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_ JpSbony mttti6; pN I south Bend• nepaltmentot CAmmunlN5.9021 eiR <br />For allmunklpal business Bl "S541t 1aW S•5outh Bend, Intllana 46601.514.135.5911•F.9A195.9021 <br />lttweidIeHers(n ere•pe MASSAGE ESTABLISHMENT <br />LICENSE XppLLICAATI PALORDE SECTION - 4-35 <br />N. PERSONAL DATA (Conrinued) <br />N_Phninorsnki <br />/ (/d <br />1 I I ( <br />d to <br />I tlln apPlRClrVrl. .n <br />,ee P! Ye > P o lu a Dates <br />Crty, state Address OM any aI4�,.�I'��t,//i <br />(Attach additional sheeu rf necessary) <br />lication. <br />V. INCLUDE WITH APPLICATION: <br />hotostaken within 6 months of apP <br />Three (3) Passport P <br />APPLICATION <br />Vt. <br />I INCL UDESS.00 PROCESSING AGE HER PIST EMPLOYED By ESTADLISHii <br />VIL INCLUDE P.LIST OF ALL MASS <br />VIII INCLUDE A LIST OF SERVICES AVAILABLE AND THE COST OF SUCH SERVICES <br />IX. AFFIRMATION <br />iven In this application is true and <br />that all of the information 1 have g <br />e I further ce ttly that l have in no way attemptedto <br />1, hereby, certify and affirm known to me. I agree to cooperate with any <br />accurate to the hest of my kn abed"Ie b <br />hcaiipn 6yomittingfacis including permission to enter and <br />mislead the Clty Inths als Procedures, <br />review conducted pursuant to the IicensmB P an person who does not <br />inspect the Plate of business and umed ai this <br />establishment by h Y revlew. 1 certify that I will no <br />6 the regulations <br />theraPY to be P <br />sage th rst gclst e. have read <br />d allow massage in the City Of outh Rend Mn cipalt e <br />currentm <br />possess Establishmen <br />Cot and/orTherap <br />dIli I)4 <br />Codee Sr eRbn4-35. <br />Date <br />�Y1 n <br />Signature 4 <br />