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For all municipal 4u5lFiess license questions, contact: City of South Bend • Department of Community Investment <br />227 West Jefferson Blvd • Suite 1400 S *South Bend. lndiana 46601 + 574.235.5912 • F: 574-7155..9�1 1,j-f7q <br />1-5'V.Asf� <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One <br />11. BUSINESS DATA <br />A. Business Name: <br />New <br />Renewal <br />C <br />B. Business Address: <br />City: Se"N7-1-i '6;5 l.D State: r A/ Zip: ; <br />C. Mailing Address (If difFerentfrom above): /6,5 141 Z22rIZ422 i2212'. <br />City: M/ �1l,�f r State. /A� Zip: l <br />D. Business Telephone dumber: 5 :Zy''OZZ — Zz9a <br />E. Business Fax Number: <br />E-Mail Address: V' 0--'2Z�r Giry'Z <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 municipality 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 occupation following thesuspension/revocation: <br />I. Describe the nature and scope of the business: � 5si%t.,r Laf,e <br />For Office Use Only <br />Application Filed JAN 2 5 2024 Public Safety Apprevai <br />Application Fee PaidJAN t 5 M4 License Fee Paid <br />Sent to Dept_ License Number <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />Not Approved _ <br />loozP1 <br />Reason <br />Elizabeth A. Maradik, President <br />Joseph R. Molnar, Vice President <br />Gary A. Gilot, Member <br />Breana N. Micou, Member <br />— Murray L. Miller, Member <br />Attest: Laura D. Hensley, Acting Clerk <br />Date: March 26, 2024 <br />