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For all municipal business license quesdons, contact City at South Bend • Department ecummundy Investment <br />227 Westlefferson BIM • Suite 1400 S -South Bend, Indiana 45501. 570.235.5912 • F: 51A2M.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 435 <br />IV. PERSONAL DATA (Continued) <br />N. Photographs: _ <br />t ....... of thr A,+-.r er.im nnfirntinn <br />e e ua Ali tthe <br />( A <br />Company Address City, State, ZlP D tes <br />Miracle MGtSSA9ue �o' M�/li lw ubmn 0 0l611 <br />SU hweAnop. 50ah 1mle Wo 120 <br />SU om I � nit 46�rY i7 l013 <br />(Attach additional sheets if necessary) <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. INCLUDE A LIST OF ALL MASSAGE THERAPIST EMPLOYED BY ESTABLISHMENT <br />Vill. 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. 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 certify that 1 will not <br />allow massage therapy to be performed at this establishment by any person who does not <br />possess a current massage therapist license. I have read and understand the regulations of the <br />Massage Establishment and/or Therapist license found in the City of South Bend Municipal <br />Code, Section 4-35. <br />ray 0l�l��2al¢ <br />Signature Date <br />4 <br />