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For all municipal business license questions, contact: City of South Bend • Department of Community Investment <br />227 west Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.735,5912 • F: 574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA (Continued) <br />N. Photographs: <br />Attach below (3) Passport photos, 1"x1", taken within 6 months of the date of this application. <br />O. Please list all previous employment for three (3) years prior to the date of this application: <br />Company Address City, State, ZIP <br />Aa1,P'G'yaY-��►5 <br />r C. r6_k .(e 6-S S to 1,476 <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 $5.00 PROCESSING FEE WITH APPLICATION <br />VII. AFFIRMATION <br />Dates <br />jt�Ja� E V 5--a$ <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 Date <br />4 <br />