Fillable 2019 06 10 License Application Massage Establishment Final Fillable (City of Duluth)

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2019 06 10 License Application Massage Establishment Final Fillable (City of Duluth)

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CITY OF DULUTH
CITY CLERK’S OFFICE
330 City Hall
411 West First Street
Duluth, Minnesota 55802
www.duluthmn.gov
Phone: (218) 730-5500
Fax: (218) 730-5293
MASSAGE ESTABLISHMENT
LICENSE APPLICATION
MASSAGE ESTABLISHMENT LICENSE
LICENSE FEE:
$119.00
INVESTIGATION FEE:
$31.00
TOTAL DUE:
$150.00
LICENSEE NAME AND ADDRESS:
(Individual, Partnership, Corporation, LLC)
__________________________________________
__________________________________________
__________________________________________
__________________________________________
PRIMARY OWNER, OPERATOR OR MANAGER:
__________________________________________
__________________________________________
____
______________________________________
LICENSEE:
EMAIL: ____________________________________
BUSINESS PHONE: ___________________________
LICENSED PREMISES ADDRESS:
__________________________________________
__________________________________________
__________________________________________
PRIMARY OWNER, OPERATOR OR MANAGER:
EMAIL: ____________________________________
BUSINESS PHONE:
___________________________
For Office Use Only
Date:
License No.
GOVERNMENT DATA PRACTICES ACT - CLASSIFICATION WARNING: The data you supply on this form will be used to process the license you
are applying for. You are not legally required to provide this data, but we will not be able to
process the license without it. Some of the
data will be classified as public data if and when the license is granted. Private finan
cial information including a social security number
are classified as private data and will be available to governmental personnel and other governmental agencies whose access is
necessary to perform their official duties.
LICENSEE HEREBY SWEARS AND ATTESTS THAT ALL INFORMATION PROVIDED IN THIS LICENSE APPLICATION IS TRUE
AND CORRECT TO THE BEST OF ITS KNOWLEDGE AND THAT LICENSEE
SHALL COMPLY WITH ALL PROVISIONS
GOVERNING ITS OPERATION UNDER A MASSAGE ESTABLISHMENT LICENSE AS SET FORTH IN CHAPTER 14 OF THE
DULUTH CITY CODE, ALONG WITH ALL OTHER APPLICABLE PROVISIONS OF LOCAL, STATE OR FEDERAL LAW, AS MAY
BE AMENDED.
BY:_______________________________________
LICENSEE
STATE OF _____________ ]
] ss:
COUNTY OF ___________
On this ____ day of ___________ 20___, before me, a Notary Public within and for said County and State,
personally appeared ________________, to me known to be the person named in and who executed the foregoing
instrument, and acknowledged that they executed said instrument as their free act and deed, for the uses and purposes
therein expressed.
_____________________________________
NOTARY PUBLIC
My Commission Expires _________________
MASSAGE ESTABLISHMENT
APPLICATION CHECKLIST
Below is a list of all documents and items required by the City of Duluth to obtain a Massage Establishment License
pursuant to Duluth City Code Chapter 14. Please ensure that you have completed all items listed below. Any missing
documents will delay the processing of your application. All massage licenses require a background investigation be
conducted by the City of Duluth Police Department. Please allow a minimum of two to three weeks to process a new
license application.
LICENSE PAYMENT (ANNUAL LICENSE FEE + INVESTIGATION FEE). Every question must be completed and the
fee must be paid or the application will not be accepted.
CORPORATE DOCUMENTATION (IF INCORPORATED OR PARTNERSHIP).
• Certificate of Incorporation from the Minnesota Secretary of State’s Office or proof of current
registration with the Minnesota Secretary of State establishing legal authorization to operate within the
State of Minnesota
• Executed statement listing all entity owners including percentage of ownership held by each individual
or entity.
OWNER/OPERATOR/MANAGER AFFIDAVITS. A completed, signed, and notarized Affidavit must be filed for all of
the following parties as applicable:
• All property owner(s), business owner(s), lessee(s) and/or manager(s);
• If applicant is a corporation, each officer and director of said corporation and each stockholder owning
more than ten percent of the stock of the corporation; and/or
• If applicant is a partnership, each partner including limited partners.
TAX IDENTIFICATION FORM PURSUANT TO MINN STAT. § 270C.72, SUBD. 3, AS MAY BE AMENDED.
MASSAGE THERAPIST IDENTIFICATION. The full name, date of birth, address and license number for each
massage therapist providing massage at the applicant’s establishment.
MINNESOTA WORKER’S COMPENSATION COMPLIANCE/EXEMPTION CERTIFICATE.
APPLICANT AFFIDAVIT. Must be fully completed, signed and notarized.
FIRE DEPARTMENT INSPECTION. Establishment has been inspected by the Duluth Fire Department.
HEALTH DEPARTMENT INSPECTION. Establishment has been inspected by the Minnesota Department of Health.
BACKGROUND INVESTIGATION.
Applications must include results of a comprehensive national criminal background check from one of the
background investigative providers listed below. The national criminal background check is to be obtained and
paid for by the massage establishment applicant. The national background check is in addition to the
background check conducted by the Duluth Police Department. The national background check must be
provided for the primary owner and primary operator or manager.
