CITY OF LITTLE CANADA APPLICATION FOR MASSAGE THERAPY ESTABLISHMENT LICENSE

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1 CITY OF LITTLE CANADA APPLICATION FOR MASSAGE THERAPY ESTABLISHMENT LICENSE Massage Therapy Principal Use License Fee $300 Massage Therapy Accessory Use License Fee $100 (Accessory or incidental use to properly zoned beauty salon) New Application Renewal Application Please complete the following application information. If the application is by a natural person, form should be completed by such person; if by a corporation, by an officer thereof; if by a partnership, by one of the partners; if by an unincorporated association, by the manager or managing officer thereof. 1. Name of Applicant (name of individual, partnership, corporation, or association): (If Individual) 2. If accessory use, name of Beauty Salon under which applicant will be doing business, business address, and telephone number: Beauty Salon Name Business Address Business Telephone 3. Type of Applicant: Individual Partnership Corporation Association Other 4. A. If applicant is an Individual: Name Date of Birth Residence Address Residence Telephone Business Address Business Telephone Social Security Number Driver s License Number

2 5. A. If applicant is a Partnership, state full name, residence and business addresses, telephone numbers, and interest of each member in the partnership: (If more than three, include them on a separate sheet.) 1. Name Date of Birth Interest % Residence Address Residence Telephone Business Address Business Telephone Social Security Number Driver s License Number 2. Name Date of Birth Interest % Residence Address Residence Telephone Business Address Business Telephone Social Security Number Driver s License Number 3. Name Date of Birth Interest % Residence Address Residence Telephone Business Address Business Telephone 2

3 Social Security Number Driver s License Number B. The managing partner will be C. Attach a true copy of the partnership agreement, and a copy of the certificate of trade name under provisions of Chapter 333, Minnesota Statutes, certified by the Clerk of District Court. 6. A. If the applicant is a Corporation or an Association, give the name of corporation or association, branch address and telephone number, and home office address and telephone number: Name State of Incorporation or Association Branch Address Branch Telephone Number Home Office Address Home Office Telephone Number B. The full names, residence address, and telephone numbers of all officers of said corporation or association: President Residence Address Residence Telephone Number Date of Birth Social Security Number Driver s License Number Vice President Residence Address Residence Telephone Number 3

4 Date of Birth Social Security Number Driver s License Number Secretary Residence Address Residence Telephone Number Date of Birth Social Security Number Driver s License Number Treasurer Residence Address Residence Telephone Number Date of Birth Social Security Number Driver s License Number C. The full names, residence address and telephone number of all persons who singly or with others own or control an interest in said corporation or association in excess of five (5) percent: 1. Full Name Date of Birth Interest % Residence Address Residence Telephone Social Security Number Driver s License Number 4

5 2. Full Name Date of Birth Interest % Residence Address Residence Telephone Social Security Number Driver s License Number 3. Full Name Date of Birth Interest % Residence Address Residence Telephone Social Security Number Driver s License Number 4. Full Name Date of Birth Interest % Residence Address Residence Telephone Social Security Number Driver s License Number D. The full name, residence address and telephone number of the manager, proprietor, or other agent in charge of the individual s, corporation s, or association s premises to be licensed: Full Name Date of Birth Interest % Residence Address Residence Telephone 5

6 Social Security Number Driver s License Number E. Attach a true copy of the Articles of Incorporation or Association Agreement. 7. How is the property classified under the Little Canada Zoning Ordinance? 8. State full name, residence and business address, and telephone numbers of owner or owners of the building wherein the licensed business will be located, if owner is other than the applicant: Name Date of Birth Residence Address Residence Telephone Business Address Business Telephone Name Date of Birth Residence Address Residence Telephone Business Address Business Telephone 9. A true copy of the lease agreement needs to be attached. 10. What permits or licenses required by State Statutes have been applied for or issued for the premises? In what name were these applied for or issued, and what is the nature of the permit 6

7 or license? Include permit or license number. I understand that 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 of Little Canada in its determination on my application for a permit. I acknowledge the providing, or failing to provide, such information may affect the City s determination on my application. I understand this information will be made available to the City of Little Canada, its City Council, agents and representatives, as well as the Minnesota Department of Revenue, or any other person or entity authorized by law to receive said information. I release the City of Little Canada from any and all liability for its receipt and use of data received pursuant to this application. STATE OF MINNESOTA ) ) COUNTY OF ), being first duly sworn, upon his/her oath, deposes and says that he/she is the person who has executed the above application, and that the statements made therein are true of his/her own knowledge and belief. Signature Title Subscribed and sworn to before me this day of, 20. Notary Public County My commission expires 7

8 CITY OF LITTLE CANADA APPLICATION FOR MASSAGE THERAPIST LICENSE Annual License Fee - $75.00 New Application Renewal Application Please complete the following. 1. True Name 2. Residence Address 3. Residence Telephone 4. Business Address 5. Business Telephone 6. Social Security Number 7. Driver s License Number 8. Date of Birth Mo./Day/Year 9. Place of Birth County City State 10. U.S. Citizen? Yes No Naturalized? Yes No If yes, give date and place Attach a copy of the naturalization papers. 11. If you have ever used or been known by a name or names other than the true name given in No. 1 above, list such names(s), and information concerning dates and places where used: Names Dates, Place, and Circumstances 8

9 12. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. 13. Address(es) at which you have lived during preceding ten years. (Begin with present or last address, and work back.) 14. Kind, name, and location of every business or occupation you have been engaged in during the preceding ten years. (Begin with present business and work back.) Business or Street Address Nature of Business Occupation City and State Or Occupation 15. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy including a minimum of 600 hours in successfully completed course work as required by City Code. 16. Have you ever been convicted of any felony, crime, or violation of any ordinance other than traffic? Yes No If yes, given information as to the time, place, and offense for which convictions were had. 17. Have you been in military service? Yes No If yes, was discharge(s) ever other than honorable? Yes No (Upon request, you may be required to exhibit all discharges.) 9

10 18. Are you directly or indirectly interested in other establishments in the City of Little Canada to which a license of the same kind has been issued? Yes No 19. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? Yes No If yes, explain in detail: 20. Have you ever made application for a massage therapist license or similar activity and had such application denied? Yes No If yes, explain in detail: I understand that 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 of Little Canada in its determination on my application for a permit. I acknowledge the providing, or failing to provide, such information may affect the City s determination on my application. I understand this information will be made available to the City of Little Canada, its City Council, agents and representatives, as well as the Minnesota Department of Revenue, or any other person or entity authorized by law to receive said information. I release the City of Little Canada from any and all liability for its receipt and use of data received pursuant to this application. STATE OF MINNESOTA ) ) COUNTY OF ), being first duly sworn, upon his/her oath, deposes and says that he/she is the person who has executed the above application, and that the statements made therein are true of his/her own knowledge and belief. Signature Title 10

11 Subscribed and sworn to before me this day of, 20. Notary Public County My commission expires 11

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