New Massage Establishment - A Healing Oasis

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For all munlcipaf business license questions, corrtact- City of South Send • Dopartincrrt of Community Investmenr 227 West Jefferson Bird + Surte 1400 5 -South Bend, Indiana 46601 • 574.235,5912 • F: 574.235,9021 LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT MUNICIPAL CODE SECTIDN - 4-35 IV_ PFRSONAI DATA iContinuedl 0, Please list all previous employment for three (3) years prior to the date of this application: Company 1st Source Bank Address City, State, ZIP Dates 100 N. Michigan St. South Bend, IN 46614 1995 - 2024 (Attach additional sheets if necessary) V. INCLUDE WITH APPLICATION: Three (3) passport photos taken within 5 months of application. VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION VII. INCLUDE A LIST OF ALL MASSAGE THERAPIST EMPLOYED BY ESTABLISHMENT None at this time Vill. INCLUDE A LIST OF SERVICES AVAILABLE AND THE COST OF SUCH SERVICES IX. AFFIRMATION I, hereby, certify and affirm that all of the information I have given in this application is true and accurate to the best of my knowledge. I further certify that I have in no way attempted to mislead the City in this application by omitting facts known to me. I agree to cooperate with any review conducted pursuant to the licensing procedures, including permission to enter and inspect the place of business and facilities in conjunction with such review. I certify that I will not allow massage therapy to be performed at this establishment by any person who does not possess a current massage therapist license. I have read and understand the regulations of the Massage Establishment and/or Therapist license found in the City of South Bend Municipal Code, Section 4.35. &&,-A Jn, 4` JUd�� Signature Date SERVICES: yoga, reiki,card readings, breathwork, holistic wellness, crystal healing, essential oils, sound healing, energy balance healing art, and soon to come massage therapy.