(Rev. 20190402)
RE: MASSAGE ESTABLISHMENT SUPPLEMENTARY APPLICATION PACKET
Dear Applicant:
In an effort to improve customer service and insure development projects are processed as quickly as
possible, the Planning Department finds it necessary to remind its clients that complete application
submittals are crucial to the plan review process. In the past, accepting incomplete applications has led to
errors and time delays at the end of the review process. I do not want this to happen to you.
Consequently, the Planning Department staff will only accept complete applications at time of submittal.
All items listed on the enclosed Massage Establishment Supplementary Application Form and the Minimum
Filing Requirements must be provided before the Planning Department counter staff can accept your
application for filing. Please review these minimum requirements prior to submitting your application, as
counter staff do not have the authority to waive these requirements.
Please remember that failure to provide all of the required plans and information will result in significant
time delays in the processing of your application. If you have any questions regarding the necessity of any
particular item on the Massage Establishment Supplementary Application Form or the Minimum Filing
Requirements, please feel free to contact the Planning Department counter supervisor to discuss your
questions.
The Planning Department looks forward to a continued efficient and professional relationship with you in
the future. If you have any questions, comments, or concerns regarding this matter, please feel free to
contact the Planning Department at (909) 395-2036.
Respectfully,
Cathy Wahlstrom
Planning Director
ATTENTION!
The City of Ontario strives to provide you with efficient and effective service in a businesslike manner. We
are committed to the principle that every interaction you have with the City must be based on honesty and
integrity.
City employees are prohibited by law from soliciting or accepting money, services, or gifts of any kind in
connection with the discharge of their duties.
If you are approached or are aware of any violation of this policy, please immediately contact any of the
following:
Scott Ochoa, City Manager ............................................. (909) 395-2396 or so[email protected]ov
Derek Williams, Police Chief ..................................... (909) 395-2710 or dwilliams@ontarioca.gov
Ethics Line ................................................................................................................. (800) 500-0333
Page 1 of 8
GENERAL INFORMATION (PRINT OR TYPE)
Property Owner:
Address:
Telephone No.:
Email:
Applicant:
Address:
Telephone No.:
Email:
Applicant’s Representative:
Address:
Telephone No.:
Email:
BUSINESS INFORMATION
Business Name:
Business Address:
Telephone No.:
Email:
Website:
Responsible managing officer in charge of the premises:
Managing officer’s current residence address:
Managing officer’s residence telephone no.:
APPLICANT/OWNER INFORMATION
Is the massage establishment business a corporation? Yes No
If yes, below, provide the name of the corporation exactly as shown in the articles of incorporation or Charter. In addition, on a separate sheet of
paper, provide the state and date of incorporation, and the names and residence addresses of each of its current officers and directors, and of each
stockholder holding more than 5% of the stock of that corporation.
Corporation Name:
Massage Establishment; Supplementary
Application Form
City of Ontario
Planning Department
303 East B Street
Ontario, California 91764
Phone: 909.395.2036
Fax: 909.395.2420
(For staff use only)
File No.:
Related File:
Date:
Rec’d by:
Fees Paid:
Cash Check (# )
Credit Card
Receipt No.:
Approved By:
Approval Date:
Expiration Date:
Massage Establishment Supplementary Application Form
Page 2 of 8
Is the massage establishment business a partnership? Yes No
If yes, on a separate sheet of paper, provide the name and residence address of each of the partners, including limited partners. If the applicant is
a limited partnership, provide a copy of the certificate of limited partnership, as filed with the county clerk. If one or more of the partners is a
corporation, the provisions pertaining to corporate applicants, above, shall apply.
