2. For License Year Ending June 30, 2024
4. Type of Applicant *

   1. Individual

   1. Partnership

   1. Corporation/Other
6. Business Name *
8. Business Address*
10. Business Phone*
11. Email*
13. MN Tax ID

    Attach Proof of MN Tax ID Form 

    
    

14. Federal Tax ID
16. Workers Compensation Insurance:
18. Name of Insurance Company
20. Policy Number
21. Dates of Coverage
23. OR I am not required to have worker's compensation liability coverage because:

    1. I have no employees covered by the law
    2. Other (specify below)
25. Please specify here:
29. Section 1: Applicant Information

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

31. Individual Applicant

    If you are an Individual Applicant complete this section 

33. First Name
34. Middle Name
35. Last Name
37. Address*
39. City*
40. State*
41. ZIP*
43. Phone*
44. Email*
46. Have you ever used or been known by any name other than the legal name given above?

    1. Yes
    2. No
48. If yes, list each full name along with dates and places where used.
50. Partnership Applicants

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

52. First Name
53. Middle Name
54. Last Name
56. Address
58. City
59. State
60. ZIP
62. Phone
63. Email
65. Have you ever used or been known by any name other than the legal name given above?

    1. Yes
    2. No
67. First Name
68. Middle Name
69. Last Name
71. Address
73. City
74. State
75. ZIP
77. Phone
78. Email
80. Have you ever used or been known by any name other than the legal name given above?

    1. Yes
    2. No
82. Corporation/Other Applicant

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

84. President First Name
85. Middle Name
86. Last Name
88. Address
90. City
91. State
92. ZIP
94. Phone
95. Email
97. Vice President First Name
98. Middle Name
99. Last Name
101. Address
103. City
104. State
105. ZIP
107. Phone
108. Email
110. Secretary First Name
111. Middle Name
112. Last Name
114. Address
116. City
117. State
118. ZIP
120. Phone
121. Email
123. Treasurer First Name
124. Middle Name
125. Last Name
127. Address
129. City
130. State
131. ZIP
133. Phone
134. Email
138. Section 2: Persons in charge of Licensed Establishment

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

140. First Name
141. Last Name
143. Address1
145. City
146. State
147. Zip
149. First Name
150. Last Name
152. Address2
154. City
155. State
156. Zip
160. Section 3: History
162. 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.

     1. Yes
     2. No
164. If you answered yes, please provide details.
166. 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.

     1. Yes
     2. No
168. If you answered yes, please provide details.
170. 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. .

     1. Yes
     2. No
172. If you answered yes, please provide details.
174. 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.

     1. Yes
     2. No
176. If you answered yes, please provide details.
178. Have you individually, or with others, made an application for a massage related license which was denied? If yes, state circumstances.

     1. Yes
     2. No
180. If you answered yes, please provide details.*
182. 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

184. Please complete and upload the following documents:

     Proof of MN Tax ID Information and MN Workers' Compensation Law Certificate of Compliance

     
     

186. 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.

      

      

      

     
     

Leave This Blank:


188. 1. Receive an email copy of this form.
189. Email address

     This field is not part of the form submission.

190. Submit Submit and Print

* indicates a required field