Loading...
HomeMy WebLinkAbout3 -Massage Premises ApplicationCity Clerk’s Office 651-747-3900 3880 Laverne Avenue North Lake Elmo, MN 55042 APPLICATION FOR LICENSE PRACTICE OF MASSAGE THERAPY PREMISES In submitting a license application, the applicant and relevant business associates declare that all requirements for issue of said license have been met and that such premises will be operated in compliance with the above regulations, statutes and ordinances. Knowingly submitting an incomplete application constitutes “fraudulent application.” License Application Checklist  Complete the attached license application in full. Unsigned or improperly completed applications will be returned to the applicant.  Attach additional sheets as required in the “Applicant Information” section of the application.  Attach a site plan of the proposed premises, drawn to scale, showing the scale used in the drawing and placement of pertinent interior facilities including waiting areas, dressing rooms, toilets, showers, sauna and steam rooms, massage and treatment tables, food preparation and serving areas, offices, laundry facilities and storage areas.  Attach a copy of a current professional liability insurance policy.  Attach the following exhibits to the application: If the applicant is a sole proprietor: •A certified copy of a trade name pursuant to Minnesota Statutes, Section 333.01, shall be attached to the application. If the applicant is a partnership: •The name(s) and address(es) of all general and limited partners and all information concerning each general partner required in subpart (1) of section 11.20. •The name(s) of the managing partner(s) and the interest of each partner in the massage therapy business. •A true copy of the partnership agreement shall be submitted with the application. If the partnership is required to file a certificate as to a trade name pursuant to Minnesota Statutes, Section 333.01, a certified copy of such certificate shall be attached to the application. If the applicant is a corporation or other organization: •The name of the corporation or business form, and if incorporated, the state of the incorporation. •A true copy of the Certificate of Incorporation, Articles of Incorporation or Association Agreement, and Bylaws shall be attached to the application. If the application is a foreign corporation, a Certificate of Authority as required by Minnesota Statutes, Section 303.06, shall be attached. •The name of the manager(s), proprietor(s), or other agent(s) in charge of the business and all information concerning each manager, proprietor, or agent required in section 11.20. •A list of all persons who control or own an interest in excess of five (5) percent in such organization or business form or who are officers of the corporation or business form and all information concerning said persons required in this section.  The names and resident and business street addresses of three (3) residents of the seven-county metropolitan area. They must be persons of good moral character and who are not related to the applicant or holding any ownership in the premises or business, who may be contacted with regard to the applicant's and/or manager's character. City Clerk’s Office 651-747-3900 3880 Laverne Avenue North Lake Elmo, MN 55042 Business Information Date of Application___________________ Type of Business __________________________________ Business Name ______________________________________________________________________ Type (circle one) Corporation / Partnership / Sole Proprietorship Business Telephone (_____) _______________ Business Address ____________________________________________________________________ Other Mailing Address _________________________________________________________________ Number of licensed therapists to be employed ______________________________________________ If Applicant is a corporation, when and where were incorporation articles filled? ____________________ __________________________________________________________________________________ Applicant Information Applicants Name__________________________________________________ DOB _______________ First Middle Last Title__________________________________ Home Telephone (_____) _________________________ Home Address (not a P.O. Box) _________________________________________________________ Previous Home Address _______________________________________________________________ Have you ever been convicted of a felony or misdemeanor violation of any federal or state statute or local ordinance, other than traffic offenses? NO______ YES______ If YES, attach a separate sheet giving the following information for each conviction: 1. Charge or offense 2. Date of arrest 3. Arresting agency 4 Date of conviction 5. Court name and location 6.Sentence Probation or parole for any violation listed above? NO______ YES______ Have you ever been known by another name? NO______ YES______ If YES, attach a separate page, giving the following information for each such name: 1. Full name 2. Period during which you used this name 3. Place used If the applicant is an individual, does he or she own or operate other businesses licensed under