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Massage Therapy Establishment License Renewal Application Corporation/Franchise

  1. For License Year Ending June 30, 2024
  2. Type of Applicant *
    1. Attach Proof of MN Tax ID Form 


    2. Workers Compensation Insurance:
    3. OR I am not required to have worker's compensation liability coverage because:
    4. Section 1: Applicant Information

      Complete appropriate Section for Individual, Partnerships or Corporation/Other. 

    5. Individual Applicant

      If you are an Individual Applicant complete this section 

    6. Have you ever used or been known by any name other than the legal name given above?
    7. Partnership Applicants

      If you are a Partnership complete this section for general and limited partners.   

    8. Have you ever used or been known by any name other than the legal name given above?
    9. Have you ever used or been known by any name other than the legal name given above?
    10. Corporation/Other Applicant

      If you are a Corporation/Other Applicant complete this section.

    11. Section 2: Persons in charge of Licensed Establishment

      General Manager, Proprietor, Managing Partner or any other individual or agent in charge of  establishment.  

    12. Section 3: History
    13. Have you, your spouse, parent, brother, sister or the child of either you or your spouse, ever been engaged as an employee or operated a spa, salon or other business which offered massage? If yes, give dates and places.
    14. Do you and/or your spouse have a direct or indirect intertest in any other establishment to which a massage therapy license has been issued? If yes, list names and addresses.
    15. Have you, your spouse, parent, brother, sister or the child of either you or your spouse, ever been convicted of any crime or violation? If yes, give date, place and nature of conviction. .
    16. Have you, or your spouse had any intertest in any previous massage establishment license that was revoked or suspended or not renewed? If yes, explain in detail.
    17. Have you individually, or with others, made an application for a massage related license which was denied? If yes, state circumstances.
    18. Background Check Required

      Please Complete and return the Tennessen form (pages 1-2) and follow instruction to initiate the background check. Your application cannot be processed until this step is completed.   

      Background Check Instructions and Tennessen Form

    19. Please read carefully

      The information that you are asked to provide on the application is classified by State law as either public, private or confidential. All data, with the exception of driver’s license numbers and social security numbers, will constitute public record if and when the license is granted. Our intended use of the information is to perform the background check procedures required prior to license issuance. If you refuse to supply the information, the license application may not be processed.

      Falsification of answers given or material submitted will result in denial of application.

       

       

       


    20. Leave This Blank:

    21. This field is not part of the form submission.

    1. Roseville MN Homepage

    Contact Us

    1. Roseville City Hall

    2. 2660 Civic Center Drive

    3. Roseville, MN 55113


    4. Monday - Friday
      8:00 a.m. - 4:30 p.m.


    5. Phone: 651-792-7000

    6. Email Us

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