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For all muniwaI business Ikensequestions, contact: Cty of South Bend • Oepartmeni of Community Investment �• f1 �-L <br />227 West Jefrerson Blvd • Suite 14005 •South Bead, IMiarra 46601 •57d.23S.5912 • F: 5 74.2 25.9021 Q p(1 Tj 1P�m <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />I. APPLICATION TYRE Check One: <br />II, BUSINESS DATA <br />A. Business Name: <br />B. Business Address: <br />New Renewal <br />C. Mailing Address (If different from above): <br />City: <br />D. Business Telephone Number: <br />E. Business Fax Number: <br />F. E-Mail Address: QV\1 <br />G. Zoning of Business Location: <br />State; Zip; <br />State: Zip: <br />H. Have you ever had a Mass a Establishment license, or similar license, suspended or revoked <br />by any governing municip ty within three (3) years prior to the date of thisapplication: <br />YES Np <br />1. If yes, what was the reason: <br />2. If yes, what was the business pation following thesuspension/revocation: <br />I. Describe the nature and scope of the business:RSSEe[et�_ <br />For Office Use Only <br />Application Filed MAR 0 3 2025 Public Safety Approval <br />Application Fee Paid 13 IRI License Fee Paid <br />Sent to Dept. 'e., i I . " <br />License Number . (l')SCo'�Q,�6--(] j <br />A5Q1+06$ ��K - <br />C L, CITY OF SOUTH BEND, INDIANA <br />Not Approved BOARD OF PUBLIC WORKS <br />Reason VA�a P1 <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />Joseph R. Molnar, Vice President <br />Briana Micou, Member <br />Murray L. Miller, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: May 27, 2025 <br />