federal or state statute or local ordinance; or if the applicant represents a corporation, does the corporation own or operate such business? NO______ YES______ If YES, attach a separate page, giving the following information for each such business: 1. Name 2. Type of business 3. Address Minnesota Tax ID#_______________________ Federal Tax ID #_____________________ City Clerk’s Office 651-747-3900 3880 Laverne Avenue North Lake Elmo, MN 55042 Has the individual or corporate applicant ever had a business license suspended or revoked? NO______ YES______ If YES, attach a separate page, giving the following information for each suspension or revocation: 1. Business name 2. Date 3. Reason for suspension or revocation. Have you previously applied for and been denied a license for a similar business? NO____ YES____ If YES, attach a separate page giving the following information for each applicant that was so denied: 1.Date and place of application 2. Type of business 3. Reason application was denied If this business will be operated / managed by someone other than the applicant, please provide the following information: Operator/Manager Name _______________________________________________________________ First Middle Last (Maiden) Date of Birth________________________Age___________ Home Telephone (_____)________________ (If applicant is an individual) Residence Address (not a P.O. Box) ______________________________________________________ Street Address City State Zip Mailing Address ______________________________________________________________________ (if different than residence) Street Address City State Zip Any falsification of answers given or accompanying material submitted will result in denial or revocation of this license. I hereby state that I have answered all of the preceding questions, and that the information contained herein is true and correct to the best of my knowledge and belief. I hereby further state that I have received no money or other consideration by way of loan, gift, contribution, or otherwise. Signature _____________________________________________ Date __________________________ Typed or Printed Name _________________________________________________________________ City Clerk’s Office 651-747-3900 3880 Laverne Avenue North Lake Elmo, MN 55042 TENNESSEN WARNING Pursuant to Minn. Statutes, 13.04, Subd. 2, 13.05, Subd. 8., and other applicable divisions of the Minnesota Government Data Practices Act, license applicants must be informed of their rights concerning the provision of private or confidential data requested in this application. Private and confidential data requested in this application is required for the following purposes: 1. To confirm the applicant's identity and qualifications to perform the functions regulated under this license. 2. To allow the city to perform necessary investigation of applicants for the protection of public health and safety. 3. To limit city liability arising from failure to exercise due care with respect to the regulation of commerce or public conduct. Private information requested, including identification, medical and criminal history data will be used by law enforcement personnel in investigating the qualifications, moral conduct, and suitability of applicants to provide service to the public. Applicants can decline to provide the information requested in this application form, however, if an applicant fails to provide the requested information or supplies incomplete or inaccurate information, the license may be denied, suspended, or revoked. If information supplied in this application is subsequently used in a criminal prosecution of the applicant, the result may include a fine, imprisonment, or other penalty order by the court subsequent to conviction. Individuals authorized access to the private or confidential data contained in this application includes city employees whose duties require such access; local, state, and federal public safety personnel conducting related investigations; and state and federal revenue authorities and lawfully mandated reporting agencies. A specific exception to the confidentiality of data supplied in this application exists as follows: Minn. Statute 13.41, Subd. 5. Any licensing agency may make any data classified as private or confidential pursuant to this section accessible to an appropriate person or agency if the licensing agency determines that failure to make the data accessible is likely to create a clear and present danger to public health or safety. Questions concerning this warning, or the effect of providing or failing to provide requested information should be directed to the City Clerk, 3880 Laverne Ave. N., Lake Elmo, Minnesota 55042, telephone number (651) 747-3914. Signature _____________________________________________ Date _________________________ City Clerk’s Office 651-747-3900 3880 Laverne Avenue North Lake Elmo, MN 55042 MASSAGE LICENSE FEE SCHEDULE Background Investigation Fee $100.00 premises $25.00 therapist License Fee $100.00 premises $50.00 therapist Annual Renewal Fee $50.00 premises $25.00 therapist Any Amendments or Changes $25.00 Please make checks payable to “City of Lake Elmo”