Lansing, MI

Application for Massage Therapist (Exempt From Health Code Ordinance)

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
Complete 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 may be notarized in the City Clerk's office.
Materials
There is a non-refundable fee of $300. Proof of insurance and bond, and documentary evidence must be filed with the City Clerk at the time of application.
Applicant's Full Name*
I do hereby make application for an exemption as a massage therapist pursuant to Chapter 822, and submit the following information:
Applicant's Home Address
Street Address*
City*
State*
Zip code*
Applicant's Phone Number*
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PRIOR CONVICTIONS:*
1. Yes
2. No
Have you ever been convicted of a felony or misdemeanor (other than traffic offenses)?
If yes, identify the nature of the offense, when it occurred, and where it occurred:
PRIOR LAW SUITS: *
1. Yes
2. No
Have you, or any business owned by you, or for whom you were employed, ever been sued for operating or maintaining a nuisance (operating illegally?)
If yes, identify when this occurred, where this occurred and the outcome:
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AMERICAN MASSAGE THERAPY ASSOCIATION:*
1. Yes
2. No
Are you currently a member in good standing in the AMTA? If yes, attach documentary evidence of your membership.
MASSAGE TRAINING:
1. Yes
2. No
Have you completed a comprehensive course of study in massage therapy at an AMT Approved school or at a school established by legislative enactments of the State Board of Education?
If yes, identify the institution, number of hours of instruction received, type of training, and the dates of attendance. Attach documentary evidence.
Identify the equipment to be installed to ready premises for this business: *
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AUTHORIZATION AND RELEASE:
By signing this application, I hereby authorize any person, institution, or agency to provide information requested by the City bearing on my qualifications and fitness and I RELEASE ALL LIABILITY in connection therewith.
FALSIFICATION:
I acknowledge by signing this application that knowing falsification shall be justification for denial of an exemption or revocation if already approved.
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
________________
AS TO VERIFICATION OF APPLICANT'S STATEMENTS AS TO FELONY AND MISDEMEANOR CONVICTIONS ONLY:
Chief of Police
Date
Date
Amount paid
Date paid
Date paid
License number

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