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For all municipal business license questions, contact: City of South Bend • Department of Community Investment <br />215 S. Dr. Martin Luther King Jr. Blvd. • Suite 500 <br />South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021 <br /> <br />1 <br /> <br /> <br />For Office Use Only <br /> <br />Application Filed Public Safety Approval <br />Application Fee Paid License Fee Paid <br />Sent to Dept. License Number <br /> <br />Not Approved <br />Reason <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br /> <br />I. APPLICATION TYPE Check One: New Renewal <br />II. BUSINESS DATA <br />A. Business Name: <br />B. Business Address: <br />City: State: Zip: <br />C. Mailing Address (If different from above): <br />City: State: Zip: <br />D. Business Telephone Number: <br />E. Business Fax Number: <br />F. E-Mail Address: <br />G. Zoning of Business Location: <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 /> <br />1. If yes, what was the reason: <br /> <br />2. If yes, what was the business occupation following the suspension/revocation: <br /> <br /> <br />I. Describe the nature and scope of the business: <br /> <br /> <br />