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Fm aN munkipal bus4iess linens¢ OYe4fYns, mman:C4r of South Bend' DEPanmenr of CommunaYlnrestment <br />2, Wert leMersPn BWd • Sune 24M S •SOYM Bentl.IW Wna 46601 • S]4135.5932 • F:5)/.2a59D21 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA (Continued) <br />N. Photographs: <br />(3)t <br />�p Company_ Address a0 <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. AFFIRMATION <br />I, hereby, certify and affirm that all of the information 1 have given in this application is true and <br />t I have <br />n no way <br />accurate to the bast of <br />is application <br />knowledge. <br />omitting facts certify <br />ant me. 1 agree t attempted to <br />cooperat with any <br />mislead the City in this app including permission to enter and <br />review conducted pursuant to the licensing procedures, <br />inspect the place of business and facilities in conjunction with such review. I have read and <br />understand the regulations ofthe Massage Establishment and/or Therapist license found in the <br />City of South Bend Municipal Code, Section 435. <br />Date <br />Signature <br />