Applicant/owner full/complete name:
List any other name(s) you have used or been known by:
Current residence address:
Residence telephone no.:
Past two places of residence:
1. Address:
2. Address:
Date of birth: California Driver’s License or ID No.:
Place of birth:
Are you a United States citizen? Yes No
Social Security No.: Gender: Male Female
Weight (lbs.): Height: Feet Inches
Hair Color: Eye Color:
Have you ever possessed an operator’s license issued by any state other than California? Yes No
If yes, provide the following information:
Name license was issued to:
License No.:
Have you ever been fingerprinted by a police agency other than for arrest? Yes No
If yes, provide the following information:
Agency Name:
Date: Purpose:
APPLICANT/OWNER PERMIT/LICENSE HISTORY
Have you had any permit or license issued by any agency, board, city, county, territory or state? Yes No
If yes, provide the following information for each permit or license received (attach additional sheets if necessary):
Permit/License received:
Issuing agency, board, city, county, territory or state:
Date of Issuance:
Was the permit/license revoked or suspended: Yes No
If yes, state the reason for revocation or suspension (attach additional sheets if necessary):
Massage Establishment Supplementary Application Form
Page 3 of 8
Have you had any vocational or professional permit or license issued: Yes No
If yes, provide the following information for each permit or license received (attach additional sheets if necessary):
Permit/License received:
Issuing vocational or professional organization:
Date of Issuance:
Was the permit/license revoked or suspended: Yes No
If yes, state the reason for revocation or suspension:
APPLICANT/OWNER CRIMINAL HISTORY
Have you ever been arrested or detained by the police (excluding traffic violations)? Yes No
If yes, provide the following details (attach additional sheets if necessary):
1. Crime Charged:
Police Agency:
Date: Disposition of Case:
2. Crime Charged:
Police Agency:
Date: Disposition of Case:
3. Crime Charged:
Police Agency:
Date: Disposition of Case:
4. Crime Charged:
Police Agency:
Date: Disposition of Case:
5. Crime Charged:
Police Agency:
Date: Disposition of Case:
Massage Establishment Supplementary Application Form
Page 4 of 8
APPLICANT AFFIDAVIT
I, the undersigned, do hereby certify and state that I am the applicant in the foregoing application, that I have read the foregoing application,
and that I know the content thereof, and do further state that the same is true and correct to the best of my knowledge and belief.
Furthermore, I hereby agree to defend, indemnify, and hold harmless the City of Ontario or its agents, officers, and employees, from any
claim, action or proceeding against the City of Ontario or its agents, officers or employees, to attack, set aside, void, or annul any approval by the City
of Ontario, whether by its City Council, Planning Commission, or other authorized board or officer, as it pertains to this application. The City of Ontario
shall promptly notify the applicant of any such claim, action or proceeding, and the City of Ontario shall cooperate fully in the defense.
Date: Signature:
Name (print or type):
NOTARY ACKNOWLEDGMENT
STATE OF CALIFORNIA )
COUNTY OF )
CITY OF )
On _________________________ before me, __________________________________________________________________________________,
Date Name of Notary Public
Notary Public, personally appeared___________________________________________________________________________________________,
Name(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged
to me that he/she/they executed the same in his/her/their authorized capacity(ies) and that by his/her/their signatures(s) on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature________________________________________
(Seal)
Note: The notary public completing this certificate is verifying only the identity of the individual
signing the document to which this certificate is attached, and not the truthfulness, accuracy, or
validity of the document.
Massage Establishment Supplementary Application Form
Page 5 of 8
PROPERTY OWNER AFFIDAVIT
I, the undersigned, do hereby certify and state that I am the owner of the property in the foregoing application, that I have read the foregoing
application, and that I know the content thereof, and do further state that the same is true and correct to the best of my knowledge and belief.
Date: Signature:
Name (print or type):
NOTARY ACKNOWLEDGMENT
STATE OF CALIFORNIA )
COUNTY OF )
CITY OF )
On _________________________ before me, __________________________________________________________________________________,
Date Name of Notary Public
Notary Public, personally appeared___________________________________________________________________________________________,
Name(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged
to me that he/she/they executed the same in his/her/their authorized capacity(ies) and that by his/her/their signatures(s) on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature________________________________________
(Seal)
Note: The notary public completing this certificate is verifying only the identity of the individual
signing the document to which this certificate is attached, and not the truthfulness, accuracy, or
validity of the document.
Massage Establishment Supplementary Application Form
Page 6 of 8
Ontario Police Department
Permit Fingerprint Application
Last Name:
First Name: M:
Date of Birth: Sex:
Height: Weight: Hair Color: Eye Color:
The City of Ontario requires that prior to granting certain permits, the person applying for a permit must submit to a fingerprint
process to be completed by the Ontario Police Department. The fingerprint process is required by the California Department
of Justice as a necessary means for the Police Department to conduct background checks as required for the permit being
applied for.
