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For all municipal business license que5vons, mntaM City of South Bend • Oepartmentnf Community Invertm0rt <br />227 West leRerson Blvd • Suite 140()S -South Bend, Ind lana 46e01 • 520.235.5912 • F: 574,235MI <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />IV. PERSONAL DATA (Continued) <br />Company Address City, State,"' Dates <br />kT Re p SPA 2y4 S Olive St 5ou0 Ben2L 41 L wxws <br />— 41uys <br />(Attach additional sheets if necessary) <br />V. INCLUDE WITH APPLICATION: <br />Three (3) passport size photos taken within 6 months of application. <br />VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION (7theraPjSt <br />VIL INCLUDE A LIST OF ALL MASSAGE THERAPIST EMPLOYED BY ESTABLISHMENT rjQr yal� 10r1 <br />Vill. INCLUDE A LIST OF SERVICES AVAILABLE AND THE COST OF SUCH SERVICES �II10 NA COYAG��. <br />IX. AFFIRMATION <br />1, 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 4-35. <br />yw i otiA� H J_ 7 7 n <br />Signature Date <br />n <br />