MASSAGE THERAPY CERTIFICATE 2016 LICENSE APPLICATION INSTRUCTIONS City of Plymouth 3400 Plymouth Boulevard, Plymouth, MN

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1 MASSAGE THERAPY CERTIFICATE 2016 LICENSE APPLICATION INSTRUCTIONS City of Plymouth 3400 Plymouth Boulevard, Plymouth, MN The following application forms must be completed, by the individual making an application for a Massage Therapy Certificate. The application must be filled out completely and submitted in person with all the items listed below together with the license fee. If there is missing information, the application will NOT be processed. (please indicate if you are applying for a temporary one-year certificate) 1. Application form for Massage Therapy Certificate. 2. For Massage Therapists working at home, a separate Home Occupation License must be obtained through the City s Planning Department ( ). 3. Certificate of Insurance for Personal Professional Liability for $1,000,000 is required. 4. Background Investigation Consent Release with Tennessen Warning (attached). 5. Government Issued Photo ID presented in person (A colored copy is required). 6. Applicants shall provide proof that they graduated with a minimum of 500 hours training from a bona fide massage therapy school or show proof that the applicant has successfully passed the National Certification Examination for Therapeutic Massage and Bodywork. (Massage Therapy School Certificate of Graduation and proof of 500 hours are needed) Applicant can prove by affidavit they have practiced massage therapy for the past one year and have not had any criminal convictions as a result of practicing massage therapy. A temporary one year certificate shall be granted, in order to allow time to complete educational requirements while practicing, to those persons who have a minimum of 250 hours of training from an accredited massage therapy school; have not had any criminal convictions as a result of practicing Massage; and otherwise meet the requirements listed in of the City Ordinance. An individual with a temporary one year certificate shall work directly under the supervision of a fully licensed massage therapist. The temporary certificate is not renewable. Above forms are to be submitted with the following fees: $150 Investigation Fee for first application only (non-refundable) $ 75 Certification Fee. The licensing year is January 1 through December 31. New license fees are not pro-rated. Please make checks payable to The City of Plymouth. City Code Requirements Attached to this application are the City Code Requirements regarding the practice of massage in the City of Plymouth. Please read and retain for your files and future reference. Review and Approval Process The applicant must submit completed application in person, pay the appropriate fee, be photographed and provide a government issued photo identification. All investigations need to be approved by the Police Department. Please note that this process may take up to 10 business days. If applications are denied, applicants may appeal the denial to the City Council in accordance with the Plymouth City Code. Received By (Initials & Date):

2 MASSAGE THERAPY CERTIFICATE LICENSE APPLICATION City of Plymouth 3400 Plymouth Boulevard, Plymouth, MN First Name Home Address Full Middle Last Name City State Zip Primary Phone Place of Birth Date of Birth Have you ever used or been known by a name other than the name on your government issued identification? YES If yes, please list: NO Addresses at which you have lived during the previous 5 years: Employment History Please list your places of employment and positions during the previous 5 years: (attach additional sheets if necessary) Name Address Phone Supervisor s Name Occupation Dates Name Address Phone Supervisor s Name Occupation Dates Name Address Phone Supervisor s Name Occupation Dates Name Address Phone Supervisor s Name Occupation Dates Name Address Phone Supervisor s Name Occupation Dates For Office Use Only Massage License Investigation Fee - $150 Code Massage License Fee - $75 Code City of Plymouth (Form 02/10/16) Massage Therapy Certificate Application Page 1

3 Describe your training and experience related to massage therapy (include length and type of experience): Original or certified copies of your degrees, diplomas, or curriculum from a bona fide school of massage therapy are required to be submitted with this application. Please list the name, address, and phone number of each of the schools for which a transcript is attached: School Name & Address Phone School Name & Address Phone Have you ever worked as a massage therapist? YES NO If yes, provide business name, location and dates: Have you ever had a license revoked, denied, or suspended related to the conduct of massage? YES NO If yes, provide date(s) and location(s). Be specific. Have you ever been convicted of any felony, gross misdemeanor, misdemeanor, or violation of any ordinance other than traffic offenses? YES NO If yes, give date, place and type of crime or offense: List two persons who are residents of Minnesota not related to you and having no financial interest in your business, who may be contacted regarding your character: Full Name / Home Address / Home Telephone # / Telephone #: Full Name / Home Address / Home Telephone # / Telephone #: The following information refers to the location you will perform massage therapy. If this is a home operated business, you must obtain an Interim Home Occupation Permit from the City s Planning Department (see attachment). Name of Address / City / State / Zip Contact Person Phone # State specific type and nature of the business at which you will perform massage therapy: I hereby swear that the statements herein are true to the best of my knowledge and belief. I have read and understand all laws and ordinances pertaining to the license for which I am applying. I agree to notify the City of any change in residence address, or a change in address of where massage therapy is practiced, 30 days prior to such change. Signature of Applicant Date City of Plymouth (Form 02/10/16) Massage Therapy Certificate Application Page 2

4 DEPARTMENT OF PUBLIC SAFETY BACKGROUND INVESTIGATION CONSENT RELEASE City of Plymouth 3400 Plymouth Boulevard, Plymouth, MN As a license applicant, I hereby give my consent for a personal background investigation, to include a criminal history check, to be used in the determination of whether my application is to be approved. The results of such investigation shall be made public pursuant to appropriate City Council approval or denial of the license application. I understand that I am under no legal obligation to consent to such investigation, but that my refusal to so consent may be the basis for denying my application. Type of License MASSAGE THERAPY CERTIFICATE Applicant Information First Name Middle Name Last Name Home Address Primary Phone # Telephone # Date of Birth Place of Birth Driver s License Number State Social Security # Physical Attributes: Sex Race Height Weight Eye Color Hair Color Have you ever used or been known by a name other than the name on your government issued identification? YES If yes, please list: NO Have you ever had a license revoked, denied, or suspended related to the conduct of massage? YES NO If yes, provide date(s) and location(s). Be specific. Have you ever been convicted of any felony, gross misdemeanor, misdemeanor, or violation of any ordinance other than traffic offenses? YES NO If yes, give date, place and type of crime or offense: TENNESSEN WARNING: In connection with your request for a license, the City has asked that you provide information about yourself which may be classified as private, confidential, nonpublic, or protected nonpublic under the Minnesota Government Data Practices Act. This means that this data is not ordinarily available to the general public. Accordingly, the City is required to inform you of the following: 1. The purpose and intended use of the information requested is to determine if you are eligible for a license from the City of Plymouth. 2. You are not legally obligated to supply the requested information. 3. The known consequences of supplying the requested information is that the information or further investigation could disclose information which could cause your application to be denied. 4. The known consequences of refusing to supply the requested information is that your request for a license cannot be processed. 5. A criminal charge, arrest, or conviction will not necessarily bar you from obtaining a license with the City, unless the conviction is related to the matter for which the license is sought, according to Minnesota Statute However, failure to reveal the requested criminal information will be considered falsification of the application and may be used as grounds for the denial of the application. 6. Other governmental agencies necessary to process your application are authorized by law to receive the information provided. 7. The City is required by law to furnish some of this information to the Department of Labor and Industry and the Minnesota Commissioner of Revenue. The undersigned, by signing this notice, acknowledges that he/she has read and understood the contents of this notice and has received a copy of this notice. Signature of Applicant These statements are true, correct and are made with the knowledge that this information may be made public. False disclosures are subject to perjury proceedings and forfeiture of the license application. City of Plymouth (Form 02/10/16) Massage Therapy Certificate Application Page 3 Date

5 ATTENTION: HOME OPERATION MASSAGE THERAPIST Before a Massage Therapist license would be granted, you must make an application and obtain a separate Home Occupation License through the City Planning Department. Planning Application includes information on: Hours of operation. How business is operated (i.e., walk ins, scheduled appointments). Number of customers at a time. Property owners within 200 feet of home would be notified and allowed to comment on home occupation business. For questions regarding Home Occupation Licenses, Call the Planning Department City of Plymouth (Form 02/10/16) Massage Therapy Certificate Application Page 4