DOJ Results review date: By:
Page 7 of 8
MINIMUM FILING REQUIREMENTS
The minimum requirements for filing a Massage Establishment
Application are listed below. An application that does not include the
below-listed items will not be accepted for processing:
Completed Discretionary Permits/Actions Applications Form,
requesting Conditional Use Permit approval for the proposed
massage establishment, and compliance with the minimum
applications for filing a Conditional Use Permit.
Completed Massage Establishment Supplemental Application
Form.
Two portrait photographs, 2 inches in width by 2 inches in height,
taken within the previous 6 months, of the applicant or person
designated by the applicant, corporation or partnership, to act as
its responsible managing officer in charge of the premises.
At least two signed statements by persons who have knowledge
of the applicant's background and qualifications, including dates
of relationships. Those persons shall have known the applicant for
at least 3 years preceding the date of application.
If the applicant/owner will be performing massages at the
massage establishment, provide current copies of the
applicant/owner California Massage Therapy Council
(“CAMTC”) certificate and license card. If the applicant/owner is
not CAMTC certified, a separate Massage Therapist Permit is
required to be obtained.
A complete description/definition of all services to be provided.
Written proof that the applicant/owner is at least 18 years of age.
Written proof that the person designated by the applicant,
corporation or partnership to act as its responsible managing
officer in charge of the premises, is at least 18 years of age.
The applicant and any person designated by the applicant,
corporation or partnership to act as its responsible managing
officer in charge of a massage establishment shall be required to
furnish fingerprints for the purpose of establishing identification.
Any required fingerprinting fee will be the responsibility of the
applicant.
A floor plan of the unit/building in which you wish to establish
your business.
Such other identification and information as the Police Chief may
require in order to discover the truth of the matters hereinbefore
specified as required to be set forth in the application.
The Police Chief, at his discretion, may require the applicant to
appear in person for the purpose of verifying identity, taking
additional photographs of the applicant, and/or confirm the height
and weight of the applicant.
Any other information that the Planning Director deems
necessary to facilitate the processing of the subject application.
Notes:
(1) Review Development Code Section 5.03.270 (Massage Services)
for operating requirements and zoning compliance.
(2) The approval of a Massage Establishment Permit does not
include employees. Each employee who performs massage as part
of the business activity must apply for, and obtain, a separate
Massage Therapist Permit, or be certified by the California
Massage Therapy Council and provide proof of such
certification.
Massage Establishment Supplementary
Application Form; Minimum Filing
Requirements
City of Ontario
Planning Department
303 East B Street
Ontario, California 91764
Phone: 909.395.2036
Fax: 909.395.2420
WHAT IS A MASSAGE ESTABLISHMENT PERMIT?
The City of Ontario is authorized by virtue of the State Constitution, the provisions of the City Charter, and Government Code Section 51031, to
regulate all massage establishments by imposing reasonable standards of massage establishment operators and reasonable conditions on the
operation of the massage establishment. The Massage Establishment Permit process has been created to ensure reasonable safeguards against
physical injury and economic loss to massage clients, brought about by improperly educated and trained massage therapists. In order to achieve
these purposes, the Zoning Administrator is empowered to grant or deny applications for Massage Establishment Permits and to impose reasonable
conditions upon the granting of a Massage Establishment Permit.
Massage Establishment Supplementary Application; Minimum Filing Requirements
Page 8 of 8
For City Use Only
Required information provided with application:
Fully completed, signed and notarized Massage Establishment Supplementary Application Form.
Fully completed, signed, and notarized Discretionary Permits/Actions Applications Form for Conditional Use Permit approval.
Two portrait photographs, at least 2-inches by 2-inches, taken within the last 6 months.
Two signed statements by persons who have knowledge of the applicant's background and qualifications.
Applicant/owner will NOT be performing massages at the establishment.
OR
Applicant/owner submitted CAMTC certification and license card OR separate Massage Therapist Permit application.
Description/definition of services to be provided.
Floor plan of building/unit.
Proof that the applicant/owner is at least 18 years of age.
Proof that the person designated by the applicant, corporation or partnership to act as its responsible managing officer in charge of the premises,
is at least 18 years of age.
Approved Denied
Police Department, By: Date:
Title:
Planning Department, By: Date:
Title:
