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For all municipal business license questions, Comad: CRy N South Bend • Department of Community Imrestment <br />227 WestleferSon Blvd• Sulte 14005 South Bend, Irarer a 466011 574.235.5912•F: 5X235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-3S <br />IV. PERSnmAI n4TA frnninnodt <br />he <br />O. Please list all previous employment for three <br />\\\(3) years prior to the date of this application: <br />Company Address City, State, ZIP Dates <br />O JZ <br />G,m S G/u�2W �/. rx.K n ZN 3 <br />�had�Sllsheeessary) <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. INCLUDE A LIST OF ALL MASSAGE THERAPIST EMPLOYED BY ESTABLISHMENT <br />Vill. INCLUDE A LIST OF SERVICES AVAILABLE AND THE COST OF SUCH SERVICES <br />IX. 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 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 certifythat 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 of the <br />Massage Establishment and/or Therapist license found in the City of South Bend Municipal <br />Code, Section 4-35. <br />Signature Date <br />4 <br />