6 Plymouth City Code Section Massage Therapy Definitions. Subdivision 1. The term "Certificate" for purpose of this Section, means a certificate issued by the City authorizing the holder thereof to practice massage in the City Exempt Persons. The practice of massage therapy is hereby declared to be distinct from the practice of medicine, surgery, osteopathy, chiropractic, physical therapy, or podiatry. Persons duly licensed in this state to practice medicine, surgery, osteopathy, chiropractic, physical therapy or podiatry, nurses or persons performing therapeutic massages who work solely under the direction of such persons, athletic directors and trainers, certified by an accrediting agency and who are employed by an accredited and licensed educational institution shall be exempt from the provisions of this Section. (Ord , 4/04/95) Illegal to Practice Without Certificate. It shall be a misdemeanor for a person to engage in, or hold himself or herself out as being engaged in, the practice of Massage Therapy in this City without first having obtained a Certificate as provided in this Section, unless said person is exempt under Section (Ord , 4/04/95) Types of Certificates. The City of Plymouth issues certificates to an individual for massage therapy. The requirements for this certification are specified in Section (Ord , 4/04/95) Application for Certificate. Subdivision 1. Contents. Application for a Certificate shall be made on forms provided by the City Manager. The application shall contain the following information together with any other information which the City Manager may require: A. The name, age, home address of the applicant, and the address of where the applicant will practice massage therapy. B. Evidence of applicant's practical qualifications to practice massage therapy, including length of experience in massage therapy and past place of employment, dates of employment, and positions held. C. The names and addresses of two persons, residents of Hennepin County, who may be referred to as to the applicant's character. D. Whether the applicant has ever been convicted of a crime or offense other than a traffic offense and if so, information as to the time, place, and nature of such crime or offense. E. Evidence of the applicant's educational qualifications, including originals or certified copies of degrees, diplomas or curriculum from a bona fide school of

7 Plymouth City Code massage therapy, for massage therapy certification. The address and phone number of the bona fide school of massage therapy are required. Massage Therapy Certificates. Applicants shall be required to provide proof (1) they graduated with a minimum of 500 hours training from a bona fide massage therapy school or (2) show proof that the applicant has successfully passed the National Certification Examination for Therapeutic Massage and Bodywork and can prove by affidavit they have practiced massage therapy for the past one year and have not had any criminal convictions as a result of practicing massage therapy. A temporary one year certificate shall be granted, in order to allow time to complete educational requirements while practicing, to those persons who have a minimum of 250 hours of training from an accredited massage therapy school; have not had any criminal convictions as a result of practicing Massage; and otherwise meet the requirements listed in Subsections A-D of this Subdivision. An individual with a temporary one year certificate shall work directly under the supervision of a fully licensed massage therapist. This temporary certificate is not renewable. (Ord , 4/04/95; Ord , 11/19/97) F. Within 90 days of the adoption of the ordinance adopting this Subdivision, applicants also may receive a massage therapy certificate by satisfying either of the following requirements: (1) show proof that the applicant has practiced massage therapy for a minimum of one year, and can prove by affidavit they have not had criminal convictions as a result of practicing massage therapy, and otherwise meeting the requirements listed in Subsections A-D of this Subdivision; (2) show proof that the applicant has successfully passed the National Certification Examination for Therapeutic Massage and Bodywork within the last four years, and otherwise meeting the requirements listed in Subsections A-D of this Subdivision. (Ord , 4/04/95) Subd. 2. Review by Other Departments. At the City Manager's discretion, the application may be referred to the Police Department for review and recommendation on granting or denying the Certificate. (Ord , 4/04/95; Ord , 2/27/2001) Subd. 3. Investigation Fee. Each application shall be accompanied by payment of a nonrefundable investigation fee set forth in Chapter X. (Ord , 4/04/95) Certificate Fee and Certificate Year Renewal. The annual Certificate fee is set forth in Chapter X. A Certificate, unless revoked, is for the calendar year, or part thereof for which it has been issued. A renewal application shall be provided by the City. (Ord , 4/04/95) Granting or Denial of Certificate. Certificate applications shall be reviewed by the Police Department and such other departments as the City Manager shall deem necessary. Thereafter Certificates shall be issued or denied by the City Manager subject to the provisions of

8 Plymouth City Code this Section. The applicant may appeal a denial by the City Manager to the Council in accordance with Section (Ord , 4/04/95; Ord , 2/27/2001) Conditions Governing Issuance. A. Certificates may be issued only to persons of good repute. B. Certificates may be issued only to persons free of convictions of prostitution or offenses which involve moral turpitude or which relate directly to the persons ability, capacity, or fitness to perform the duties and discharge the responsibility of the occupation. C. Certificates shall not be issued to a person who, within one year prior to the date of application, has been denied certification or who has had a certificate revoked. D. Certificates may be issued only to persons who have answered fully all of the information requested in the application and have paid the full investigation and certification fees. (Ord , 4/04/95) E. Certificates may be issued only to persons 18 years of age or older. F. Certificates may be issued only to persons with sufficient practical experience or training to perform the duties and discharge the responsibilities of the occupation. G. Certificates may be issued only to persons who have professional liability insurance, with policy limits as required by the City, for a term no shorter than the Certificate period. (Ord , 4/04/95) (Ord , 11/19/97) Restrictions and Regulations. Subdivision 1. Display of Certificates. Any certified Massage Therapist shall have the Certificate or a true copy thereof displayed in a prominent place at the place massage therapy is practiced. (Ord , 4/04/95) Subd. 2. Identification. Upon demand by any police officer, a certified Massage Therapist practicing massage therapy shall give proper identification including true legal name and correct address. (Ord , 4/04/95) Subd. 3. Change of Address. A certified Massage Therapist shall inform the City Manager of any change in residence address, or a change in the address of where massage therapy is practiced, 30 days prior to such change. (Ord , 4/04/95) Subd. 4. Hours. No certified Massage Therapist shall perform such service between the hours of 1:00 a.m. and 6:00 a.m. on the same day. (Ord , 4/04/95)

