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For all muodpal business license questions, contact: City of South Bend • Departmental Cammunity Invertment <br />227 WeStJenerson Blvd • Suite 1400 S -South Bend, Indiana 46601 • 574.23i5912 • F: 514235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MLINI CI PAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA (Continued) <br />N. P <br />Atta 1", :ofth -. <br />tF <br />I ! <br />O. Please list all previous employment for three (3) years prior to the date of this application: <br />Company Address City, State, ZIP Dates <br />%W lPttt ot0 a?%q E.'l�tt6�wV6Y.t �t r%pIA1 t��14 _D42DUllli <br />mtr Ltnkr SB 9(D6u.W4siun he Ill Walebi 61 1CM111 -vall <br />1tthyd ?mV (knhalf� 1a6, E.Ir l.hd s6 wy�p�l ) ab SU3F <br />(Attach additional sheets if necessary) 12G <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 />VIL INCLUDE A LIST OF ALL MASSAGE THERAPIST EMPLOYED BY ESTABLISHMENT <br />90" WWdS <br />Vill. 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 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 certify that I 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 />azolil '% 42) ca Ja.3/ay <br />17 Signature Date <br />4 <br />