Lansing, MI

Application for Health Club License

Contact us
If you desire assistance or have questions about this form, you can email us at city.clerk@lansingmi.gov, call us at (517) 483-4133, or visit us in the City Clerk's office, located on the 9th floor of City Hall (124 W Michigan Avenue, Lansing, MI 48933).
Instructions
Fill out and print this form. Bring this form and the materials listed below to the City Clerk's office to complete the application process. This form can be notarized at the City Clerk's office.
Materials
This application is to be accompanied by plans and specifications of the quarters showing such details as entrances, partitions, windows, openings, ventilation, plumbing fixtures and water supplied. A copy of the insurance policy and proof of bond must be filed with the City Clerk at the time of application. There is a non-refundable fee of $300.
An application for renewal of a license must be made at least 60 days before the current license held by the applicant expires.*
1. Initial License
2. Renewal
Application is hereby made on behalf of*
Health Club Name
to operate a health, massage, bath or similar establishment, pursuant to Chapter 822 of the Codified Ordinances of Lansing, Michigan.
Health Club Address
Street Address*
City*
State*
Zip code*
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Insured By*
For Public Liability up to $100,000 for injury or death of one person and for up to $300,000 for injury or death to more than one person and for property damage in the sum of $100,000. (Copy of policy must be filed with the City Clerk before a license will be issued.)
Policy Number*
Issue Date*
Issue Date
Expiration Date*
Expiration Date
Bonded By*
In the sum of $1,000. (Bond must be filed with the City Clerk prior to issuance of a license.)
Bond Number*
Issue Date*
Issue Date
Expiration Date*
Expiration Date
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Name(s) of individual(s) who shall be on the premises that hold(s) exemption(s) from the City of Lansing as qualified and certified massage therapist(s). *
Only a licensed massage therapist can provide massage services to members of the opposite sex.
NOTE:
If the applicant does not intend to provide massage services, indicate by signing after the following: "I do not plan to provide massage services."
Applicant's Signature
DO NOT sign except in the presence of a notary.
Date
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I, the undersigned, am the owner/president of the business for which this license is requested. I authorize the Building Division and Fire Department to inspect the premises of the business applied for and further understand that a false statement on this application may result in either a denial of this application or subsequent revocation if this license is granted.
Applicant's Signature (DO NOT sign except in the presence of a notary)
___________________________________________________________________
Date
________________
Subscribed and sworn to before me this ________ day of ____________________, 20_______, acting in the County of ____________________, Michigan.
Notary Signature
___________________________________________________________________
Date
________________
Print Notary's Name
___________________________________________________________________
Commission Expires
________________
Approved by Building Safety Division
Date
Date
Approved by Fire Marshal
Date
Date
Amount paid
Date paid
Date paid
License number

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