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�'z RA -Tr- *i m..Cp C-Ac�4 <br />For all municlpal business license questions, contao: City of South Band * department of Community Investment <br />227 West Jefferson Blvd *Suite 1404 S -South Send, Indiana 4660L - 574.235,5912 • F: 574.235.9021 <br />ice W'AIq r�' <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One: New I* Renewal <br />II. BUSINESS DATA <br />A. Business Name <br />B. Business Address: <br />a v <br />City: �ql f }�jpM- State Zip: <br />C. Mailing Address flf different from above): <br />City: State: Zip: <br />D. Business Telephone Number: <br />E. Business Fax Number: <br />F. E-Mail Address: yl lr' a 1'6 <br />G. Zoning of Business <br />C co <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 suspensionjrevocation: <br />I. Describe the nature and scope of the business; <br />For Office Use Only <br />Application Filed SEP 0 5 2023 public Safety Approval <br />Application Fee Paid SEP 0 5 7n9l License Fee Paid qFp <br />Sent to Dept,_ SEP- 0- 5 223 License Number _ Tris b I <br />CITY OF SOUTH BEND, INDIANA <br />Not Approved ` BOARD OF PUBLIC WORKS <br />Reason Wa a �M <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />Murray L. Miller, Member <br />Joseph <br />pR,. ,Molnar, Vice President <br />i <br />Alexandra Dolz-Lane, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: October 24, 2023 <br />