member <br />%YLwy K <br />Joseph <br />✓✓R. Molnar, Vice President <br />U P5 <br />Jordan V. Gathers, Member <br />rea <br />L. Miller, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: May 23, 2023 <br />