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For all municipal business license quesdom, coma¢: City of South Bend • 0epartmemof communlN Investment <br />227 Wertlefferson Bivd • Suite 34m S -South Bend, Income 45501 • 574.235.5912 • F. 574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -435 <br />IV. PERSONAL DATA (Continued) <br />O. Please list all previous employment for three (3) years prior to the date of this application: <br />Company Address <br />Dates <br />N <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. INCLUDE A LIST OF ALL MASSAGE THERAPIST EMPLOYED BY ESTABLISHMENT <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 certifythat 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 certifythat 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 ofthe <br />Massage Establishment and/or Therapist license found in the City of South Bend Municipal <br />Code, Section 435. <br />Doc <br />Sign Lure Date <br />n <br />