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For all nr WI business license quest am, content: cry of South Bend• Department ofrummunity IIII ant <br />222 West Jefferson Blad • Sulte 14005 •South Bend, Indiana 46601 • 374.235.5912 • F: 5)Q235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />IV. PERSONAL DATA (Continued) <br />N. Photographs: <br />as 6 ition. <br />u. rleaae ,uL <II, prev,ouIn.........—__ L-, ,_airs pooroo u,c va,=.., .l.... mr..__tion: <br />Company Address City, State, ZIP Dates <br />146 /4/1gS'Vcr 26/2i y `r1e 16 O �� O s P�22 -7aZy <br />✓L4�E �PSA�sI-- .(iv h% �'IYsO.v .4e; 'm<t�+��iuic4!000V <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. INCLUDE A LIST OF ALL MASSAGE THERAPIST EMPLOYED BY ESTABLISHMENT <br />Vill. AFFIRMATION <br />I, hereby, certify and affirm that all ofthe 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 omittingfacts 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 certify that 1 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 />i J Z LP-�tiC� l/ 22 z o2 <br />�S Bra tore Date <br />4 <br />