Agenda Packets - 2024/04/08 - Laserfiche WebLink

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3/12/24, 9:36 AM Revize Online Forms Have you ever used or been known by a name other than your true name? ❑ yes 0 no If yes, please list the name(s) and any information concerning the dates and places where used. List street addresses which you have lived during the preceding five years: Street Address City, State, Zip Street Address 1415 Jessamine Ave W #212 Saint Paul MN 55108 City, State, Zip Street Address City, State, Zip Street Address City, State, Zip List employers for the previous five years, including employers' name, address and dates of employment. Alexei Levine The Massage School 76 River Dr Hadley MN 01035 Names and address of the applicant's employers from the preceding five years: Kelly Thompson & Jason Erickson Eagan Massage Center 3424 Denmark Ave, Eagan, MN 55123 Have you ever been convicted of a felony, crime or violation of an ordinance other than a minor traffic ticket? ❑ yes ® no If yes, provide information as to time, place and offense involved in the convictions: ADDITIONAL FORMS/REQUIREMENTS: Each individual massage therapist must provide the following: • Certificate of Insurance showing liability limits of at least $1,000,000 for professional liability in the practice of massage; • Proof of a minimum of 70 hours of resident study; • Proof of 400 hours of certified therapeutic massage training as part of earning a diploma or certificate from a recognized school • Color copy of driver's license or valid government -issued ID Give your training or experience in performing massage services (name, placed and length of time): Self Employment; Minnesota Muscle Recovery, LLC (1.5 years and counting) 801 Front Ave St Paul MN 55103 Massage Therapy Dean, Instructor (7 years and counting) The Massage School 801 Front Ave St Paul MN 55103 Eagan Massage Center (8 years) 3424 Denmark Ave, Eagan, MN 55123 Self Employment; Awaken For Wellness (1.5 years) 1821 St Clair Ave, St Paul, MN 55105 Valid ID, Diploma or other Documents Choose File No file chosen PRIVACY NOTICE: I understand the information provided in this application may be considered private or confidential data. I further understand that I may not be required by law to provide such information. The purpose of providing such information is to aid the City in its determination on said application. I acknowledge that providing, or failing to provide, such information may affect the City's determination on said application. I understand this information will be made available to the City of Mounds View, its City Council, agents and representatives, as well as the Minnesota Department of Revenue, the Internal Revenue Service, or any other person or entity authorized by law to receive said information. I release the City of Mounds View from any and all liability for its receipt and use of data received pursuant to this application. * Applicant Signature Crystal D Hoon * Date 03/11/2024 Format: MM/DD/YYYY https://moundsviewmn.rja.revize.com/reports/482442 2/3