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For all municipal business license questions, mMatt: City of South Bend • Department of Cemmunity Investment <br />227 West Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601. 574235.5912 • F. 51A235.9023 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />O. Please list all previous employment forth ree (3) years prior to the date ofthis application: <br />Company Address <br />VaLhIld (DIUC (401 Rvr <br />es3f�+� of I <br />(Attach additional sheets if necessary) <br />V. INCLUDE WITH APPLICATION <br />City, State, ZIP Dates <br />5,1rh�nd� y�vn �nfs-citrvcn-+ <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 />Vill. 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 ofthe <br />Massage Establishment and/or Therapist license found in the City of South Bend Municipal <br />Code, Section 4-35. <br />1pat PU �63lavlau� u <br />Sig ure Date <br />