Massage Establishment License

License Application for - Massage Establishment

MUNICIPAL CODE SECTION – 4-35
South Bend 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. Assemble all required information and materials before filing application.
2. Thoroughly review all applicable Municipal Code Sections listed above.
3. Licenses expire on the last day of February.
4. Add 10% to license fee for renewal after February 28.
5. Include $5.00 license application fee payable to City of South Bend. You may pay this in-person at City Hall, or call the Business Licensing Manager at 574-235-5912 to pay over the phone.
6. License fee payable to City of South Bend due at issuance - $200.00
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.
7. List of massage therapists employed by said establishment
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:
  1. The application reasonably conforms to the provision of this section.
  2. The applicant has not knowingly made a material misrepresentation in the application for a license.
  3. The applicant has reasonably cooperated in the review of his application.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. The applicant, if a corporation, is licensed to do business and is in good standing in the State of Indiana.
  9. 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.

Application Type
Is this application pertaining to a new business or are you renewing your existing permit?*

New PermitRenew Permit
Business Data
Business Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does Mailing address differ from Property Address?*

Yes, different addressNo, Same address
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Business Email Address*
example@example.com
Zoning of Business Location
To find your business location's zoning type, use the South Bend Zoning Map.
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?

YesNo
if yes, what was the reason?
If yes, what was the business occupation following the suspension/revocation?
Describe the nature and scope of the business
List all Massage Therapists employed by this establishment
Attach list of services available and the cost of such services

Cancelof
Ownership
Type of ownership

Sole ProprietorshipPartnershipCorporation
Owner's Legal Name*

First NameMiddle NameLast Name
Owner's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Partner 1's Legal Name*

First NameMiddle NameLast Name
Partner 1's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Partner 2's Legal Name*

First NameMiddle NameLast Name
Partner 2's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Name of Corporation
State of Corporation
Date of Corporation

MonthDayYear
List officers and directors who own 15% or more stock. Include name, title, business address, and residential address.
Personal Data
Applicant's Legal Name*

First NameMiddle NameLast Name
Applicant's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant's Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant's Email*
example@example.com
Applicant's Position with Business

Please list all criminal convictions (if any), excluding traffic violations

Rows	Nature of Conviction	City	State	Date
Conviction 1
Conviction 2
Conviction 3
Conviction 4

Add more information if necessary

Please list all addresses for three (3) years prior to application date

Rows	Street Address	City	State	Dates
Address 1
Address 2
Address 3
Address 4

Add more addresses if necessary

Please list all employers for three (3) years prior to application date

Rows	Street Address	City, State, Zip	Dates	Company Name
Company 1
Company 2
Company 3
Company 4

Add more employers if necessary
Last four digits of Applicant's Social Security Number*
Upload a picture of Applicant's Driver's License or other Government-Issued ID

Cancelof
Applicant's Gender*
Applicant's Race*
Applicant's Date of Birth*

MonthDayYear
Attach 3 1"x1" photos, taken within 6 months of this application.

Cancelof
Signature
I, hereby, certify and affirm that all 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 certify that I will not allow massage therapy to be performed at this establishment by any person who does not possess a current massage therapist license. 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.
Electronic Signature*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

License Application for - Massage Establishment

Definition

GENERAL INSTRUCTIONS:

REQUIRED INFORMATION AND MATERIALS:

APPLICATION PROCESS:

Application Type

Business Data

Ownership

Personal Data

Signature