Fillable MASSAGE ESTABLISHMENT PERMIT (City of Riverside, California)

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MASSAGE ESTABLISHMENT PERMIT (City of Riverside, California)

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BROWSE CITY OF RIVERSIDE, CALIFORNIA (CA) FORMS

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Submit items 1 - 5 along with completed application.
Application processing may take up to 90 days.)
Once application approved, the Massage Establishment Permit will be issued.
The permit will be valid for one (1) year from issue date listed on permit.
5. Apply and obtain a Business Tax License.
The Business Tax Office is located at 3900 Main Street, Riverside, CA 92522.
For tax information or for electronic filing visit: www.riversideca.gov/finance/license.asp
1. Pre-Application Zoning Approval
2. Acknowledgement of Property Owner (Notary Requirement)
3. Copy of Lease Agreement
4.
Original State Certificate and ID issued by California Massage Therapy Council (CAMTC). As
applicable,copies
will be made.
The following steps must be completed in order to obtain a Massage Permit within the city of Riverside.
The city of Riverside Municipal Code 5.52.040 has the following massage establishment permit
requirements.
B. Any person desiring a massage establishment permit shall file, under penalty of perjury,
a written application on forms provided by and submitted to the Chief of Police
accompanied by a non-refundable application fee in such amounts established by
resolution of the City Council.
A. No person shall own, operate, or manage any massage establishment in any location
within the
City without first having obtained a massage establishment permit.
FEES: (Credit/Debit card or Cash/Check/Money Order Payable to City of Riverside)
$919 Massage Establishment Permit Fee (New business/Change of Ownership)
$32 Department of Justice Livescan Fee
$584 Massage Establishment Permit Annual Renewal Fee
Massage Establishment Permits must be renewed every year. There is no grace period for permit
renewals.
For further questions contact the Special Investigations Division - Vice Unit at (951) 353-7206 or
e-mail RPDVice@RiversideCa.gov
Permit renewal applications must be received prior to expiration of your existing permit or you will
have to reapply and pay the full permit fee of $919, plus the Livescan fee of $32.
Complete applications will be accepted by appointment only (walk-ins will not be seen).
Appointments are available Tuesday through Thursday from 8:00 AM to 4:30 PM. To schedule an
appointment contact Riverside Permits at (951) 353-7614. Appointments will be seen at the Riverside
Police Department - Orange Station, located at 4102 Orange Street, Riverside, CA 92501.
RIVERSIDE POLICE DEPARTMENT
MASSAGE ESTABLISHMENT PERMIT
GENERAL INFORMATION
Pre-Application Zoning Approval
Applicant Name:
Type of Business:
License/Permit Type:
Proposed Business Site:
City Planning Approval: Zoning Approved
Zoning Not Approved
City of Riverside Planning Approver:
Staff Name: __________________________________________
Title: __________________________________________
Telephone: _______________________________________
The undersigned acknowledges and understands that the approval set forth on this form in no way
represents that the business proposed to be conducted on the site listed above, complies with
applicable zoning laws, planning requirements or use permits, and that additional conditions may
need to be met prior to conducting business on the site.
Contact the Planning Department directly prior to beginning your business.
__________________________________________
(Applicant Signature)
__________________________________________
(Print or Type Name)
Page 1 MPA_5.52_RPD-Vice 1/2020
Massage Permit Application
What are you applying for? Massage Establishment Permit
Renewal Massage Establishment Permit
1. Do you understand the questions in this Massage Application?
Yes
No
Applicant's Name:
Applicant's Signature Date
Please Complete This Section First
a. Do you need a translator or interpreter to understand the questions within this Massage
Application?
Yes No
If "Yes," please list language and dialect:
Language: Dialect:
b. Has the translator assisted you in understanding the questions within this application?
NoYes
Translator/Interpreter Name (Print)
Translator/Interpreter Signature Date
Relationship to Applicant
Applicant's Name (Print)
Applicant's Signature Date
Page 2 MPA_5.52_RPD-Vice 1/2020
2. Translator or Interpreter Acknowledgement:
(Last)
3. Applicant's Name
(First)
(Middle)
4. List any and all names, nicknames or aliases you have used in the past:
(Street Address)
5. Home Address:
(State)
(Zip)
(City)
Home Telephone Number:
Cell Phone Number:
6. List all the places you have lived for the past 5 years:
Dates Street Address City State
7. Mailing address (if different from Home Address):
(Zip)
(State)
(City)
(Street Address)
8. E-mail Address:
9. Driver's License or Identification Number:
State of Issuance:
10. Other Identification:
Number:
11. Social Security Number:
12. Place of Birth:
Date of Birth:
Page 3 MPA_5.52_RPD-Vice 1/2020
13. Applicant Physical Description:
Sex
Height
Weight
Hair Color Eye Color
Nationality
Scars, Tattoos or Identifying marks:
(Business Name)
14. Current Employment:
(Zip)
(State)
(City)
(Street Address)
