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For all municipal business license questions, contact: City of South Bend @ bepartment of Community Investment <br />227 West Jefferson Blvd • 5ulte 1400 5.5outh Bend, Indiana 46601 • 574.235.5912 • F: 574.235,9021 <br />-Ree.I01ta84'��J° <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One: New Renewal <br />II. BUSINESS DATA <br />A. Business Name: <br />B. Business Address: <br />City:l State: zip: <br />C. Mailing Address (If different from above). �-,li />-. <br />City: State: Zip. <br />D. Business Telephone Number: r. <br />E. Business Fax Number: N /W <br />F. E-Mail Address: r- In-_-)_YIL V " 11(/T )I ) I `-1 (1) C 111 Y11 l - <br />G. Zoning of Business Location: i L_)GLutr9]I L)rj <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 V <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: _ r� <br />r <br />For Office Use Only <br />Application Filed JAN 0 8 2025- Public Safety Approval <br />Application Fee Paid AKI U 8 NE License Fee Paid <br />Sent to Dept. TINE 8 20 .rBOARD <br />Number MSEA 5 —Oct <br />Fire Approval SBPD Approval CITY D SOUTH BEND, INDIANA <br />D OF PUBLIC WORKS <br />-*1� <br />Not Approved Health Permit <br />Elizabeth A. Maradik, President Joseph R. Molnar, Vice Presidcnt <br />Reason a� 4 <br />Gary A. Gilot, Member <br />%YL✓✓y � %IZc�G <br />Briana Micou, Member <br />1 Murray L. Miller, Member Attest: Hillary Horvath, Acting Clerk <br />Date: 06/24/2025 <br />