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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 14OD S -5outh Bend, Indiana 46601 •574135.5912 • F: 574.233.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLIS MENr� <br />MUNICIPAL CODE SECTION - 4-35CC f'�� <br />CV, y l ] $ <br />I. APPLICATION TYPE Check One: <br />II. BUSINESS DATA <br />A. Business Name: a <br />New Renewal <br />B. Business Address: 7 f L—vvVV <br />City: 56 State: <br />C, Mailing Address (If differentfrorn above); <br />Zip: <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 NOr <br />1. If yes, what was the reason: <br />Z. If yes, what was the business occupation following thesuspensionjrevocation: <br />I. Describe the nature and scope of the business: L r — ` <br />For Office Use Only <br />Application Filed F E B 2 8 2025 Public Safety Approval <br />Application Fee Paid F" M License Fee Paid FEB2M <br />Sent to Dept. License Number <br />s <br />zonlrw$— <br />Not Approved <br />CITY OF SOUTH BEND, INDIANA <br />Reason BOARD OF PUBLIC WORKS <br />vl�a <br />Elizabeth A. Maradik, President <br />�� Qs�lr%tet <br />Gary A. Gilot, Member <br />� t 7rt, <br />Joseph R. Molnar, Vice President <br />Breana Micou, Member <br />�4 <br />Murray L. Miller, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: April 8, 2025 <br />