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For alt muneipal business license Questions, tone tt: City of South Bend • Deparrrnent of community Investment <br />n7 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • S74235.5913 • F: S7A335.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />IV. PERSONAL DATA (Continued) <br />N. Photographs: <br />Company Address City, State, ZIP Dates <br />Ireland Park Dentshry 1902 E. Ireland Rd South Bend, IN, 46614 05/2020-present <br />Salvation Amy Khoo Carrier 900 W. Western Ave South Bend, IN, 46617 0112019-present <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 WITHAPPLICATION <br />VII. 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 furthercertify 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 />