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for all mun cquil business license questions, [nntact Ciry of South Bend • Departmentol Cammunity Investment <br />227 West Jefferson Blyd • Suite 1400 S -South Bend, Indiana 46601 •574.235.59U • F. 574.2359@3 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA (Continued) <br />0. Please list all previous employment forth ree (3) years prior to the date of this application: <br />Company Address City, State, ZIP Dates <br />Kota 4240 Main St. Mishawaka IN 46545 <br />King Sedan massage 914 s Ironwood dr. South Bend In 46616 712022 current <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 I have given in this application is true and <br />aaurate 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. 1 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 />4 <br />2/19/2024 <br />Date <br />