HomeMy WebLinkAboutSauna(s) or Massage Parlor(S) License & Massage Therapist Cert/License Application
CITY OF CENTERVILLE
APPLICATION FORM FOR SAUNA(S) OR MASSAGE PARLOR(S) LICENSE
TRADE NAME DATE OF APPLICATION
LICENSING PERIOD
FULL NAME OF APPLICANT PHONE NUMBER
OWNER IF INDIVIDUAL
ADDRESS CITY STATE
DATE OF BIRTH PLACE OF BIRTH
ADDRESS OF BUSINESS
LOCATION
LIST OWNERS OF BUILDING OR PREMISE TO BE LICENSED:
NAMES ADDRESSES DATE OF BIRTH
MANAGER’S NAME ADDRESS PHONE
OPERATOR’S NAME ADDRESS PHONE
LIST THREE (3) CHARACTER REFERENCES
NAME ADDRESS PHONE
HAS APPLICANT/OWNER HIS/HER DESIGNEE EVER BEEN CONVICTED OF A CRIME,
OTHER THAN A TRAFFIC VIOLATION?
??
YES NO
IF YES, GIVE EXPLANATION ON A SEPARATE SHEET OF PAPER, INCLUDING TIME,
PLACE AND NATURE OF EACH CRIME OR OFFENSE AND DISPOSITION THEREOF.
LIST ALL CREDITORS INVOLVED IN THE CONSTRUCTION AND MAINTENANCE IN ANY
WAY PROVIDING DEBT OF EQUITY FINANCING TO SAID OPERATION:
LIST CORPORATE OR PARTNERSHIP TITLE, IF ANY
CORPORATE OR PARTNERSHIP ADDRESS:
LIST ALL OFFICERS, MANAGERS OR DIRECTORS, IF CORPORATION:
NAMES ADDRESS DATE OF BIRTH
Please submit accurate and complete business records showing names and addresses of all individuals
having an interest in business including partners, officers, owners and creditors furnishing credit for
establishment acquisition and maintenance and furnishing of said business.
Please furnish accurate documentation establishing the interest of the applicant and any other person
having interest in the premises upon which the building is proposed to be located or furnished thereof.
The documentation shall be in the form of a lease, deed, contract for deed, mortgage deed, etc. and any
other documents establishing interest of the applicant or any other person in the operation.
Please provide blueprints, diagrams, layouts, etc. showing construction and or remodeling to the
premises and specifically showing the layout of the bathing and restroom facilities to be used.
Applicants and his/her associates will strictly comply with all regulations promulgated by the City
Council of City of Centerville and all ordinances of said municipality.
I hereby certify that I have read the foregoing questions and that the answers to said questions are true
of my own knowledge. I further understand that an investigation fee, not to exceed $250.00 shall be
charged an applicant by the City.
Signature of Applicant
Subscribed and sworn to before me
This day of , 2007
(Seal)
Notary Public Signature
My Commission Expires
APPLICATION FOR MASSAGE THERAPIST CERTIFICATION/LICENSE
CITY OF CENTERVILLE
Date
MASSAGE LOCATION/ADDRESS
HOURS/DAYS OF OPERATION
NAME OF APPLICANT
(first) (middle) (last)
DATE OF BIRTH HOME TELEPHONE #:
SCHOOL ATTENDED AND DEGREES RECEIVED:
LIST QUALIFICATIONS REQUIRED TO PRACTICE MASSAGE:
LIST THREE CHARACTER REFERENCES (INCLUDE ADDRESS AND BIRTH DATE):
HAS APPLICANT EVER BEEN CONVICTED OF A CRIME, OTHER THAN A TRAFFIC VIOLATION?
YES NO
IF YES, PLEASE GIVE AN EXPLANATION ON A SEPARATE PIECE OF PAPER, INCLUDING TIME, PLACE AND
NATURE OF SUCH CRIME OR OFFENSE AND DISPOSITION THEREOF.
THE APPLICANT SHALL PROVIDE THE FOLLOWING INFORMATION:
A. EVIDENCE OF APPLICANT’S EDUCATION INCLUDING CONTINUING EDUCATION IF APPLICABLE.
B. EVIDENCE OF APPLICANT’S QUALIFICATIONS AND CHARACTER REFERENCES.
C. EVIDENCE IN THE FORM OF A CURRENT CERTIFICATE FROM A LICENSES PHYSICIAN
PRACTICING IN MINNESOTA INDICATING THAT SAID MASSAGE THERAPIST WAS EXAMINED
AND IS FREE OF ANY COMMUNICABLE DISEASE THAT WOULD DISQUALIFY THE APPLICANT
FROM ENGAGING IN THE PRACTIC OF MASSAGE.
A RENEWAL CERTIFICATE WILL BE REQUIRED EACH CALENDAR YEAR, ALONG WITH A PHYSICAL
EXAMINATION CERTIFICATE, COMPLETED APPLICATION AND RENEWAL FEE OF $50. APPLICANTS WILL
STRICTLY COMPLY WITH ALL REGULATIONS PROMULGATED BY THE CITY COUNCIL OF THE CITY OF
CENTERVILLE AND ALL ORDIANCES OF SAID MUNICIPALITY.
I hereby certify that I have read the foregoing questions and that the answers to said questions are true
of my own knowledge.
Signature of Applicant
Subscribed and sworn to before me
This day of , 2006
(Seal)
Notary Public Signature
My Commission Expires