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For all munldpal buslness Ilcense quewons, contact: OW&South send • 0epartaneMMeommunitp Investment <br />222 Wastleeerson BIM • suite14005 -South Bend, Indlam "601 •574.25.5912 • F: 574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <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 City, State, ZIP g6L4_ Dates <br />L' FL floc <br />B., cF'4wo-rfL 3524 Mi3ha.ua4 Sa W4 Ra wj3N .Ta..ZY-Tri-I LS <br />$'e• CL[- ZSIZZSIZ C.1� 011,.54dout&a ZN 4/LSwu to 21-2-0 L2 <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 />VIL INCLUDE A LIST OF ALL MASSAGE THERAPIST EMPLOYED BY ESTABLISHMENT <br />Vill. INCLUDE A LIST OF SERVICES AVAILABLE AND THE COST OF SUCH SERVICES <br />IX. 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 />)jam LVIA 01 J912025" <br />C Signature Date <br />