BACKGROUND INVESTIGATION PROVIDERS:
American Data Bank
800-200-0853
www.americandatabank.com
Hire Right
www.hireright.com
Good Hire
855-496-1572
www.goodhire.com
Universal Background Screening
1-877-263-8033
www.universalbackground.com
Verified Credentials, Inc.
20890 Kenbridge Court
Lakeville, MN 55044
1-952-985-7200
www.verifiedcredentials.com
Western Reporting
855-910-8443
www.westernreporting.com
MASSAGE ESTABLISHMENT
MASSAGE THERAPIST AFFILIATIONS
List the full legal name, date of birth, and address of each massage therapist providing massage at the applicant’s
massage establishment. A list of all massage therapists providing massage at the applicant’s establishment must remain
current and on file at all times in the City Clerk’s Office. Please supplement this form as necessary.
LICENSEE NAME: _________________________________________________________________________________
THERAPIST NAME:
ADDRESS
D.O.B.
CITY OF DULUTH LICENSE NO.
MASSAGE ESTABLISHMENT
APPLICANT AFFIDAVIT
The following affidavit must be fully completed, signed, and notarized by the applicant. Pursuant to Duluth City Code
Chapter 14, any misrepresentation, fraud, or misstated material fact herein is grounds for denial, suspension, or
revocation of a license.
LI
CENSEE NAME: ________________________________________________________________________________
1. List the method of payment under which massage therapists are paid and the economic basis upon which
massage therapists are paid:
2. Provide the legal description of the premises to be licensed together with a plan of the area showing
dimensions, location of buildings, street access, and parking facilities; include floor number, street number, and
all rooms where massage services will be conducted:
3. List all of the following (all parties identified hereunder are required to file a corresponding
Owner/OperatorAffidavit):
• All property owner(s), business owner(s), lessee(s) and/or manager(s);
• If applicant is a corporation, each officer and director of said corporation and each stockholder owning more
than ten percent of the stock of the corporation; and/or
• If applicant is a partnership, each partner including limited partners.
NAME
TITLE
OWNER/OPERATOR AFFIDAVIT ATTACHED?
4. Have any of the individuals identified in Question 3 above been convicted of any crime or offense other than a
traffic offense? Yes No If Yes, identify the individuals and provide the date, place and
nature of conviction.
5. Have any of the individuals identified in Question 3 above ever held a license to run a massage establishment or
similar business in another jurisdiction. Yes No If Yes, was such license ever revoked,
suspended or denied? Yes No If Yes, provide details of the circumstances:
6. Have any of the individuals identified in Question 3 above been disciplined pursuant to Minnesota Statutes
Chapter 146A or its successor, or similar laws of any other jurisdiction? Yes No
If Yes, identify the individuals and provide details of the circumstances:
7. Have any of the individuals identified in Question 3 above, individually or with others, made an application for a
massage establishment or similar license, which was denied? Yes No If yes, provide
details of the circumstances.
BY: __________________________________
LICENSEE
] ss:
STATE OF __
___________ ]
COUNTY OF ___________
On this ____ day of ___________ 20___, before me, a Notary Public within and for said County and State, personally appeared
________________, to me known to be the person named in and who executed the foregoing instrument, and acknowledged that they executed
said instrument as their free act and deed, for the uses and purposes therein expressed.
_____________________________________
NOTARY PUBLIC
My Commission Expires _________________
LICENSEE HEREBY SWEARS AND ATTESTS THAT ALL INFORM
ATION PROVIDED ON THIS AFFIDAVIT IS TRUE AND CORRECT TO THE BEST
OF ITS KNOWLEDGE AND THAT LICENSEE SHALL COMPLY WITH ALL PROVISIONS GOVERNING ITS OPERATION UNDER THE MASSAGE
ESTABLISHMENT LICENSE AS SET FORTH IN CHAPTER 14 OF THE DULUTH CITY CODE, ALONG WITH ALL OTHER APPLICABLE PROVISIONS
OF LOCAL, STATE OR FEDERAL LAW, AS MAY BE AMENDED.
MASSAGE ESTABLISHMENT
OWNER/OPERATOR/MANAGER
AFFIDAVIT
(Duplicate Form as Necessary)
NAME: ______________________________________
ADDRESS: ______________________________________
______________________________________
______________________________________
PHONE: ______________________________________
D.O.B: ______________________________________
PROOF OF RESIDENCY AND AGE. Owner/Operator must be eighteen (18) years of age or older. Provide a color
photocopy of valid Minnesota Driver’s License or Minnesota ID (front and back), Passport, or any other
government-issued ID evidencing applicant’s age and residency.
1. State full legal name and whether you have ever used or been known by any other name, and if so, the name(s)
and information concerning places where used:
2. List the type, name, location, and date of every business or occupation you have been engaged in during the
preceding ten years:
3. List all street addresses and dates of residency for all residences where applicant has lived in the preceding ten
years.
