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mmu <br />For all muncipal buslness license questions, nomad: cry of South Bend.cepartmentof co Aunty In021meod <br />32]N'aariaffemon BWI Sune 1Y005•Soutti Bend, n iana nd1 <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 Dates i) <br />(Attach additional sheets it necessary) <br />JV. INCLUDE WITH APPLICATION: <br />Three (3) passport photos taken within 6 months of application. <br />N/ VI. INCLUDE$5.00 PROCESSING FEE WITH APPLICATION <br />J VIL INCLUDE A LIST OF ALL MASSAGE THERAPIST EMPLOYED BY ESTABLISHMENT <br />JVill. 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 />accurateto 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 />/I td Z -Lrr'Z.S <br />1� Date <br />Signature <br />