Massage Therapy Enterprise License A,lbertiville
Smog T ,n uvkm.ft city Ula.
MASSAGE THERAPY
ENTERPRISE LICENSE
Cost: 300 LICENSE NO.
I. BUSINESS INFORMATION
Business Name:
Business Address:
City: State: Zip:
Business Phone:
Have all real estate and personal property taxes been paid for the premises? (Please circle) ❑Yes ❑No
If no,how much is therein unpaid taxes?
"New applicants must provide a legal description of the property with a plan of the area showing
buildings,dimensions,street access,and parking(please attach).
Indicate Type of Business:
Individual Partnership Corporation Other
II. APPLICANT INFORMATION
Applicant Name(First,Middle,Last):
Home Address:
City: State: Zip:
Home Phone: Cell Phone:
Height: Weight: Eye Color: Hair Color:
DOB: Place of Birth: SSN#:
(This information is kept confidential and is used for background investigation purposes only.)
Will you be performing massage therapy services at the business location? (please circle) ❑Yes ❑No
Ifyes,please complete an application for an individual Massage Therapy license.
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763-496-6801
CITY OF ALBERTVILLE ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
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A,lbertiville
Smog T ,n uvkm.ft city Ula.
COMPLETE THIS SECTION IF YOU SELECTED INDIVIDUAL FOR BUSINESS TYPE:
(Use additional sheets of paper as needed.)
Name(First,Middle, Last):
Address:
City: State: Zip:
DOB: Home Phone: Cell Phone:
Have you been known by any name s other than the name above?
Y I 0
If so,please list the names,dates and places used:
Have you been convicted of a felony,crime,or violation of a law other than a I Y I IN
minor traffic offense?If so,list date,place and offense.
Please list all addresses where you have resided in the last 5 years:
List the type,name and location of every business/occupation you have been engaged in the last 5 years:
List the name(s),address(e)s and phone number(s) of your employer(s) for the past 5 years:
If you have been engaged in the operation of massage therapy services in the past,please list the name,
address,phone number and length of time you were involved in such activity:
These statements are true and correct to the best of my knowledge and I understand that falsification of
information contained in this application may result in ineligibility for a massage therapy license.
Signature Date
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763-496-6801
CITY OF ALBERTVILLE ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
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A,lbertiville
Smog T ,n uvkm.ft city Ula.
COMPLETE THIS SECTION IF YOU SELECTED PARTNERSHIP FOR BUSINESS TYPE:
(Use additional sheets of paper as needed)
Please list the names,addresses and the interest in the business of general and limited partners below. Each
general partner must complete the INDIVIDUAL information page.
Please list the designated managing partners:
A true copy of the partnership agreement must be submitted with this application as well as a certified
copy of the fled certificate of trade name,if one.
COMPLETE THIS SECTION IF YOU SELECTED CORPORATION FOR BUSINESS TYPE:
(Use additional sheets of paper as needed)
State of
Name of Corporation: Corporation:
Please list the names of those persons in charge of the premises to be licensed(manager,corporate officers,
proprietor). Each must complete the INDIVIDUAL information page.
Please list the persons who own or have a controlling interest in the corporation or are officers of the
corporation.
Please list the designated managing officers:
A true copy of the certificate of incorporation and,if a foreign corporation,a certificate of authority
must be submitted with this application.
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763-496-6801
CITY OF ALBERTVILLE ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
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A,lbertiville
Smog T ,n uvkm.ft city Ula.
III. BUILDING INFORMATION (if not owned by business or applicant)
Owner Name(First,Last):
Address:
City: State: Zip:
Phone: E-mail:
Property Manager(First,Last):
Phone: E-mail:
IV. MASSAGE THERAPISTS EMPLOYED BY BUSINESS
Please provide a list of all massage therapists that will be working in your establishment. (Use
additional paper if needed.)
V. IMPORTANT REMINDERS
❑ A therapeutic massage enterprise may only employ licensed massage therapists to provide massage
services.
