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For all municipal business license questions, contact CM of South Send • Department of community Investment <br />227 West Jefferson Blvd • Suite 1400 s •South Bend, Indiana 46601 •574235.5912 • F: 574.235.9031 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION — 4-35 <br />IV. PERSONAL DATA (Continued) <br />0. Please list all previous employment for three (3) years prior to the date of this application: <br />_gig,of <br />1i&GT2_ DON <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 WITHAPPLICATION <br />VII. AFFIRMATION <br />(,hereby, certify and affirm that all of the! nformation 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 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 />U u SS%nature `j Date <br />