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For all municipal business license questions, contact Cily of south Bend • Department of Community investment <br />227We4l rson Blvd • Suite 14W S 150uth Bend, Indiana 46601 '574'235.5912 • F:52a.135.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA (Continued) <br />or <br />no <br />ion. <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 />p� <br />Prphoyice .\'\h 7bk Palrrs.av /pnm,}Ed fa.ksLad4 cA 94ok) rn�ygY_� n�. <br />Vitl.inwn idmi1y DwM 39IS Pa.kil Am 59t IA1 10"I of 12022-2961ilyxy <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 />5 ptniq VAoDf2 <br />U <br />VII. AFFIRMATION �MA cvA <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 have read and <br />understand the regulations of the Massage Establishment and/or Therapist license found in the <br />City of South Bend Municipal Code, Section 4-35. <br />_ II3glaoas <br />Signature Date <br />