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For all muniupal business license nuesnons, contactCity of5outh Bend • oepan mein ed Cammuney Investment <br />227 Wert Jefferson 61W • Suite 1400 S -South Bend, Indiana 461 •5]4.B5.5912 • F: 570.2 S 9 UI <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA(Continued) <br />N. Photoeraohse <br />Company Address City, State, ZIP Dates <br />! . — ,=v�w7 4 tea' — _ r <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 WITHAPPLICATION <br />VII. INCLUDE A UST OF ALL MASSAGE THERAPIST EMPLOYED BY ESTABLISHMENT <br />T4�';T+�Zftp— �30<% V_aun.t Nt� /SPp-t>AN, S,- ¢ kAA <br />Cm�CokJoiEv���or� <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 noway attempted to <br />mislead the City in this application by omitting facts known tome. 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 I 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 43S. <br />Signature Date <br />