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I municipal business license questions, contact: City of South Bend • Department of Community Investment <br />227 West Jefferson Blvd • Suite 14005 -South Bend, Indiana 46601. 574.235.5912 • P. 574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAUDATA (Continued) <br />t pf <br />of <br />O. Please list all previous employment for three (3) years prior to the date of this application: <br />Company • , Address <br />City, State, ZIP Dates <br />—f6P o2rf�.Er�M�4ssa6�M?t Nu�o/ty, svvr+�>3�a�,��1.w�rS _ <br />P2 Zoo-- S' 2D4(S' <br />(Attach additional sheets It 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. 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 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 />i <br />Zi9 i % <br />Signature Date <br />10 <br />