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For all munid pal business Ilcense 9uertlons, contact: City of South Bend • oepartment of Community Investment <br />227 West.aelferson BIW • Suite 1400 $ •South Bend, Indiana 464301 •94.Zi5.5912 • F'. 57&235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />IV. PERSONAL DATA (Continued) <br />N. Photographs: <br />`-'---"1 Pass - "" "" "" north of the date of this application. <br />A <br />Company Address - C <br />1A e �osw I o�T <br />(Attach additional sheets ifnecessary) <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 certifythat I have in no way attempted to <br />mislead the City in this application by omitting facts known to me. I 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 />due �r zlC. /i0�>_3 <br />Soo ure Date <br />4 <br />