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<br /> <br />tervi{{e <br /> <br />'Esta6fisfu:d 1857 <br /> <br />CITY OF CENTERVlLLE <br /> <br />APPLICATION FORM FOR TATTOO, BODY PIERCING, <br />PERMANENT COSMETIC MAKE-UP, BODY BRANDING, AND <br />BODY PAINTING ESTABLISHMENT LICENSE <br /> <br />TRADE NAME <br /> <br />DATE OF APPLICATION <br /> <br />LICENSING PERIOD <br /> <br />FULL NAME OF APPLICANT <br />OWNER IF INDNIDUAL <br /> <br />PHONE NUMBER <br /> <br />< <br /> <br />ADDRESS <br /> <br />CITY <br /> <br />STATE <br /> <br />DATE OF BIRTH <br /> <br />PLACE OF BIRTH <br /> <br />ADDRESS OF BUSINESS <br />LOCATION <br /> <br />LIST OWNERS OF BUILDING OR PREMISE TO BE LICENSED: <br /> <br />NAMES <br /> <br />ADDRESSES <br /> <br />DATE OF BIRTH <br /> <br />MANAGER'S NAME <br /> <br />ADDRESS <br /> <br />PHONE <br /> <br />Page 10 of 12 <br />