❑ Hours of operations for massage enterprises may not extend past 9 p.m.or before 7:00 a.m.
❑ You must schedule an annual inspection of your facility. Our building inspection services are run
through the City of St.Michael and you may call 763-497-9923 to schedule an inspection. This
inspection must occur before we can issue your license.
❑ A therapeutic massage enterprise must follow all State health and sanitation guidelines.
❑ Once licensed,the license certificate must be posted in a conspicuous spot in your facility.
VI. APPLICANT OATH
I hereby state:
• The answers and statements given by me are true and accurate to the best of my knowledge and
belief.
• I understand that providing false information in this application may result in denial of a license.
Signature of Applicant Date
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763-496-6801
CITY OF ALBERTVILLE ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
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A,lbertiville
Smog T ,n uvkm.ft city U1•.
BUSINESS TAX IDENTIFICATION INFORMATION
Pursuant to Minnesota Statute 270C.72,the agency issuing you this license is required to provide to the
Minnesota Commissioner of Revenue your Minnesota business tax identification number and the Social
Security number of each license applicant Under the Minnesota Government Data Practices Act and the
Federal Privacy Act of 1974,we must advise you that:
• This information may be used to deny the issuance,renewal or transfer of your license if you owe the
Minnesota Department of Revenue delinquent taxes,penalties or interest;and
• The licensing agency will supply it only to the Minnesota Department of Revenue.However,under
the Federal Exchange of Information Act,the Department of Revenue is allowed to supply this
information to the Internal Revenue Service;and
• Failure to supply this information may jeopardize or delay the issuance of your license or processing
your renewal application.
Please fill in the following information and return this form along with your application to the agency issuing
the license. Do not return this form to the Department of Revenue.
Licensing Authority: City of Albertville
I. LICENSE INFORMATION
Name of license being applied for:
License application or renewal date:
II. PERSONAL INFORMATION
Applicant's Name (Last,first,middle initial):
Applicant's Address:
Social Security Number:
III. BUSINESS INFORMATION
Business Name:
Business Address:
Minnesota Tax Identification Number:
Federal Tax Identification Number:
Signature: Date:
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763-496-6801
CITY OF ALBERTVILLE ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
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bertiville
sffmvrn uvkm.ft city Ula. LIC 04(3/13)
Certificate of Compliance
Minnesota Workers' Compensation Law
THIS FORM MUST BE COMPLETED BY THE BUSINESS LICENSEAPPLICANT
PRINT IN INK or TYPE.
Minnesota Statutes,Section 176.182 requires every state and local licensing agency to withhold the issuance or
renewal of a license or permit to operate a business in Minnesota until the applicant presents acceptable
evidence of compliance with the workers'compensation insurance coverage requirement of Minnesota Statutes,
Chapter 176.If the required information is not provided or is falsely stated,it shall result in a$2,000 penalty
assessed against the applicant by the Commissioner of the Department of Labor and Industry.
A valid workers'compensation policy must be kept in effect at all times by employers as required by law.
LICENSE or CERTIFICATE NO(if applicable) BUSINESS TELEPHONE NO. FAX TELEPHONE NO.
BUSINESS NAME(Use the person(s)name if business structure is sole proprietor or partnership(i.e.,John Doe,or John Doe and Jane Doe),
otherwise it is the legal name of the business entity.)
DBA("doing business as"or also known as an assumed name)(if applicable)
BUSINESS ADDRESS(must be physical street address,no PO boxes) CITY STATE ZIP CODE
COUNTY EMAIL ADDRESS
YOUR LICENSE OR CERTIFICATE WILL NOT BE ISSUED WITHOUT THE
FOLLOWING INFORMATION. You must complete number 1 or 2 below.
NUMBER 1 - Workers' compensation insurance policy information
INSURANCE COMPANY NAME(not the insurance agent) NAIC Number
POLICY NO. EFFECTIVE DATE EXPIRATION DATE
NUMBER 2 - Reason for exemption from workers' compensation insurance
If you have questions regarding the need to obtain workers'compensation coverage,including exemptions,
contact 651.284.5032 or 1-800-342-5354.
