Massage Establishment License Application

City of Royal Oak Code: Chapter 447

The undersigned hereby applies to the city of Royal Oak for a license to conduct business. In support of this application, the following representations are made:

List the proposed location where business is to be conducted:

Applicant business name:

Applicant phone number:

Business will be conducted under one of the following types of organization:

Corporation

Partnership

Proprietorship

Limited Liability Co.

Principal office of applicant:

Individual responsible for filing and certifying this application:

Is the business location(s) owned by the applicant, or leased?

Owned

Leased

Name of parent company, if any:

Is the applicant or any of its affiliates currently conducting business outside the City of Royal Oak (including other states)?

Yes

If yes to the answer above, please provide the location, the name/trade name, and the amount of years in operation.

Is the applicant, or any business entity controlled by the applicant currently conducting business within the City of Royal Oak?

Yes

If yes to the answer above, please provide the location, the name/trade name, and the amount of years in operation.

If a corporation, indicate state of incorporation and the date of incorporation:

Please upload a Certificate of Good Standing issued by the State of Michigan.

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Name and address of registered agent in Michigan:

If a partnership, indicate city / town / state of partnership:

General

Limited

Date of partnership:

If a proprietorship, list the name and address of proprietor:

List the name / title in organization / number of shares owned / percentage of each director, officer, manager and partner:

Has the applicant or any of its affiliates, directors, manager, or officers even been the subject of any civil proceeding by an federal, state, county or municipal authority challenging its ability to engage in business?

Yes

If yes to the answer above, please provide complete detail:

Has the applicant or any of its affiliates, directors, a manager, or officers ever been refused a license to engage in business or had any license revoked or suspended in any state or municipality?

Yes

If yes to the answer above, please provide complete detail:

Briefly describe the experience (business qualifications) of the applicant and its director(s), officer(s), and principal owner(s) if a corporation:

Provide a general description of the proposed business activities of the applicant and its methods of conducting business. At a minimum, include what services the applicant will provide to the public, how the applicant plans to generate business, etc.:

Please list all names and addresses of each massage therapist who is or will be employed in the said establishment

Name and address of any other massage business or other establishments in which the person owns stock or has any financial interest:

Name and address of any other massage business or other establishment owned, managed or operated wherein the business or profession of massage is carried on.

Please provide a description of any other business to be operated on the same premises or on adjoining premises owned or controlled by the applicant.

Business, Occupation or Employment Record

Furnish a complete record of business, occupation, or employment for the last 10 years immediately preceding the date of application.

NOTE: all periods of time must be accounted for, periods of unemployment should be indicated and dates given. (including name, address & telephone number of all employers)

Business, Occupation or Employment Record

NOTICE: The City of Royal Oak reserves the right to request additional information from the applicant.

Personal Disclosure Statement - City of Royal Oak

Information as indicated herein is requested to be filed by every officer, director, or owner of 10% or more of the stock of a corporate applicant, by every partner of a partnership applicant, by the owner when the application is a sole proprietorship, and certain employees of businesses as mandated by City Ordinance. A separate form is to be filed by each person. The information indicated must be furnished fully and in detail. Separate exhibits should be attached when space provided is not sufficient to set forth the information completely.

Omissions will be constructed as an intentional failure to disclose a material fact and will be sufficient grounds for denial.

The following information is furnished by the undersigned in conjunction with and is made a part of the application of:

Applicant Business Name: ___________________________________________________________

Name: ___________________________________________________________________________

Other names (to include all nicknames, maiden names, and/or aliases) ________________________

Residence Address_________________________________________________________________

_________________________________________________________________________________

Mailing address if different: ___________________________________________________________

_________________________________________________________________________________

Date of Birth: ______________________________________________________________________

Height: ___________________________________________________________________________

Weight: __________________________________________________________________________

Eye Color: ________________________________________________________________________

Hair Color: ________________________________________________________________________

Sex: _____________________________________________________________________________

Social Security Number: _____________________________________________________________

Driver License Number (State): ______________________ Number: _________________________

Telephone Number: ________________________________________________________________

Click here for a blank form to print and fill out.

Please upload a personal disclosure statement for EACH person listed above

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Affidavit

Official Signing of Application – City of Royal Oak

I, _______________________________________________ of

Name and Title of Official

___________________________________________________

Applicant Name

a corporation organized in the State of ____________________ do hereby declare

that I am duly authorized to file the foregoing application and that the statements and

representations set forth therein are true to the best of my knowledge and belief.

