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a <br />5 4._ L.}`i'S i i r <br />P `Cb Ch& [ <br />For all municipal business license questions, contact: City of south Bend ■ epartment of Community Investment <br />227 West Jefferson Blvd ■ Suite 1400S •South Bend, Indiana 4MI ■ 74.235.5912 • F: 574.235.9D21 <br />. -7 L , <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-3S <br />I. APPLICATION TYPE Check One: <br />II. BUS INESSDATA <br />New Renewal X <br />A. Business Name: A 1' kdt eefo CO qU �2, An _5S e(,,V e <br />B. Business Address: <br />City. [-� a a- f'-�it �5tate:� Zip: _4�61?1> <br />C. Mailing Address (If different from above): <br />City: State: Zip: <br />D. Business Telephone Number: - 7 <br />E. Business Fax Number: <br />F. E-Mail Address: �1_—l_ic 7 -3 ► 40 1,L . r_, M Cr,-i► -) <br />G. Zoning of Business Location: W <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 _1 <br />1. If yes, what was the reason: <br />z. If yes, what was the business occupation following the suspension/revocation: <br />I. Describe the nature and scope of the business: _ '1GtC S C C> <br />J. Include a list of massape therapist employed at this location: )include a separate sheet if necessary) <br />`z i) .o t-tt fie c CA.fY? <br />For Office Use Only <br />Application Filed FEB 0 3 2023 Public Safety Approval <br />Application Fee Paid FR 0 3 7023 License Fee PaidFEB <br />Sent to Dept. FEY 4 3 2073 License Number MIr-A 5_00' <br />CITY OF SOUTH BEND, INDIANA <br />Not Approved BOARD OF PUBLIC WORKS <br />Reason 1*64 <br />Elizabeth A. Maradik, President Joseph R. Molnar, Vice President <br />Q�rit t <br />Gary A. Gilot, Member <br />Jordan V. Gathers, Member <br />�4 <br />Murray L. Miller, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: February 28, 2023 <br />