HomeMy WebLinkAboutMassage Business Form rev 9-24
CITY OF IOWA CITY
MASSAGE BUSINESS FORM
Ordinance No. 18-4766 (to be codified at Title 5, Chapter 3 of the City Code) requires all
businesses where “massage therapy” is practiced or administered produce this completed form
upon request of a City staff member. Massage therapy means the same as it does in the
massage therapy licensing provision in the state code found at Section 152C.1 of the Code of
Iowa: performance for compensation of massage, myotherapy, massotherapy, bodywork,
bodywork therapy, or therapeutic massage including hydrotherapy, superficial hot and cold
applications, vibration and topical applications, or other therapy which involves manipulation of
the muscle and connective tissue of the body, excluding osseous tissue, to treat the muscle
tonus system for the purpose of enhancing health, muscle relaxation, increasing range of
motion, reducing stress, relieving pain, or improving circulation.
Note: It is illegal for a business to engage in or offer to engage in the practice of massage
therapy, or use the initials “L. M. T.” or the words “licensed massage therapist”, “massage
therapist”, “masseur”, “masseuse”, or any other word or title that implies or represents that a
person practices massage therapy at the business, unless the person is a LMT.
1. Name of Business:______________________________________________________
2. Street Address of Business: ______________________________________________
3. Name and mailing address of tenant leasing the space listed on number 2 above:
___________________________________________
Name of Tenant
____________________________________________________________________
Mailing Address of Tenant
4. Name, residential address, email address, and telephone number of Business Manager
(must be Iowa resident):
__________________________________________ ________________
Name Telephone Number
___________________________________________________________________
Residential Address
__________________________________________
Email Address
5. Names and telephone numbers of all persons who have an ownership in the business :
________________________________________ ________________
Name Telephone Number
________________________________________ ________________
Name Telephone Number
________________________________________ ________________
Name Telephone Number
6. Names of all Licensed Massage Therapists (LMT) who work at this location (whether
employees or independent contractors) and their state license number:
_______________________________________ _____________
Name License Number
_______________________________________ _____________
Name License Number
_______________________________________ _____________
Name License Number
_______________________________________ _____________
Name License Number
7. Names and addresses of all persons other than LMTs who perform work at this business
location along with a description of the work performed:
______________________________________ _________________________
Name Description of Work
______________________________________ _________________________
Name Description of Work