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For a II mu n I c I p a I business I icense qu es tI❑n a, contact' City of South Bend • Department of Community Investment <br />227 West Jcfferson Blvd • Suite 1400 5 ■South Bend, Indiana 45501 • 574.235.5912 • F. S74.235.W2� � � � i l $5(r <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />I. APPLICATION TYPE Check One <br />II. BUSINESS DATA <br />A. Business Name: <br />New Renewal <br />r 1j f <br />ea(tat, 00SL5 <br />B, BuslnessAddress: 9I'f ( - J t �-P C5a(\ ) Lj,)fQ <br />City: 5 4u{-k �e a —state; -S J Zip; (2 (k _ <br />C. Mailing Address (If different from above): a5 a ty LQ GU f Da d <br />City: sf}uf le state: r 1�j Zip: <br />D. Business Telephone Number: 5 7 LI <br />Business Fax Nu <br />E-M ail Address: <br />G. Zoning of Business Location: IV(-' <br />H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked <br />by any governing munlcipa' within three (3) years prior to the date of this application: <br />YES NO <br />1. If yes, what was the reason: &)/a <br />2. if yes, what was the lousiness occupation following the suspension/revocation; <br />!A <br />I, Describe the nature and scope of the business:, W eV 5 � w Dll` `� <br />c en4 e r -HhvNol I ra Lbij m e r co n _ 0 Ira C-H( e <br />1. Include a list of massage herap€st employed at this location- {include a se crate sheet if nec sa j <br />qo `�j g s Cf G1 P `}"� V f CA 0 I'S+ 0. �` Vllif - L��� iLltVl � i , t, <br />For Office Use Only h - 1 TO I <br />Application Filed AQl$ 9 2 Z07 3 _ _ Public Safety Approval <br />Application Fee Paid RUiJ G 4 ZUZJ License Fee Paid <br />Sent to Dept. Al IG 2 2 -2Q-2�3 License Number j -D l a, <br />Police Fire Zoning Health <br />Not Approved_ CITY OF SOUTH BEND, INDIANA <br />Reason BOARD OF PUBLIC WORKS <br />t1a �k <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />7,z,, ,. a <br />Joseph R. Molnar, Vice President <br />ao, <br />Alexandra Dolz-Lane, Member <br />Murray L. Miller, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: October 24, 2023 <br />