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For all municipal thinness Ilcense questions, contact: City of South Bend • Departmentof Community Investment <br />227 West Jefferson Blvd • Suite 14M S -South Bend, Indiana 46601 •574.235.5912 • F: 570.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />IV. PER <br />♦r <br />it <br />0. Please list all previous employment for three (3) years prior to the date of this application: <br />Company Address(14 L toQ1 City, State, ZIP Dates <br />I— )U C)AIIId n C401 SQ LLIW4 <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 />VI I. 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 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 Est lishmentand/or Therapist license found in the City of South Bend Municipal <br />QOde, Sect n -35. <br />ulfV Y J�0 �� <br />�Ig Fdture Date <br />4 <br />