4. Are you currently licensed in any other community to perform massage? Yes No .
If yes, please list all locations:
5. Have you ever been arrested, charged or convicted of any felony, crime, or violation of any ordinance other than
a minor traffic offense? Yes No . If yes, provide the date, time, place and offense for
which arrests, charges or convictions were had:
6. Have you ever had an interest in, as an individual or as part of a corporation, partnership, association,
enterprise, business or firm, a massage license that was revoked or suspended within the last ten years?
7. Have you ever been the subject of an investigation, public or private, criminal or non-criminal, regarding
massage therapy? Yes No . If yes, provide details of the circumstances:
8. I attest, that I am (check one of the following boxes):
1. A citizen of the United States.
2. A noncitizen national of the United States.
3. A lawful permanent resident.
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):___________________
OWNER/OPERATOR/MANAGER HEREBY SWEARS AND ATTESTS THAT ALL INFORMATION PROVIDED ON THIS
AFFIDAVIT IS TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE AND THAT OWNER/OPERATOR/MANAGER
SHALL COMPLY WITH ALL PROVISIONS GOVERNING ITS OPERATION UNDER THE MASSAGE THERAPIST LICENSE AS SET
FORTH IN CHAPTER 14 OF THE DULUTH CITY CODE, ALONG WITH ALL OTHER APPLICABLE PROVISIONS OF LOCAL,
STATE OR FEDERAL LAW, AS MAY BE AMENDED.
BY: __________________________________
OWNER/OPERATOR/MANAGER
STATE OF _____________ ]
] ss:
COUNTY OF ___________
On this ____ day of ___________ 20___, before me, a Notary Public within and for said County and State, personally appeared
________________, to me known to be the person named in and who executed the foregoing instrument, and acknowledged that they executed
said instrument as their free act and deed, for the uses and purposes therein expressed.
_____________________________________
NOTARY PUBLIC
My Commission Expires _________________
MN STATUTE 270C.72 TAX IDENTIFICATION FORM
PURSUANT TO Minnesota Statute 270C.72, Tax Clearance Required: The licensing authority is required to
provide the Minnesota Commissioner of Revenue the business tax identification number and social security
number of each applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of
1974, we are required to advise you of the following regarding the use of this information:
1. This information may be used to deny the issuance, renewal, or transfer of your license in the event you
owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest.
2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department
of Revenue. However, under the Federal Exchange of Information Agreement, the Department of
Revenue may supply this information to the Internal Revenue Service.
3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or
renewal application.
Please supply the following information and return along with your application to the agency issuing
the license.
License applied for or renewed: _________________________________________________________________
Licensing authority: City of Duluth, St. Louis County, Minnesota
License renewal date: ______________________________________
Personal Information (if applicable)
Applicants Name: ________________________________________________________________________
Applicant’s Address: ________________________________________________________________________
Social Security Number: _____________________________
Business Information (if applicable)
Business Name: ________________________________________________________________________
Business Address: ________________________________________________________________________
MN Tax Identification Number: _____________________________________
Federal Tax Identification Number: __________________________________
Signature__________________________________________________________Date______________________
LIC 04 (11/16)
Certificate of Compliance
Minnesota Workers’ Compensation Law
This form must be completed by the business license applicant.
Print in ink or type
Minnesota Statutes § 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 Minn. Stat. 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 number (if applicable)
Business telephone number
Alternate telephone number
Business name (Provide the legal name of the business entity. If the business is a sole proprietor or partnership, provide the owner’s
name(s), for example John Doe, or John Doe and Jane Doe.)
DBA (“doing business as” or “also known as” an assumed name), if applicable
Business address (must be physical street address, no P.O. boxes)
City
State
ZIP code
County
Email address
You must complete number 1 or 2 below.
Note: You must resubmit this form to the authority issuing your license if any of the information you have provided changes.
1. I have a workers’ compensation insurance policy.
Insurance company name (not the insurance agent)
Policy number
Effective date
Expiration date
I am self-insured for workers’ compensation. (Attach a copy of the authorization to self-insure from the Minnesota
Department of Commerce; see www.mn.gov/commerce/industries/insurance/licensing/self-insurance.)
2. I am not required to have workers’ compensation insurance because:
I only use independent contractors and do not have employees. (See Minn. Stat. § 176.043 for trucking and messenger
courier industries; Minn. Stat. § 181.723, subd. 4, for building construction; and Minnesota Rules chapter 5224 for other
industries.)
I do not use independent contractors and have no employees. (See Minn. Stat. § 176.011, subd. 9, for the definition
of an employee.)
I use independent contractors and I have employees who are not required to be covered by the workers’
compensation law. (Explain below.)
I only have employees who are not required to be covered by the workers’ compensation law. (Explain below.) (See
Minn. Stat. § 176.041 for a list of excluded employees.)
Explain why your employees are not required to be covered
I certify the information provided on this form is accurate and complete. If I am signing on behalf of a business, I certify I am
authorized to sign on behalf of the business.
Print name
Applicant signature (required)
Title
Date
If you have questions about completing this form or to request this form in Braille, large print or audio, call (651) 284-5032 or
1-800-342-5354.
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2019 06 10 License Application Massage Establishment Final Fillable (City of Duluth)

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Completed 16 July 2020

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