Fillable TherapeuticMassageLicense2019Fillable City of Farmington

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TherapeuticMassageLicense2019Fillable City of Farmington

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CITY OF FARMINGTON
LICENSE PROCESS
Therapeutic Massage License
A license is not required for massage therapists working in a medical, chiropractic or dental office.
An applicant and all employees must have 100 hours of certified therapeutic massage training from an
approved school recognized by a national or state professional therapeutic massage organization. Please
review Title 3 Chapter 15 of the City Code for complete details. All licenses expire December 31 of each
year. Following is the process to obtain a Therapeutic Massage license:
1. Application forms, fees and a Certificate of Insurance showing coverage through December 31 of
the current year should be submitted to the city of Farmington at least three weeks prior to a City
Council meeting.
2. A background check will be performed by the Farmington Police Department.
3. A public hearing is required to be held at a City Council meeting. The public hearing requires 10
days’ notice prior to the meeting. The public hearing notice is submitted to the newspaper a week
prior to this 10-day period. Council meetings are held the first and third Mondays of every month.
4. Upon City Council approval, a license is issued. The entire process takes approximately three
weeks.
5. Fees: Business License $50 (includes one therapist)
Business Investigation $300
Therapist Investigation $200
Additional Therapists $50/each
Total fee upon application: $550 (if one therapist)
Yearly Renewal Fee: $50
If you have questions, please contact:
Cynthia Muller, Administrative Assistant
City of Farmington
430 Third Street
Farmington, MN 55024
Tel: 651-280-6803
E-mail: CMuller@FarmingtonMN.gov
Checklist for Therapeutic Massage License
Business Name: _________________________________________
Please return this list with your application materials. Incomplete applications cannot be
processed until all of the items listed are received and complete.
Required Applicant City Staff
Documents Initials Initials
1. Therapeutic Massage Practitioner License App. (Form MLIC2009) ____________ ____________
2. Workers’ Comp. Certificate of Compliance (Form FGTN2009) ____________ ____________
3. Certificate of liability insurance __________ __________
4. All applicable Fees (See fee schedule below) ____________ ____________
5. Copy of Therapeutic Massage Ordinance __________ ___N/A____
For New Applicants:
Recent photo of applicant __________ __________
Birth certificate or naturalization papers __________ __________
Copy of lease for business space (if renting) __________ __________
Evidence of educational qualifications listed on application; __________ __________
Including original or certified copies of degrees or diplomas.
License Fees
Renewal of existing license
Renewal $50
New License:
Business License $50 (includes 1 therapist)
Therapist License $50 (for each additional therapist)
Business Investigation $300
Therapist Investigation $200
Application for Therapeutic Massage License
(Form MLIC2009)
APPLICANT INFORMATION
Applicant’s Full Name:_______________________________________ Date of Birth ____/____/________
(First) (Middle) (Last)
Maiden Name or Any Other Names Used:____________________________________________________
Address:______________________________________________________________________________
(Street) (City, State, ZIP) (County)
Home Phone: __________________ Cell Phone:___________________ Email: ____________________
Are you a U.S. citizen? ___Yes ___No
Naturalized? ___Yes ___No If yes, date/place _______________
TRAINING / EXPERIENCE
1. Have you ever received formal training in massage? ____Yes ____No
If yes, please complete the following:
Name of school and address: _______________________________________________________
Dates attended: __________________________________________________________________
Hours of training: _________________________________________________________________
Diploma received: ________________________________________________________________
By whom is the school accredited: ___________________________________________________
2. How long have you worked as a massage practitioner? __________________
3. List all places of employment in this field during the last 5 years: ____________________________
_______________________________________________________________________________
_______________________________________________________________________________
4. List your present employer, address and telephone number: ______________________________
_______________________________________________________________________________
5. Have you worked as a massage therapist in another municipality? ____Yes ____ No
If yes, please provide name of municipality and dates: ____________________________________
_______________________________________________________________________________
6. Have you ever been convicted of any felony, crime, or violation of any city ordinance other than
traffic related? ____Yes ____ No
If yes, please complete the following:
Date of arrest: ____________ Municipality: ___________________________________________
Charge: _______________________________________________________________________
Date of Conviction: __________ Sentence received: _____________________________________
7. Have you ever had a license denied, revoked or suspended? ____Yes ____ No
If yes, please complete the following:
Where: ______________________________ When: ____________________________________
Type of license: _________________________________________________________________
Reason: _______________________________________________________________________
8. Have you ever been committed for one of the following:
Psychological problems _____ Inebriation _____ Drug Use _____ Alcohol Use ______
Other, please explain _____________________________________________________________
9. At what location(s) within the city of Farmington do you intend to perform massage: ___________
_______________________________________________________________________________
10. Will you be leasing property for your therapeutic massage business? ____Yes ____ No
If yes, please provide a copy of the lease and the owner’s name, address & phone number:
_______________________________________________________________________________
REFERENCES
11. List the name and address and phone number of two persons who can attest to your character:
________________________________ _________________________________
________________________________ _________________________________
________________________________ _________________________________
________________________________ _________________________________
Please read the following statements carefully.
By signing below, you agree to, and are bound by each item:
I have received a copy of the city of Farmington Therapeutic Massage Ordinance and will
familiarize myself with its provisions.
I understand that a criminal conviction will not bar me from obtaining a license unless the conviction
is directly related to the occupation for which the license is sought and there is no showing of
sufficient rehabilitation and present fitness to perform the duties of the occupation. I understand
that failure to reveal a criminal conviction is falsification of the application and constitutes grounds
for denial of license.
The information I have provided on this application is truthful. I authorize the city of Farmington to
investigate the information and contact persons/organizations named on this application.
Name of Applicant (please print) ___________________________________________________
Signature _________________________________________________Date _______________
Subscribed and sworn to before me this _______ day of _______________, ________.
Signature of Notary Public __________________________________
APPROVALS
Department Signature Date Comments
Police ______________________ __________ _____________________________
City Clerk/Deputy Clerk_____________________ __________ _____________________________
Please return completed application to: City of Farmington
Attn: Licensing
430 Third Street
Farmington, MN 55024
CITY OF FARMINGTON
GENERAL AUTHORIZATION AND RELEASE OF DATA
In order to comply with State and Federal Data Privacy Act Laws, the city of Farmington is requesting your
authorization and consent to permit the city to conduct a background investigation. Please provide the
following personal data, read the paragraphs below and sign where indicated.
Full Name: ____________________________________________________________________
(First, Middle, Last)
Address: ______________________________________________________________________
Number Street City County State Zip Code
Date of Birth: _________________ Driver’s License Number: __________________________
Month/Date/Year
Have you ever been convicted of any crime, either felony or misdemeanor? ________ If yes, please state
place and nature of offense: _____________________________________________
______________________________________________________________________________
I, the undersigned, hereby authorize and grant my informed consent to permit the Bureau of Criminal
Apprehension (hereafter “BCA”) and the Farmington Police Department (hereafter “FPD”) to release to and
make available to the city of Farmington, Minnesota (hereafter “city”) and/or its representatives all data
classified as private which concerns me and which may be in your possession. The data, classified as
private under M.S. 13.02, Subd. 12, includes all data which has been collected, created, received, retained or
disseminated in whatever form which in any way relates to my dealings with the BCA and/or the FPD. I
understand the purpose of permitting the city to have access to this information is to determine my
suitability for licensure.
By signing this authorization, I hereby release the BCA and the FPD from any and all liability which
otherwise may or does accrue as a result of the release of any and all data, regardless of its accuracy. I also
release the city from any and all liability for its receipt and use of data received pursuant to this consent. I
understand that if I am rejected on the basis of a criminal conviction, I will be notified in writing and be
given rights of redress subject to applicable laws. I also understand that I am not legally required to sign
this form, but if I do not, the city will not be able to determine whether my conviction record is a license-
related consideration.
This authorization shall be valid for a period of one year, but I reserve the right, at any time prior to that
expiration, to cancel the written authorization by providing written notice to the city of that intent.
_______________________________________________ ________________________
(Signature) (Date)
_______________________________________________
(Full Name Printed)
Please return to:
City of Farmington
Attn: Administration
430 Third Street
Farmington, MN 55024
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CITY OF FARMINGTON – DATA PRACTICES ACT NOTICE
Minnesota law requires that you be informed of your rights as they pertain to private information (“private
data”) collected from you by the city of Farmington (“the city”). Private data is that information held by the
city which is available to you, but not to the public.
You have the right to refuse to provide the information requested on this application form, however, without
certain information, the city may be unable to approve the license applied for. If you feel that certain
information requested is an unwarranted invasion of privacy, please contact the Human Resources Director.
The dissemination and the use of private data we collect is limited to that necessary for the administration
and management of the city’s licensing program. Persons or agencies with whom this information may be
shared include:
City personnel, including law enforcement personnel, administering the license program;
The Bureau of Criminal Apprehension;
The city attorney and support staff of the city attorney’s office;
Federal, state, local, and contracted private auditors;
Federal and state agencies with oversight or responsibility related to the licensed business;
Those individuals or agencies as to whom you give your express written permission for release of
the information.
Unless otherwise authorized by state statute or federal law, other governmental agencies utilizing the
reported private data must also treat the information as private.
You may wish to exercise your rights as contained in the Minnesota Government Data Practices Act. These
rights include:
The right to see and obtain copies of data maintained about you;
The right to be told the contents and meaning of the data; and
The right to contest the accuracy and completeness of the data.
To exercise these rights, contact the Farmington Human Resources Director at 430 Third Street,
Farmington, MN 55024 (651) 280-6800. I have read and I understand the above information regarding my
rights as a subject of government data.
___________________________________________ _______________________
Applicant Date
CERTIFICATION OF COMPLIANCE
MINNESOTA WORKERS’ COMPENSATION LAW
Form FGTN2009
Minnesota Statute, 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 or engage in an activity in
Minnesota until the applicant presents acceptable evidence of compliance with the workers’
compensation insurance coverage requirement of Chapter 176. The information required will be
collected by the licensing agency and retained in their files. The information required is: name of
insurance company, policy number, and dates of coverage or permit to self-insure.
This information is required by law, and licenses and permits to operate a business may
not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this
information is not provided or falsely stated, it may result in a $2,000 penalty assessed
against the applicant by the Commissioner of the Department of Labor and Industry.
Insurance Company Name: ______________________________________________________
(Not the insurance agent)
Policy Number: ________________________________________________________________
Dates of Coverage: ____________________________ to ______________________________
(or)
I am not required to have workers’ compensation liability coverage because:
( ) I have no employees.
( ) I am self-insured (include permit to self-insure).
( ) I have no employees who are covered by the workers’ compensation law,
(these include: spouse, parents, children and certain farm employees).
I certify that the information provided above is accurate and complete and that a valid workers’
compensation policy will be kept in effect at all times as required by law.
Name: ________________________________________________________________________
(Last) (Middle) (First)
Doing business as (DBA): _______________________________________________________
(Business name if different than your name)
Business address: _____________________________________________________________
(Street) (City, State, ZIP)
Phone: _________________________ Email: ________________________________________
Signature: _______________________________________Date: ________________________
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176.182 BUSINESS LICENSES OR PERMITS; COVERAGE REQUIRED
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 Section 176.181,
subdivision 2, by providing the name of the insurance company, the policy number, and the dates
of coverage or the permit to self-insure. The commissioner shall assess a penalty to the employer
of $2,000 payable to the assigned risk safety account, it the information is not reported or is falsely
reported.
Neither the state nor any governmental subdivision of the state shall enter into any contract
for the doing of any public work before receiving from all other contracting parties acceptable
evidence of compliance with the workers’ compensation insurance coverage requirement of
Section 176.181, subdivision 2.
This section shall not be construed to create any liability on the part of the state or any
governmental subdivision to pay workers’ compensation benefits or to indemnify the special
compensation fund, an employer, or insurer who pays workers’ compensation benefits.
HIST: 1982 c 346 s 94; 1983 c 290 s 114; 1987 c 332 c 332 s 47; 1992 c 510 art 3 s 19; 1995 c
231 art 2 s 72
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Completed 12 July 2020

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