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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 1400 S -South Bend, Indiana 46601 • 574.235.5912 - 'PI <br />74.23W2 <br />4. 3�2 5 -far,� <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT C - .� <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One: <br />II. BU51NESS DATA <br />A. Business Name <br />B. Business Addres <br />New Renewal <br />City: State: Zip: <br />C. Mailing Address (If different from above): <br />City: State: Zip: <br />D. Business Telephone Number: � ji <br />E. Business Fax Number: )p��, !A <br />r. E-Mail Address: 29 e4 2S c <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 municlp ity within three (3) years prior to the date of thisapplication: <br />YES NO 7 <br />1. If yes, what was the reason: <br />2. If yes, what was the business occupation following the suspension/revocation: <br />I. Q,!pscribe the nature and scope of the business: <br />For Office Use Only <br />Application Filed J -P' ] $ 224 public Safety Approval <br />Application Fee Paid'iA l 1 O ZL'Z`I License Fee Paid <br />Sent to Dept. JAN 1 8 2C24 License Number .Q_4E. )a14_ <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />Not Approved V'W <br />Reason <br />Elizabeth A. Maradik, President <br />�—.� Gfsilcit� <br />Gary A. Gilot, Member <br />4 9yL_1&__1 <br />Murray L. Miller, Member <br />1,1:;;-2M <br />Joseph R. Molnar, Vice President <br />Breana N. Micou, Member <br />Attest: Laura D. Hensley, Acting Clerk <br />Date: March 26, 2024 <br />