2002-07-02 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 - Personal Infonnatlon 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 carll. 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: Maiden Name: (.....) (First) (F...U Middle Namll) Residence Address: City in which you live: lusiness Name: Phone: (Street, City, ~e, Zip Code) County in which you live: (Eltabliflhment for which the m..~. lieenM il granted or ~plied for) Business Address: Phone: (Street, Cirr, SIaM, ZiP ewe) Place of Birth: Date of Birth: (Clty,Count)',Slale, (Month. Day, Year) Height: Weight: U.S. Citizen Status: Yes_ No_ Social Security Number: Name of Spouse, if applicable: Color of Hair: Color of Eyes: 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 time 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: