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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 Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021 <br />AEC173P <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT lK l IDS <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYPE Check One: <br />11. BUSINESS DATA <br />New Renewal <br />A. Business Name, V t _i D pjl�5.Mof <br />B. Business Address: 6 • QA- <br />City: 5z1WM State: � � Zip; <br />C. Mailing Address (If different from above): <br />City: State: Zip: <br />D. Business Telephone Number: 5 `7 q ITUA <br />E. Business Fax Number: <br />F. E-Mail Address: D1 C4 r, t&12 5 -74 L(.422L ! XWO <br />G. Zoning of Business Location: u <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 thisappl+cation: <br />YES NO d <br />1. If yes, what was the reason: <br />2. If yes, what: was the business occupation following thesuspension/revocation, <br />I. Describe the nature and scope of the business: <br />N&c�S Cta 0 1* W WiAla_ C. <br />For Office Use Only <br />Application Filed FEB ? 8 2 2�j Public Safety Approval <br />Application Fee Paid l- E k 1 � 209t License Fee Paid <br />Sent to Dept. � F� 7i�7ri License Number flrl aQ D � <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />Not Approved <br />Reason <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />Murray L. Miller, Member <br />Joseph R. Molnar, Vice President <br />Breana Micou, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: April 8, 2025 <br />