Fillable Additional Managerial Officials and Controlling Individuals Information (Minnesota Department of Revenue)

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Additional Managerial Officials and Controlling Individuals Information (Minnesota Department of Revenue)

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Assisted Living Licensure Application Addendum:
Additional Managerial Officials and Controlling
Individuals Information
This is an addendum to the assisted living licensing application form. Use this document if
additional managerial officials or controlling individuals need to be identified when submitting
the assisted living licensure application.
Submitting Attachments
Applicants must upload attachments to the MDH application portal with their application.
No assisted living services shall be provided until MDH issues a license.
Keep a copy of application and attachment materials. They will not be returned to applicants.
Questions?
EMAIL: health.assistedliving@state.mn.us
Additional Managerial Officials and Controlling Individuals
Information
Minn. Stat, sect. 144G.12, subd. 1(4) (https://www.revisor.mn.gov/statutes/cite/144G.12)
Provide the information below for all managerial officials and controlling individuals of the
assisted living. State law requires that all applicants for assisted living licensure disclose the
legal names, email, mailing addresses and telephone numbers of all managerial officials and
controlling individuals regardless of the nature of the entity applying for licensure. The purpose
of this section is to collect information about the person(s) and/or entity responsible for the
operation this assisted living facility.
A separate addendum is required for each managerial official and controlling individual.
A controlling individual means an owner and the following individuals or entities, if
applicable: each officer of the organization, including the chief executive officer and chief
financial officer; each managerial official; and any entity with at least a five percent mortgage,
deed of trust, or other security interest in the facility.
A managerial official is an individual who has the decision-making authority related to the
operation of the facility and the responsibility for the ongoing management or direction of
the policies, services, or employees of the facility.
Direct contact means providing face-to-face care, training, supervision, counseling,
consultation, or medication assistance to residents of a facility.
1
ASSISTED LIVING LICENSURE APPLICATION ADDENDUM:
BUILDING INFORMATION
Legal name (or entity name): ____________________________________________________
Known names (if applicable): ____________________________________________________
Permanent address: ___________________________________________________________
City: _________________________________________________State: _________________
ZIP:___________________________Telephone: ____________________________________
Email address: ________________________________________________________________
Type:
☐ Controlling Official
☐ Managerial Official
Will this individual provide direct [care] contact?
☐ Yes
☐ No
Has any individual listed above been convicted of or had any of the disqualifying situations
listed in Minn. Stat. sect. 144G.12 subd. 1(13)(14)
(https://www.revisor.mn.gov/statutes/cite/144G.12)?
☐ Yes (see below)
☐ No
If yes, attach the following information for individual found guilty of the actions listed in
Minn. Stat. sect. 144G.12, subd. 1(13)-(14)
(https://www.revisor.mn.gov/statutes/cite/144G.12):
▪ Legal name of direct or indirect owner.
▪ Written explanation including the reason for action taken, dates, and the jurisdiction in
possession of your record.
▪ A copy of the disciplinary action.
For more information contact:
Minnesota Department of Health
Health Regulation Division
PO Box 64900
St. Paul, MN 55164-0900
651-539-3049 or 844-926-1061
health.assistedliving@state.mn.us
www.health.state.mn.us
3/24/2021
To obtain this information in a different format, call: 651-201-4101.
2
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Completed 28 May 2021

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