2001-04-03 P & Z Agenda - Laserfiche WebLink

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FOR POUCE DEPARTMENT USE Date of Application: -1-1_ CITY OF MINNETONKA Reviewed Denied Approved IN SUPPORT OF AN APPLICATION FOR A NEW MASSAGE SERVICE BUSINESS LICENSE PART 2 - Personallnfonnation This application form requests information which may be classified as private or confidential under the Minnesota Data Practices Act. This information is required by State law or City ordinance. The information will be used to determine your eligibility for issuance of a license, permit, or identification card. Failure to provide the information will result in a denial of the license, permit. or identification carel. Directions: This form must be filled out with typewriter or by printing in ink by the sole owner, by each partner, by each officer, or director, by each manager, proprietor or other with management responsibilities for the premises, by each person who by combined ownership or control has an interest in a corporation or association in excess of 5%. True Name: Residence Address: Maiden Name: (laIt) (Fnt) (FuJI MiddJe NeI.) Phone: (Street, City, SllIle, Zip Code) ^ity in which you live: usiness Name: County in which you live: (Establiltlment kif which the mlllMQ8 IiceOM is granted or applied for) Business Address: Phone: (SIrHt. City, State, ZiP Code) Place of Birth: Date of Birth: Height: U.S. Citizen Status: (City, county, State) Weight: Yes_ No_ Color of Hair: (Month, Day, Year) . Color of Eyes: Social Security Number: Name of Spouse, if applicable: If naturalized, date and place: Driver's License Number: 1. Is the applicant licensed in any other community? Yes No If yes, where: 2. Has the applicant been denied a massage license by any licensing authority? Yes No If yes, give the name and location of the licensing authority, approximate lime period of the denial, and the reason given for the denial: 3. Does the applicant have any training or experience in performing massage service? Yes No If yes, specify the training or experience: