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For all municipal business license 9uesflpns, wmaa: aty of South Bend • Department of Communlry Inve4ment <br />227 Wert Jefferson Blvd • Suite 1400 S •Soudr Bend, Indiana 46601 1574.235.5912 • F: 57U35.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA (Continued) <br />Company Address <br />King Asian massage 914 5 Ironwood <br />Koto 4240 Main <br />(Attach additlonal sheets ff necessary) <br />hs <br />r to the date of this application: <br />City, State, ZIP Dates <br />South Bend IN 7/22 to current <br />Mishawaka <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 />Vd. 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 have read and <br />understand the regulations of the Massage Establishment and/or Therapist license found in the <br />City of South Bend Municipal Code, Section 4-35. <br />Signature <br />13 <br />MAR 10 2025 <br />Date <br />