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For all munidpal busmen license quill ions,mound: City of south Send• Department of Community hrvestrnem <br />227 WertleRerson BIW • Suite 340*5 -South Bend, Indiana M601 • 526235.5912 • F: M235 9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA (Continued) <br />tian. <br />^I. <br />J <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 />��eca\ae.Atic eiG+)o�z s; Sb.liV3 rle\� ZG13-CwtP <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. INCLUDE A LIST OF SERVICES AVAILABLE AND THE COST OF SUCH SERVICES <br />DL 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 noway attempted to <br />mislead the City in this application by omitting facts known tome. 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 />CodIF VHiiiiii <br />�--� Signature Date <br />4 <br />