9 Plymouth City Code , Subd. 5 Subd. 5. Photographic Identification. Every certified Massage Therapist shall appear personally at the Police Department to receive delivery of the Certificate, and upon such appearance shall be photographed for identification purposes. One copy of the photograph shall be permanently affixed to the Certificate and a second copy shall be kept in the files of the Police Department. (Ord , 4/04/95) Subd. 6. Location of Practice. Massage may be practiced only by a certified Massage Therapist and only at the following locations: at a Massage Therapy Center licensed pursuant to Section 615 of this code; at the place of residence of the Massage Therapist; or at an office, business, or institution, excluding hotel and motel guest rooms, and dwellings. (Ord , 4/04/95; Ord , 01/10/2006; Ord , 1/09/2007) Subd. 7. Massage Therapy Purpose. Massage therapy may be practiced only for the purposes of physical fitness, relaxation, therapeutic or other purpose set forth in Section , Subd. 37. The practice of massage therapy for any other purpose is prohibited. (Ord , 4/04/95) Revocation and Suspension of Certificate. Subdivision 1. Grounds. A Certificate may be revoked or suspended or not renewed by the City Manager for any of the following: A. Fraud, deception or misrepresentation in connection with the securing of certification. B. Habitual drunkenness or intemperance in the use of drugs including but not limited to the use of drugs defined in either 26 USC Sec or Minnesota Statutes, Chapter 152, as amended, barbiturates, hallucinogenic drugs, amphetamines, Benzedrine, Dexedrine, or other sedatives, depressants, stimulants or tranquilizers. C. Conduct inimical to the interests of the public health, safety, welfare or morals. D. Engaging in conduct involving or demonstrating moral turpitude, including, but not limited to, prostitution. (Ord , 4/04/95) E. Failure to comply with the requirements of this Section. (Ord , 4/04/95) Subd. 2. Appeal. The Applicant/Certificate holder may appeal a denial, suspension, revocation or non-renewal to the City Clerk within 30 days of the date of notice. If no appeal is received within this time period, the denial, suspension, revocation, or non-renewal shall stand. The Council shall consider the appeal at the next regularly or specially scheduled Council meeting 10 days after service of the notice of appeal upon the City Clerk by the Applicant/Certificate holder. Hearing on the appeal shall be open to the public and the Applicant/Certificate holder shall have the right to appear and be represented by legal counsel

10 Plymouth City Code , Subd. 2 and to offer evidence in behalf of certification. At the conclusion of the hearing, or as soon thereafter as practicable, the Council may order: (Ord , 1/22/2013) A. That the denial, revocation, suspension or non-renewal by the City Manager be affirmed. (Ord , 4/04/95) B. That the denial, revocation, suspension or non-renewal by the City Manager be lifted and that the Certificate be issued or returned to the Certificate holder. (Ord , 4/04/95) C. The Council may base its order regarding the Certificate upon any additional terms, conditions and stipulations which it may, in its discretion, impose Certificate Required for Employment. No employer shall employ a person to practice Massage Therapy unless that person has been granted a Certificate pursuant to this Section; and every such employer shall require that the Certificate be prominently displayed on the business premises. (Ord , 4/04/95) Offenses. Any person who commits or attempts to commit, conspires to commit, or aids or abets in the commission of, any act constituting a violation of this Section, whether individually or in connection with one or more other persons or as principal, agent, or accessory, is guilty of a misdemeanor. Every person who falsely, fraudulently, forcibly or willfully induces, causes, coerces, requires, permits or directs another to violate any of the provisions of this Section is guilty of a misdemeanor. (Ord , 10/25/2011)

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