MASSAGE THERAPIST APPLICATION CITY OF PALM DESERT Permit No. City use only: Attach Photo Date Application Received: Deposit Amount: Received By: Approved Denied Check One: Reasons for denial: By: Date Full Name Home Address City State Zip Code (Last) (First) (MI) Home Phone *** Please Print or Type Application*** Yes No Have you used any other name? If so, please list all names used Business Name, if doing business under any name other thean legal name shown above: Business Address Business Phone Fax SSN Driver's License No. Date of Birth Eye Color Hair Color Weight Height Have you ever held a similar license or permit in another city, county or state? Yes No If yes, list the name of the agency, address and phone number: Agency Address City State Zip Code Phone No: Was such permit revoked or suspended? Yes No If yes, list the reason for such revocation or suspension Attach additional sheet, if necessary.
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MASSAGE THERAPIST APPLICATIONCITY OF PALM DESERT
Permit No.
City use only:
Attach Photo
Date Application Received: Deposit Amount: Received By:
Approved DeniedCheck One:
Reasons for denial:
By: Date
Full Name
Home Address
City State Zip Code
(Last) (First) (MI)
Home Phone
*** Please Print or Type Application***
Yes NoHave you used any other name?
If so, please list all names used
Business Name, if doing business under any name other thean legal name shown above:
Business Address
Business Phone Fax SSN
Driver's License No.
Date of BirthEye ColorHair Color WeightHeight
Have you ever held a similar license or permit in another city, county or state? Yes No
If yes, list the name of the agency, address and phone number:
Agency
Address
City State Zip Code
Phone No:
Was such permit revoked or suspended? Yes No
If yes, list the reason for such revocation or suspension
Attach additional sheet, if necessary.
Address
City State Zip
Date of Residence
Phone
Address
City State Zip
Date of Residence
Phone
Address
City State Zip
Date of Residence
Phone
Address
City State Zip
Date of Residence
Phone
Address
City State Zip
Date of Residence
Phone
Address
City State Zip
Date of Residence
Phone
List all places of residence for the past ten (10) years. List present address first.
Attach additional sheet if necessary
Employer
Address
City State Zip
Job Title
Type of Business
Phone Number
From: To:
Employer
Address
City State Zip
Job Title
Type of Business
Phone Number
From: To:
Employer
Address
City State Zip
Job Title
Type of Business
Phone Number
From: To:
Employer
Address
City State Zip
Job Title
Type of Business
Phone Number
From: To:
Employer
Address
City State Zip
Job Title
Type of Business
Phone Number
From: To:
Employer
Address
City State Zip
Job Title
Type of Business
Phone Number
From: To:
Beginning with your most current employment, please list all places of employment for the past ten years.
Attach additional sheet, if necessary.
Has the applicant ever been convicted of a crime for any felony, misdemeanor or violation of a local ordinance, excluding misdemeanor traffic violations? (Any traffic offense designated as a felony shall not be construed as a minor traffic offense.)
Yes No If yes, list below and explain fully:
Name Date
Charge
Penalty
Place
Explanation
Name Date
Charge
Penalty
Place
Explanation
Attach additional sheet if necessary.
Please use the following checklist to show all items attached to this application
A certified letter of intent to employ from the operator of a massage therapy establishment lawfully operating within the City. Each such letter shall verify that the operator of the massage therapy establishment has reviewed the applicant's qualifications and that the applicant has met the requirements necessary to perform massage therapy at the establishment.
A certified statement from a physician licensed to practice medicine in the United States that provides that, within 60 days prior to the date of this application, the physician has examined the applicant and has determined that the applicant is free of communicable disease. For purposes of the physician's statement, "communicable disease" means tuberculosis, or any disease, which may be transmitted from a massage therapist to a patron through normal physical contact during the performance of massage therapy services.
Written evidence that the applicant is at least eighteen years of age.
Two front-face portrait photographs taken within 30 days of the date of this application, at least two inches by two inches in size.
Applicant's fingerprints taken within the previous sixty (60) days by an agency approved by the City (or Permit Administrator).
A certified copy of the therapeutic massage and bodywork credential issued by the National Certification Board for Therapeutic Massage and Bodywork OR a certified copy of applicant's diploma or certificate of graduation, or equivalent documents, establishing that applicant has successfully completed a course of study for competency as a massage therapist, consisting of at least 300 hours of massage therapy training, offered by a Recognized School of Massage, as defined in the Coachella Valley Model Massage Ordinance. A nonrefundable application deposit fee of $150.00 (or $100.00 if this is a renewal application.
I, the undersigned applicant, declare: 1. I have read and I am familiar with and understand the provisions of the Coachella Valley
Model Massage Ordinance and, if this application is approved, I agree to abide by all such provisions and any revisions that might be passed according to law.
2. I certify that all entries made by me or under my direction in this application are true, complete and correct to the best of my knowledge.
3. I voluntarily consent and authorize the City, its agents, and employees to seek information and to conduct an investigation into the truth of the statements set forth in this application and my qualifications for the permit.
4. I certify that I am not required to register as a sex offender pursuant to the California Penal Code Section 290, or any other law.
