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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 5 -South Send, Indiana 46601 •574,235.5912 - F: 574.23SM21 y <br />rec- �-, ?_UN Ii? ? <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT OV431�5�'fi <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One <br />II. BUSINESS DATA <br />A. Business Name: <br />B. Business Addres. <br />New Renewal <br />City:- - —State; lip _Zip: <br />C. Mailing Address (If differentfromabove): <br />City- State: �7 Zip: <br />D. Business Telephone Number: 5� 93 — 6 37 <br />E. Business Fax Number: <br />t <br />F. E-Mail Address: <br />G. Zoning of Business location: <br />L-1 <br />H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked <br />by any governing municipality with' 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 />I. Describe the nature and scope of the business: <br />For Office Use Only <br />Application Filed Public Safety Approval <br />Application Fee Paid License Fee Paid <br />Sent to Dept._ License Number —% <br />-leal44_N-"5* Q1q <br />CITY OF SOUTH BEND INDIANA <br />Not Approved <br />Reason <br />BOARD OF PUBLIC WORKS <br />Elizabeth A. Maradik, President <br />C - Gfsl�ile-� <br />Gary A. Gilot, Member <br />Murray L. Miller, Member <br />Joseph R- Molnar, Vice President <br />Briana Micou, Member <br />KI«/ <br />Attest: Theresa M. Heffner, Clerk <br />Date: April 23, 2024 <br />