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For all municipal business Ycense questions, contact- City of Soutr Bend • Devartment of Community Investment <br />227 West Jefferson Blvd - Suite 14CO 5 •5outh Bend, Indiana 46641 • 74.Z35.5912 - F: 574.235.9021 <br />nu- W7 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT CY—L'045 <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One: New Renewall <br />Ii. BUSINESS DATA <br />A. Business Name: <br />B. Business Address: <br />City <br />C. Mailing Add <br />City: <br />Wft <br />D. Business Telephone Number: <br />E. Business Fax Number: <br />F. E-MaiIAddress: <br />G. Zoning of Busirn <br />H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked <br />by any governing municipality Rhin three (3) years prior to the date of this a pplication: <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 />I. Describe the nature and scope of the business: <br />For Office Use Only <br />Application Filed_ S Yl Public Safety Approval <br />Application Fee Paid License Fee Paid <br />Sent to Dept. MA R 90,7a License Number M Se-f1D -01 <br />CITY OF SOUTH BEND, INDIANA <br />Not Approved BOARD OF PUBLIC WORKS <br />Reason 1*1�(4 <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />pZ—, A <br />Murray L. Miller, Member <br />�7�t <br />Joseph R. Molnar, Vice President <br />Briana Micou, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: May 14, 2024 <br />0 <br />