And ACKNOWLEDGE that the City of Royal Oak, its agents and employees are

authorized to seek information and conduct and investigation into the truth of the

statements set forth in this application and that I am required to provide such

additional information as may be requested of me.

Authorized Signature Title

STATE OF _________________________________

COUNTY OF _________________________________

Subscribed and sworn to before me, a Notary Public in and for said County, on

this _________________ day of __________________, ________________.

(NOTARY SEAL)

_____________________________________________

Signature of Notary Public

A Notary in and for _____________________________ County

State of ______________________________________

My commission expires: ________________________

You can download a blank form here to use.

Please upload your notarized affidavit.

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Background Information Consent Form

City of Royal Oak

By signing the Consent, I understand and agree to the following:

The following information about me is necessary to assist the City of Royal Oak in evaluation the application of _____________________________________________________________________.

The information will be used to evaluate, among other things, my experience, character, business reputation, general fitness, and suitability to conduct business as legally required by Ordinance 425 (with any amendments) of the City of Royal Oak.

I understand that omissions or inaccuracies in completing the application may result in denial of the application. The City of Royal Oak may also conduct an independent investigation of me which may include, but not limited to, contacting federal and state law enforcement agencies. If any information the City of Royal Oak received indicates a violation of law, the information will be shared any agency responsible for investigating or prosecuting the violation.

If the information about me would warrant denial of the application, the City of Royal Oak will give the applicant, through the person designated for contact, notice of that fact, including a statement of the legal and/or factual basis which would warrant denial and applicant’s rights in respect thereto.

Full Name: ________________________________________________________________________

Address: _________________________________________________________________________

_________________________________________________________________________________

Telephone Number: ________________________________________________________________

Social Security Number: _____________________________________________________________

Driver’s License Number (State): ______________________________________________________

Date of Birth: ______________________________________________________________________

Other names by which I am known or have used in the past: ________________________________

Signature ________________________________________________ Date ___________________

Click here for a blank form to print and fill out.

Please upload your background information consent form here.

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Authorization to Release Information

City of Royal Oak

I, _______________________________, whose residence address is _________________________

_________________________________________________________________________________

am making application to conduct business in the City of Royal Oak at: _________________________________________________________________________________

Name and address where business in the business will be conducted.

I hereby give my consent and permission to release any record, report, or information pertinent I may have to the City of Royal to obtain a business license.

Date: ______________________________________________

Signature: __________________________________________

Date of Birth: ________________________________________

Social Security Number: _______________________________

The person whose signature appears above personally appeared before the undersigned, a Notary Public in and for the above named County and State, the day and date named, and acknowledged the execution of the foregoing instrument to be the voluntary act and deed of the applicant therein named and for the purposes therein set forth, that they are duly authorized to execute the instrument, and that the statements and representations therein contained are true to the best of their knowledge and belief.

______________________________________________

Signature of Notary Public

A Notary in and for ______________________________ County

State of _______________________________________

My commission expires: _________________________

Click here for a blank form to print and fill out

Please upload your notarized authorization to release information form here.

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Criminal Offenses

Please list all criminal convictions other than misdemeanor traffic violations, including the dates of convictions, nature of the crime and place convicted.

If the application is a corporation or limited liability company, the names and residence addresses of each of the officers, directors and members of the business and of each stockholder, its address (if different from the address of the massage establishment), and the name and address of a resident agent in Oakland County, Michigan.

Charge or Indictment / Name of Charging Authority / Date/Place of Charge / Date of Discharge

You will have to obtain a criminal background check from the Michigan State Police Department by going to the website:

WWW.MICHIGAN.GOV/ICHAT.

You will have to enter a credit or debit card number for the $10 fee. Attach the results and submit with this application.

Please upload a copy of your ichat report here

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Please upload a copy of your driver's license here.

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Please upload a passport photo (color) taken within the past 60 days - 2X2 inch size (head and shoulders)

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Once you submit your application, it will be reviewed to be sure that all information fields are complete.

Once the review is complete, you will be emailed a payment link for the non-refundable $1000 application fee.

Upon receipt of payment, your application will be sent for review. You will be contacted upon approval or denial.

Applicant's Signature

First Name

Last Name

Choose how to sign

Draw Type

All information required by this application shall be provided at the applicant's expense. Upon completion of the above provided form and teh furnishings of all the foregoing information, the City of Royal Oak shall accept the application for necessary investigations. The holder of the massage establishment license shall notify the City of Royal Oak of each change in any of the date required to be furnished by this section within10 days after such change occurs.

For office use only

Amount paid / method of payment (if check, include check number) / receipt number