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Far all municipal business license questions, contact: City of South Bend • De--artmen:of Community Investr:ient <br />227 West Jefferson Blvd • 5ulte 1400 5 -SDuth Bend, Indiana 4E601 • 574.235.5912 • F: 57,4.235.9021 j <br />W- &9 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT' <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One <br />11. BUSINESS DATA I <br />A. Business Name: QCIM1 T <br />B. Business Address: <br />New -Rtenewal <br />fllkf <br />State: aj 7ip: ql � 17 <br />C. Mailing Address (If differentfrom above): <br />City: <br />D. Business Telephone Number: J li-0`t`1-JV/V <br />E. Business Fax Number: <br />F. E-M a I Address: 1 a014 -4 VY)wsanj , PDI k A� fl VW1111 - t b ryY <br />Zip: <br />j{ L � . <br />G. Zoning of Business Location: V <br />H. Nave you ever had a Massage Establishment license, cr simiIa r license, suspended or revoked <br />by any governing municipality within three (3) years prior to the date of th is a p plicatio n: <br />YES NO� <br />1. If yes, what was the reason: <br />2. If yes, what was the business occupation following thesuspens ion/revocation: <br />L Describe the nature and scope of the business: <br />0 <br />For Office Use Only <br />Application Filed MAR 0 3 2025 Public Safety Approval <br />Application Fee Paid l 1Hlt 0 3 2 OF License Fee Paid rv)!', { 0 3 WS <br />Sent to Dept. 1 rvlh;� t -q ?D17 License Nurnber ry SC AVn <br />�5010 ` J& CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />Not Approved <br />Reason <br />taa4 <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />pt",,r 7rrti0� <br />Joseph R. Molnar, Vice President <br />Breana Micou, Member <br />Murray L. Miller, Member Attest: Theresa M. Heffner, Clerk <br />Date: March 25, 2025 <br />