Business Telephone Number:
15. HOURS OF OPERATION
Hours Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Open
Close
16. Employment History for the past 5 years:
Dates Employer Address Telephone # Reason for Leaving
Page 4 MPA_5.52_RPD-Vice 1/2020
17. All name(s) under which you will advertise and/or conduct your business:
(Zip)
(State)
(City)
18. Address where you will conduct business:
19. (For Massage Establishment Permits Only) I understand that I must attach a signed and
notarized Acknowledgment of Property Owner form at the time of the initial application and all
location changes.
Applicant's Initials ______________
20. Have you held any similar licenses, permits or certificates in the last five years?
If "Yes," please list:
NoYes
Type Date Issued Date Expired Issuing Agency
21. a. Have you had any application for a similar license, permit or certificate denied?
NoYes
If "Yes," explain:
b. Have you had any similar license, permit or certificate issued to you revoked?
If "Yes," explain:
NoYes
If "Yes," explain:
NoYes
c. Have you had any similar license, permit or certificate issued to you suspended?
Page 5 MPA_5.52_RPD-Vice 1/2020
(Street Address)
NoYes
22. Have you ever been arrested or given a citation for violating any law related to massage or a
similar practice?
If "Yes," list dates and locations, and explain:
If "Yes," list dates and locations, and explain:
Yes No
23.
To your knowledge, have any business partners, employees, or persons working at your
establishment ever been arrested or given a citation for violating any law related to massage therapy?
If "Yes," list dates and locations, and explain:
NoYes
24.
To your knowledge, have any business partners, employees, or persons working at your establishment
ever been arrested or given a citation for violating any law related to a similar non-massage practice?
(example: spa, chiropractic, acupuncture, etc)
If "Yes," list dates and locations, and and names under which the practice or
business was conducted:
NoYes
25. Have you ever worked at a similar business that did not require a license? (example: spa,
chiropractic, acupuncture, etc)
NoYes
26. In the past 10 years, have you been arrested or convicted of a crime?
If "Yes," provide the following:
Offense
Date of
Arrest/Conviction Location Parole or Probation?
Page 6 MPA_5.52_RPD-Vice 1/2020
27. List any and all persons, associations, partnerships, or corporations holding an interest or
involvement in the practice for which you are applying:
Name Title Address Phone Number
NoYes
28. Have you read and understand Riverside Municipal Code Chapter 5.52, which applies to massage
therapist and massage businesses?
Applicant's Initials _________
Riverside Police Department shall complete an investigation of the qualifications and moral
character of the applicant and either grant or deny the permit within ninety (90) days after the
submission of the completed application; provided, however, if good cause exists, the
Riverside Police Department may extend the period of investigation for an additional thirty (30)
days, provided the applicant is mailed notification or verbally notified that the investigation
has not been completed.
1. I have read the provisions of Chapter 5.52 of the Riverside Municipal Code governing
the practice of Massage.
2. I understand that I am required to comply with all laws related to massage therapy and
massage businesses. If this application is approved, I agree to abide by applicable
laws and ordinances.
3. I understand that I must apply for renewal of my permit or certificate before it expires. I
also understand that if I do not apply for my renewal before the expiration date, I will be
required to re-apply and pay all application fees.
4. I have read this entire application and all of the answers provided above. I understand
that any material misrepresentation or omission, intentional or not, may result in the
denial of this application or revocation of any license, permit or certificate issued
pursuant to this application.
5.
I hereby declare that I am authorized to submit this application on behalf of the entity or
individual listed on the application because I am an owner of the entity, I have authority
from the owner or am the owner.
6. I acknowledge that any false, misleading, or fraudulent statement of material fact in
this application by an
agent of an owner, or an owner, will be held against the owner
and is grounds for denial of this application,
or suspension or revocation of the permit
associated with this application.
Page 7 MPA_5.52_RPD-Vice 1/2020
Initials: ____
Initials:_____
Initials: ____
Initials: ____
Initials: ____
Initials: ____
7. I hereby declare that I have read and understand all the laws, rules and regulations,
and policies and procedures associated with this application; and that I fully
understand the nature, meaning, and content of such laws, rules, and policies. I
warrant and represent that I will adhere to all laws, rules, and policies, during the
application process and after a permit is issued by the City.
8. I hereby declare that I have conducted my own research and investigation regarding
the compliance of the proposed location with state and local laws, including, but not
limited to, location requirements, zoning regulations, and address requirements. I
