Fillable HUNTINGTON BEACH POLICE DEPARTMENT ESTABLISHMENT REGISTRATION CERTIFICATE APPLICATION (City of Huntington Beach)

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HUNTINGTON BEACH POLICE DEPARTMENT ESTABLISHMENT REGISTRATION CERTIFICATE APPLICATION (City of Huntington Beach)

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HUNTINGTON BEACH POLICE DEPARTMENT
ESTABLISHMENT REGISTRATION CERTIFICATE APPLICATION
/
IMPORTANT INFORMATION: The following items must be completed in their entirety, as is required per 5.24 HBMC. Failure to complete the application or
providing false information will cause delay or revocation of application. Any establishment owner or operator who fails to be in possession of a valid
Establishment Registration Certificate shall be guilty of a MISDEMEANOR, punishable by a fine of one-thousand dollars ($1,000) each day the violation
occurs, or by imprisonment in the county jail for a period not to exceed six (6) months, or by both such fine and imprisonment.
2) PERSONAL INFORMATION:
Legal Name (First, Middle, Last): _____________________________________________________________________
Other Names Used
(Last 10 Years): __________________________________________________________________
______________________________________________________________________________________________
Date of Birth: ___________________ SSN: _________________________ Driver’s License____________________
Home Address: _________________________________________________________________________________
Mailing Address: ________________________________________________________________________________
Home Ph: ________________________ Cell Ph: _______________________ Work Ph: ______________________
Email: ________________________________________________________________________________________
Please indicate the best way to contact you
(Circle one): Cell Ph Email Home Ph Work Ph Mail
3) CALIFORNIA MASSAGE THERAPY COUNCIL (CAMTC) CERTIFICATE INFO:
I am certified with CAMTC: Yes CAMTC# _____________________________
No, I am not certified *
If establishment owner is not CAMTC certified a valid CAMTC Certificate must be provided for an employee or
independent contractor. List below:
Legal Name
(First, Middle, Last): ____________________________________________CAMTC# _________________
*In addition to above the establishment owner must complete fingerprinting and a background check through
the Department of Justice on forms provided by the City of Huntington Beach Police Department.
1) BUSINESS INFORMATION:
Name of Business: ____________________________________________ Tax ID #: __________________________
(If applicable)
Address: ______________________________________________________________________________________
Mailing Address: ________________________________________________________________________________
Type of Business: ____________________________Description of All Services: _____________________________
______________________________________________________________________________________________
Are you operating any other business on this premise or adjoining premise? Yes No
If yes please describe: ___________________________________________________________________________
HBPD E.R.C. APPLICATION Page 2 of 2
ERC Rev. 3-28-13
4) OTHER BUSINESSES OWNED:
(List other massage businesses owned by applicant, or partnered with for the 10 years
preceding this application.)
Business Names and Addresses: __________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
FOR OFFICE USE ONLY
Business License # ________________________ ERC#_____________________________
Cash Receipt#____________________________
Paid by: Cash Credit Card Check #________________
Processed by: ________________________________________ Date: ____________________________
5) I authorize the City of Huntington Beach and its officers, agents and employees, to seek information and conduct an
investigation into the truth of the statements set forth in the application and to ensure continual compliance with all
applicable provisions of law.
Signature: ________________________________________________________ Date: __________________________
Print name: _______________________________________________________
6) I shall employ only State Certified Massage Practitioners or Therapists to provide massage services.
Signature: ________________________________________________________ Date: __________________________
Print name: _______________________________________________________
7) I agree that all independent persons on establishment premises will be in possession of a valid current city business
license.
Signature: ________________________________________________________ Date: __________________________
Print name: _______________________________________________________
8) I acknowledge that I, as the owner/applicant, shall be responsible for the conduct of all employees or independent
contractors working on premises of the business and acknowledge that failure to comply with California Business and
Professions Code Section 4600 et seq, with any local, state, or federal law, or with the provisions of this chapter may
result in the revocation of the Establishment Registration Certificate.
Signature: _________________________________________________________ Date: ________________________
Print name: _________________________________________________________
9) The applicant, corporation or partnership shall designate one of its officers or partners to act as its responsible
managing officer/employee. Such person shall complete and sign all application forms required of an individual applicant
under this chapter. This responsible person must at all times meet all the requirements set by this chapter or the
corporation’s or partnership’s Establishment Registration Certificate may be canceled.
Signature: _________________________________________________________ Date: ________________________
Print name: ________________________________________________________
Establishment Registration Certificate Fee $565.00
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HUNTINGTON BEACH POLICE DEPARTMENT ESTABLISHMENT REGISTRATION CERTIFICATE APPLICATION (City of Huntington Beach)

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Completed 4 February 2022

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