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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 - F: 574.235.9021 Cti <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One <br />II. BUSINESS DATA <br />A. Business Name: <br />New Renewal <br />YT <br />P11 <br />B. Business Address: _ ao tj Zr^on alaa4TLL.cit <br />State:_ i Zip:_�i(��,3 <br />C. Mailing Address (if different from above): <br />City: State: Zip: <br />D. Business Telephone Number: _�, ��� �= / t <br />E. Business Fax Number: <br />F. E-Mail Address: <br />G. Zoning of Business Location: _L� s�45L+J_L�L�Ls4L_L� I S 7 �11c[i41� <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 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 />Describe the nature and scope of the business: <br />J. Include a list of massage therapist employed at this location: (include a separate sheet if necessary) <br />For Office Use Only <br />Application Filed F E B 2 8 2024 Public Safety Approval <br />Application Fee Paid Fig License Fee Paid <br />Sent to Dept. LF R 2 12D24 License Number _M'SE CAS <br />�S.� <br />Not Approved <br />- SLF <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />Reason <br />tjl�a <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />Murray L. Miller, Member <br />ME <br />Joseph R. Molnar, Vice President <br />Briana Micou, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: —April 23, 2024 <br />