Fillable LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT MUNICIPAL CODE (City of South Bend)

Fill Online, Printable, Fillable, Blank LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT MUNICIPAL CODE (City of South Bend) Form

Use Fill to complete blank online CITY OF SOUTH BEND (IN) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT MUNICIPAL CODE (City of South Bend)

On average this form takes 35 minutes to complete

The LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT MUNICIPAL CODE (City of South Bend) form is 7 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 136 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of South Bend

BROWSE CITY OF SOUTH BEND (IN) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
DEFINITION:
Massage Establishment means any business located in a building, room, place or establishment,
utilized for the practice of massage therapy, other than a recognized school of massage therapy
or an Indiana State Department of Health licensed medical facility.
Massage establishments include any establishments having a fixed place of business where any
person engages in, conducts, carries on, or permits to be engaged in, conducted or carried on,
massages or baths.
Massage Therapy means the manipulation of the superficial and deep layers of the muscle and
connective tissue using various techniques, to enhance function, aid in the healing process, or
promote relaxation and well-being with the hand, fingers, elbows, knees, feet and legs.
Massage involves working and acting upon the body with pressure through structured and
unstructured, stationary, or moving tension, motion, or vibration, performed manually or with
mechanical aids. Target tissues may include muscles, tendons, ligaments, fascia, skin, joints, or
other connective tissue, as well as lymphatic vessels, organs or the gastrointestinal system.
Target tissue specifically excludes the genitals or female breasts.
IF DESCRIPTION DOES NOT APPLY, SEE:
Massage Therapist (Ord. §4-35)
GENERAL INSTRUCTIONS:
1. Print legibly and complete all sections to ensure efficient processing.
2. Assemble all required information and materials before filing application.
3. Thoroughly review all applicable Municipal Code Sections listed above.
4. Licenses expire on the last day of February.
5. Add 10% to license fee for renewal after February 28.
6. Include $5.00 license application fee payable to City of South Bend.
7. License fee payable to City of South Bend due at issuance - $200.00
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
REQUIRED INFORMATION AND MATERIALS:
1. Business form (corporate, partnership, etc.) and ownership information.
2. Proposed business location (including zoning), and description of nature and scope.
3. (3) Passport photos, 1"x1", taken within 6 months.
4. Licensure and employment history for previous (3) years.
5. Applicant addresses for previous (3) years.
6. List of non-traffic criminal convictions.
APPLICATION PROCESS:
1. Review Municipal Code Section 4-35 thoroughly.
2. Submit Application with $5.00 Processing Fee.
3. Review and recommendations by appropriate city offices to Board of Public Safety.
4. Health Department inspections as required.
5. Public hearing, per Municipal Code Section 4-35
6. Within thirty (30) days of receipt of the application and after proper publication and receipt
of the aforesaid recommendations, the Board of Public Works shall conduct a public hearing
and shall instruct the City Controller to issue a license to operate a massage establishment if
it is found that:
a. The application reasonably conforms to the provision of this section.
b. The applicant has not knowingly made a material misrepresentation in the application
for a license.
c. The applicant has reasonably cooperated in the review of his application.
d. The massage establishment as proposed by the applicant would comply with all
applicable laws, including but not limited to the City’s building, zoning, health, fire and
safety regulations.
e. The applicant if an individual, or any of the stockholders of the corporation, any officers
or directors, if the applicant is a corporation, or any of the partners, including limited
partners, if the applicant is a partnership, have not been convicted of any crime
involving deviate conduct, deviate sexual conduct, or unlawful sexual conduct, as
defined in Title 35 of the Indiana Code, within three (3) years prior to the date of
application.
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
APPLICATION PROCESS (Continued):
f. The applicant has not had a massage establishment license or a massage technician
permit or other similar license or permit denied or revoked for cause by this City or by
any other city in this or any other state within three (3) years of the date of application.
g. The applicant, if an individual, or any of the officers and directors, if the applicant is a
corporation, or any of the partners, including limited partners, of the applicant is a
partnership, is eighteen (18) years of age.
h. The applicant, if a corporation, is licensed to do business and is in good standing in the
State of Indiana.
i. The massage establishment as proposed by the applicant would comply with the
requirements of this Article (Municipal Code Section 4-35).
7. License issued on payment of fee.
8. Permit holder may do business with properly displayed License, and in compliance with §4-
35, including Building Department, Fire Department, and Health Department inspections as
required.
1
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
I. APPLICATION TYPE Check One: New Renewal
II. BUSINESS DATA
A. Business Name:
B. Business Address:
City: State: Zip:
C. Mailing Address (If different from above):
City: State: Zip:
D. Business Telephone Number:
E. Business Fax Number:
F. E-Mail Address:
G. Zoning of Business Location:
H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked
by any governing municipality within three (3) years prior to the date of this application:
YES NO
1. If yes, what was the reason:
2. If yes, what was the business occupation following the suspension/revocation:
I. Describe the nature and scope of the business:
For Office Use Only
Application Filed Public Safety Approval
Application Fee Paid License Fee Paid
Sent to Dept. License Number
Not Approved
Reason
2
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
III. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship (If sole proprietorship, proceed to 1).
Partnership (If partnership, proceed to 2).
Corporation (If corporation, proceed to 3).
1. Sole Proprietor
Name:
Residential Address:
City: State: Zip:
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City: State: Zip:
Name #2:
Residential Address:
City: State: Zip:
3. Corporation
Legal name of corporation:
Date and state of incorporation:
List officers and directors who own 15% or more of stock:
Name #1:
Title:
Business Address:
City: State: Zip:
Residential Address:
City: State: Zip:
Name #2:
Title:
Business Address:
City: State: Zip:
Residential Address:
City: State: Zip:
3
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
III. OWNERSHIP (Continued)
3. Corporation (Continued)
Name #3:
Title:
Business Address:
City: State: Zip:
Residential Address:
City: State: Zip:
IV. PERSONAL DATA
A. Applicant's Legal Name:
B. Residential Address:
City: State: Zip:
C. Residential Telephone Number:
D. Residential Fax Number:
E. Cellphone Number:
F. E-Mail Address:
G. Position with business:
H. Please list all criminal convictions (if any), excluding traffic violations:
Nature of Conviction City State Date
(Attach additional sheets if necessary)
I. Please list all addresses for three (3) years prior to application date:
Street Address City State Dates
(Attach additional sheets if necessary)
J. Date of birth:
K. Gender:
L. Social Security Number:
M. Race:
4
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
IV. PERSONAL DATA (Continued)
N. Photographs:
Attach below (3) Passport photos, 1"x1", taken within 6 months of the date of this application.
O. Please list all previous employment for three (3) years prior to the date of this application:
Company Address City, State, ZIP Dates
(Attach additional sheets if necessary)
V. INCLUDE WITH APPLICATION:
Three (3) passport photos taken within 6 months of application.
VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
VII. 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 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.
Signature Date
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT MUNICIPAL CODE (City of South Bend)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document