further declare that the proposed location of the Massage Permit fully complies with
applicable state and local law.
9. I acknowledge that any promise, representation, or any other statement made to me
by any agent or employee of the City that is not contained within this application is
null, void, and unenforceable and that I am not relying on any such promise,
representation, or statement.
10. I acknowledge the City will review this application for compliance with applicable laws,
regulations, and ordinances, and that this application may be denied as allowed by
laws, rule, or policies of the City.
11. I acknowledge that this application does not confer an entitlement or a vested right to
receive a permit, and I acknowledge that I must follow all rules and procedures to
obtain a permit prior to operating or otherwise claiming that I have any such right to a
permit or to operate.
12. I hereby declare that I have read this acknowledgement and advisement, that I have
had the opportunity
to consult with, and be represented by, legal counsel of my own
choice prior to the execution and submission of this application, and that I am knowingly
and voluntarily submitting this application in compliance with this acknowledgement
and advisement and all applicable laws.
13. I acknowledge that I am jointly and severally liable for any and all taxes, fees, and
charges associated with the permit.
14. I consent for the City of Riverside, by and through its appropriate officers, agents, and
employees to verify and confirm the information contained in this application, and to
conduct such other investigations as may be reasonably required by the City of
Riverside, its officers, agents, and employees for the purpose of determining the
capability, fitness, and capacity of the applicant to obtain a Massage Establishment
Permit.
15. Whenever there is a change in information that was required to be submitted in the
application. Such notification shall be in writing to the Riverside Police Department
within ten (10) business days of the change.
I declare under penalty of perjury under the laws of the State of California
that the foregoing is true and correct.
Initials: ____
Initials: ____
Initials: ____
Initials: ____
Initials: ____
Initials: ____
Initials: ____
Initials: ____
Initials: ____
Applicant's Signature Date
Print Name
Page 8 MPA_5.52_RPD-Vice 1/2020
PROPERTY OWNER CONSENT AND AUTHORIZATION
OF MASSAGE ACTIVITIES
I, , declare under penalty of perjury that
1. I am the Property Owner of record, or the duly authorized representative of the Property
Owner, for the real Property located at (“the
Property”)
2. The Property Owner acknowledges and consents to the business, ,
, conducting the proposed
massage activities at the Property.
3. No person shall engage in any massage activities on the proposed Property without all
licenses and permits required by the Riverside Municipal Code (RMC) while a massage
application is pending.
4. The City of Riverside may enter the property to conduct inspections of the Property during the
application process in order to thoroughly investigate whether a massage permit should be
granted.
5. I have read, understand,and will ensure compliance with the terms in RMC Section 5.52
(Massage), as applicable. I further understand that as the legal owner of the property, I am
responsible for any violation and nuisance activity which may occur at the above-mentioned
property.
I certify
under penalty of perjury under the laws of the State of California that the foregoing is
true and correct.
*This authorization form will not be valid without notarization. The authorization form automatically expires
upon sale or transfer of the property to a new legal owner. If sale or transfer of the property occurs prior to the
applicant obtaining a massage permit, the applicant must resubmit this notarized form with approval of the
new legal owner of the property.
(Date)
(Printed Name & Title)
(Authorized Representative Business Name)
Page 9 MPA_5.52_RPD-Vice 1/2020
(Name of Property Owner/Authorized Representative)
(Address)
(Business Name)
Tenant Applicant Name (Corporation/LLC/Partnership/Sole Owner)
(Signature of legal owner/owner representative)
(Authorized Representative Business Address)
(Business Telephone)
Riverside Police Department
PERMIT APPLICATION
NOTARY ACKNOWLEDGMENT
CALIFORNIA ACKNOWLEDGMENT CIVIL CODE § 1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
)State of California
County of ______________________________
On _________________________ before me, _____________________________________________,
Date Here Insert Name and Title of the Officer
personally appeared __________________________________________________________________
Name(s) of Signer(s)
__________________________________________________________________________________,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/
her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the
laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature _________________________________
Place Notary Seal and/or Stamp Above
Signature of Notary Public
)
Page 10 MPA_5.52_RPD-Vice 1/2020
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MASSAGE ESTABLISHMENT PERMIT (City of Riverside, California)

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Completed 25 February 2021

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