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

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2019 06 10 License Application Massage Therapist 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 THERAPIST
LICENSE APPLICATION
LICENSE FEE:
$52.00
INVESTIGATION FEE:
$31.00
TOTAL DUE:
$83.00
MASSAGE THERAPIST LICENSE
LICENSEE LEGAL NAME AND ADDRESS
__________________________________________
_________________________________________
D.O.B.____________________________________
PREVIOUS LEGAL NAME AND/OR ALIAS:
_________________________________________
_________________________________________
_________________________________________
_
EMAIL: ____________________________________
PHONE: ___________________________________
PRIMARY BUSINESS ADDRESS:
__________________________________________
__________________________________________
LICENSEE HEREBY SWEARS AND ATTESTS THAT ALL INFORMATION PROVIDED IN THIS LICENSE APPLICATION IS TRUE
AND CORRECT TO THE BEST OF THEIR KNOWLEDGE AND THAT LICENSEE SHALL COMPLY WITH ALL PROVISIONS
GOVERNING THEIR OPERATION UNDER A 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.
B
Y:_______________________________________
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 _________________
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.
APPLICANT MUST FILE IN PERSON IN THE
CITY CLERK'S OFFICE .
MASSAGE THERAPIST
APPLICATION CHECKLIST
Below is a list of all documents and items required by the City of Duluth to obtain an individual Massage Therapist
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.
fee must be paid or the application will not be accepted.
PROOF OF RESIDENCY AND AGE. Applicant must be eighteen (18) years of age or older. Provide a color
photocopy of applicant’s valid Minnesota Driver’s License or Minnesota ID (front and back), Passport, or any
other government-issued ID evidencing applicant’s age and residency.
TAX IDENTIFICATION FORM PURSUANT TO MINN STAT. § 270C.72, SUBD. 3, AS MAY BE AMENDED
MASSAGE ESTABLISHMENT AFFILIATION FORM. The full name and address of each massage establishment
located within the city at which the licensee will perform massage.
CERTIFIED Official Transcript showing a minimum of 500 hours or certified therapeutic massage training with
content that includes the subject of anatomy, physiology, hygiene, ethics, massage theory and research, and
massage practice from either:
1) An Accredited Institution, an Accredited Institution is an educational institution holding accredited status
with the United States Department of Education or Minnesota Office of Higher Education;
OR,
2) An Accredited Program, proof from an educational institution showing a professional massage program is or
was accredited by the Commission on Massage Therapy Accreditation (COMTA) at the time of attendance and
proof of attendance.
Note: Transcript must be sent directly from the Institution to the City Clerk’s Office. Copies will not be
accepted.
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 therapist licensee. The national background check is in addition to the background
check conducted by the Duluth Police Department.
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
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______________________
MASSAGE THERAPIST
MASSAGE ESTABLISHMENT AFFILIATIONS
List the full name and address of each massage establishment located within the city at which the applicant will perform
massage.
LICENSEE NAME: _________________________________________________________________________________
ESTABLISHMENT NAME:
ADDRESS
MASSAGE THERAPIST
AFFIDAVIT
The following questionnaire must be fully completed, signed, notarized and dated 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.
LICENSEE NAME: ________________________________________________________________________________
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 .
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):___________________
LICENSEE HEREBY SWEARS AND ATTESTS THAT ALL INFORMATION PROVIDED ON THIS AFFIDAVIT IS TRUE AND
CORRECT TO THE BEST OF THEIR KNOWLEDGE AND THAT LICENSEE
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: _
_________________________________
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 __
_______________
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2019 06 10 License Application Massage Therapist Final Fillable (City of Duluth)

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Completed 16 July 2020

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