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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 S -South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA (Continued) <br />N. Photographs: <br />AtfP� h holn r 01 D­­.-..- 'l—t ru„ ru s_L_ ...L•L:,_ / .____�L �SaL I s LtL:_ __-1:__a:_ <br />Company Address <br />(Attach additional sheets if necessary) <br />City, State, ZIP Dates <br />g° it <br />V. INCLUDE WITH APPLICATION: <br />Three (3) passport photos taken within 6 months of application. <br />VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION <br />VII. AFFIRMATION <br />I, hereby, certify and affirm that all of the information I have given in this application is true and <br />accurate to the best of my knowledge. I further certify that I have in no way attempted to <br />mislead the City in this application by omitting facts known to me. 1 agree to cooperate with any <br />review conducted pursuant to the licensing procedures, including permission to enter and <br />inspect the place of business and facilities in conjunction with such review. I have read and <br />understand the regulations of the Massage Establishment and/or Therapist license found in the <br />City of South Bend Municipal Code, Section 4-35. <br />Signatur <br />4 <br />7) 2a— �; - <br />Date <br />