5. I certify that, within the last five (5) years, I have not been convicted of any of the following conduct:
(a) Pandering as set forth in California Penal Code Section 266i; (b) Keeping or residing in a house of ill-fame as set forth in California Penal Code Section
315; (c) Keeping a house for the purpose of assignation or prostitution, or other disorderly
house as set forth in California Penal Code Section 316; (d) Prevailing upon a person to visit a place of illegal gambling or prostitution as set forth
in California Penal Code Section 318; (e) Lewd conduct as set forth in California Penal Code Section 647, subdivision (a); (f) Prostitution activities as set forth in California Penal Code Section 647, subdivision (b); (g) Any offense committed in any other state which, if committed or attempted in this state,
would have been punishable as one or more of the offenses set forth in California Penal Code Sections 266 (i), 315, 316, 318, or 647, subdivisions (a) or (b);
(h) Any felony offense involving the sale of any controlled substance specified in California Health and Safety Code Sections 11054, 11055, 11056, 11057, or 11058;
(i) Any offense committed in any other state which, if committed or attempted in this state, would have been punishable as a felony offense involving the sale of any controlled substance specified in California Health and Safety Code Sections 11054, 11055, 11056, 11057, or 11058;
(j) Any misdemeanor or felony offense which relates directly to the practice of massage therapy, whether as a massage therapy business owner or operator, or as a massage therapist; or
(k) Any felony the commission of which occurred on the premises of a massage therapy establishment.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Applicant Signature Date
CITY OF PALM DESERT REQUEST FOR RELEASE OF INFORMATION
Applicant's Name
Applicant's Signature Date
Permit No.
To whom it may concern::
I have applied for a license to practice business in the City of Palm Desert and hereby authorize you to provide the City of Palm Desert or its authorized representative any information relevant to my business license application.
THIS APPLICATION REQUIRES THE CITY, ITS AGENTS AND EMPLOYEES TO SEEK INFORMATION AND CONDUCT AN INVESTIGATION INTO THE TRUTHS OF THE STATEMENTS SET FORTH WITHIN THIS APPLICATION AND THE QUALIFICATIONS OF THE APPLICANT.
TO: CHIEF OF POLICE
FROM: BUSINESS LICENSE DIVISION, CITY OF PALM DESERT
If recommending denial, please state reasons:
Please investigate the background of the applicant for this permit application and return as promptly as possible with your recommendations.
I recommend approval of this application.
I recommend denial of this application.
Signature of Police Chief or other official Date
The City of Palm Desert Municipal Code, Section 5.87.080, requires all applicants to submit a medical certificate stating that they have been tested by a physician and are free3 of communicable disease, which may be transferred through the normal course of massage. This should be interpreted as any type of illness / disease that could be transmitted while providing a massage, via touch or airborne pathogen. The certificate must be signed by a physician (not a nurse or PA) and dated within 60 days prior to the date the application is submitted.
For your convenience, you may use this form for that purpose (please return the entire form). Please be advised that applications will not be accepted without the physician's certification. If you have any questions or concerns, please call (760) 346-0611, ext. 443.
Sincerely, Claudia Jaime Finance Department
HEALTH CERTIFICATION FORM
Name of Applicant: Date:
The individual named above is an applicant for a Massage Therapist Permit and is required to be examined by a Physician to insure that the applicant is free of any communicable diseases that may be transmitted to the patrons of the business establishments through the normal course of Massage Therapy. Please complete the information requested below
TB Test Results: Positive Negative
Physician Signature
Physician Name (Print)
Address
Date
Medical Certification Number
Phone
BCII 8016 ( 3 /0 7 )
State of California
Applicant Submission
REQUEST FOR LIVE SCAN SERVICE Department of Justice
ORIGINAL – Live Scan Operator; SECOND COPY – Applicant; THIRD COPY (if needed ) – Requesting Agency
Code assigned by DOJ Type of Application:
Job Title or Type of License, Certification or Permit:
ORI:
Agency Address Set Contributing Agency:
Agency authorized to receive criminal history information Mail Code (five-digit code assigned by DOJ)
Street No. Street or PO Box Contact Name (Mandatory for all school submissions)
( ) City State Zip Code Contact Telephone No.
Name of Applicant: (Please print) Last First MI
Alias: Driver’s License No: Last First
Date of Birth: Sex: Male Female Misc. No. BIL - Agency Billing Number
Height: Weight: Misc. Number:
Home Address:
Eye Color: Hair Color: Street No. Street or PO Box
City, State and Zip Code
Social Security Number:
Place of Birth:
Your Number: OCA No. (Agency Identifying No.) Level of Service: DOJ FBI
If resubmission, list Original ATI Number:
Employer: (Additional response for agencies specified by statute)
Employer Name
Street No. Street or PO Box Mail Code (five digit code assigned by DOJ)
( ) City State Zip Code Agency Telephone No. (optional)
Live Scan Transaction Completed By: Name of Operator Date
Transmitting Agency ATI No. Amount Collected/Billed
Terminal No.
Transmitted to DOJ Card Printout
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