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4 <br />For all municipal business license questions, contact: City of South Bend • Department of Community Investment <br />227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV.PERSONAL DATA (Continued) <br />N. Photographs: <br />Attach below (3) Passport photos, 1"x1", taken within 6 months of the date of this application. <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 />(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 />VIII.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 />Signature Date