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

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

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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 THERAPIST
MUNICIPAL CODE SECTION - 4-35
DEFINITION:
Massage Therapist means an individual who practices massage therapy.
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, or organs or the gastrointestinal system.
Target tissue specifically excludes the genitals or female breasts.
IF DESCRIPTION DOES NOT APPLY, SEE:
Massage Establishment (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. Add 10% to license fee for renewal after February 28.
5. Include $5.00 license application fee payable to City of South Bend.
6. License fee payable to City of South Bend due at issuance - $75.00.
REQUIRED INFORMATION AND MATERIALS:
1. Copy of driver’s license or government issued identification.
2. Copy of Indiana State Board of Massage Therapy Certificate.
3. Copy of diploma or certificate of graduation from a recognized school, if any.
4. The massage establishment, if any, at which the applicant is or expects to be employed.
5. (3) Passport photos, 1"x1", taken within 6 months.
6. Other information as required to determine diploma/certificate validity.
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 THERAPIST
MUNICIPAL CODE SECTION - 4-35
REQUIRED INFORMATION AND MATERIALS (Continued):
7. Addresses and employment history for previous (3) years.
8. List of non-traffic criminal convictions.
9. If the Indiana State Board of Massage Therapy ceases to require background checks for
applicants or validate the massage therapy school which provided training to the applicant,
see alternate requirements in Ord. §4-35.
APPLICATION PROCESS:
1. Review Municipal Code Section 4-35 thoroughly.
2. Submit Application with $5.00 Processing Fee.
3. Within thirty (30) days of receipt of the application and aforesaid recommendations, the
City Controller shall issue a massage license 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 investigation of his application.
d. The applicant has not, within three (3) years immediately preceding the date of
applications, been convicted of the crimes of unlawful deviate conduct, deviate sexual
conduct or unlawful sexual conduct as defined in Title 35 of the Indiana Code.
e. The applicant has furnished an acceptable diploma or certificate of graduation from a
Recognized School or, in lieu thereof, has demonstrated competence and proficiency to
the satisfaction of the City Controller pursuant to the requirements of this Section.
f. The applicant has not previously had a massage therapist license or a similar license
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 is eighteen (18) years of age.
4. License issued on payment of fee.
5. Permit holder may do business with properly displayed License, and in compliance with
§4-35.
6. If a license is denied, the applicant may appeal to the Legal Department for a hearing
pursuant to Section 4-16 of this Chapter.
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 THERAPIST
MUNICIPAL CODE SECTION - 4-35
I. APPLICATION TYPE Check One: New Renewal
II. 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. Please list all residential addresses for three (3) years immediately prior to application date:
Street Address City State Dates
(Attach additional sheets if necessary)
H. Date of birth:
I. Gender:
J. Social Security Number:
K. Race:
For Office Use Only
Application Filed Health Dept. Approval
Application Fee Paid Police Dept. Approval
Sent to Dept. License Fee Paid
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 THERAPIST
MUNICIPAL CODE SECTION - 4-35
II. PERSONAL DATA (Continued)
L. Photographs:
Attach below (3) Passport photos, 1"x1", taken within 6 months of the date of this application.
M. Please list all criminal convictions including ordinance violations (if any), excluding traffic
violations:
Nature of Conviction City State Date
(Attach additional sheets if necessary)
N. 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)
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 THERAPIST
MUNICIPAL CODE SECTION - 4-35
III. BUSINESS DATA
A. Do you intend to be employed with a Massage Establishment: Yes No
If yes, name and address of establishment:
B. Have you ever had a Massage Therapist 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:
IV. INCLUDE WITH APPLICATION:
• Copy of driver’s license or government issued identification.
• Copy of Indiana State Board of Massage Therapy Certificate.
• A diploma or certificate of graduation from a recognized school of massage.
• Three (3) passport photos taken within 6 months of application.
• St. Joseph County Massage Therapist Permit
V. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
VI. 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 the
City in the investigation of this application. 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.
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LICENSE APPLICATION FOR - MASSAGE THERAPIST MUNICIPAL CODE (City of South Bend)

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Completed 16 July 2020

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