❑ 1 have no employees.(See Minn. Stat.§ 176.011,subd.9 for the definition of an employee.)
❑ I am self-insured for workers'compensation(attach a copy of the authorization to self-insure from the
Minnesota Department of Commerce).
❑ I have employees but they are not covered by the workers'compensation law. (See Minn. Stat.§ 176.041
for a list of excluded employees.) Explain why your employees are not covered:
❑ Other:
I certify that the information provided on this form is accurate and complete.If I am signing on behalf of a business,I certify
that I am authorized to sign on behalf of the business.
PRINT NAME
APPLICANT SIGNATURE(required) TITLE DATE
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763-496-6801
CITY OF ALBERTVILLE ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
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A,Ibertvillc
Small'rown uVIIng.1119 C1W urt.
BACKGROUND INVESTIGATION
CONSENT FORM
APPLICATION TYPE:
❑ Massage Therapy—Individual ❑ Liquor License
Date: ❑ Massage Therapy—Business ❑ Mobile Food Truck
(Ice Cream Vendor)
Last Name, First Name, Middle Name(full)of Applicant(please print):
Maiden,Alias or Former(please print):
Date of Birth: Place of Birth: Sex(M or F):
Month/Day/Year
Social Security Number(optional):
The undersigned, having filed an application with the City of Albertville for a business license, realizing that the
City has need to investigate the background and history of the applicant in order to better evaluate his or her
application does hereby authorize and request Wright County Sheriff's Office,MN Bureau of Criminal
Apprehension,every law enforcement official and every other person,firm,officer,corporation,association,
organization or institution having control of any documents,records,or other information pertaining to me
to furnish the original or copies of such documents,records and other information to the City or any of its
representatives to inspect and make copies of any such documents, records, and other information; I further
authorize any such persons to answer any inquiries,questions, or interrogations concerning the undersigned,
which may be submitted to them by the City or its authorized representative, I fully understand that the
information so obtained by the City may be used by it in its evaluation of my application.
I hereby release and exonerate any person who shall comply with the authorization and request made herein
from any and all liability of every nature and kind growing out of and in any way pertaining to the furnishing or
inspection of such documents, records, and other information.
Signature of Applicant Date
Subscribed and sworn before me,this day of 20
Signature of Notary Public
Notary Seal
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763.496.6801
CITY OF ALBERTVILLE ALBERTVILLE, MN 55301 WWW.CI.ALBERTVILLE.MN.US
A,Ibertvillc
Small'rown UWng.1119 C1W urt.
TENNESSEN WARNING
In connection with your request for a license,the City has asked that you provide information about yourself which
may be classified as private,confidential, nonpublic,or protected nonpublic under the Minnesota Government
Data Practices Act.This means that this data is not ordinarily available to the general public.Accordingly,the City is
required to inform you of the following:
1. The purpose and intended use of the information requested is to determine if you are eligible for a
license from the City of Albertville.
2. You are not legally obligated to supply the requested information.
3. The known consequence of supplying the requested information is that the information or further
investigation could disclose information which could cause your application to be denied.
4. The known consequence of refusing to supply the requested information is that your request for a
license cannot be processed.
S. A criminal charge, arrest,or conviction will not necessarily bar you from obtaining a license with the
City, unless the conviction is related to the matter for which the license is sought, according to
Minnesota Statute 364.03. However,failure to reveal the requested criminal information will be
considered falsification of the application and may be used as grounds for the denial of the
application.
6. Other governmental agencies necessary to process your application are authorized by law to receive
the information provided.
The undersigned, by signing this notice,acknowledges that he/she has read and understood the contents of this
notice and constitutes agreement of the Tennessen Warning and its application.
Applicant's Signature Date
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763.496.6801
CITY OF ALBERTVILLE ALBERTVILLE, MN 55301 WWW.CI.ALBERTVILLE.MN.US