Massage or Public Bath Permit Application

Establishment Name
Trade Name or Doing Business as Name (DBA)

Address

City

State

Zip Code

First Name

Last Name

Address

City

State

Zip Code

Phone Number

Email

Do You Have a Past Employer?
- select - Yes No

Past Employer
Manager/Supervisor First & Last Name, Business/Company Name, Address, City, State, Zip Code, Phone Number & Email

Do You Have Another Past Employer?
- select - Yes No

Past Employer
Manager/Supervisor First & Last Name, Business/Company Name, Address, City, State, Zip Code, Phone Number & Email

Do You Have Another Past Employer?
- select - Yes No

Past Employer
Manager/Supervisor First & Last Name, Business/Company Name, Address, City, State, Zip Code, Phone Number & Email

Exact Nature of The Massage or Services to be Administered?

Has The Person Ever Been Convicted of Any Crime Except Traffic Violations?
- select - Yes No

Has Such Person, in Previously Operate in this or Any Other City or State Under License, has had Such License Revoked or Suspended?
- select - Yes No

If yes, please state the reason for the suspension.

Detailed Description of Work

We accept .gif,.jpg,.jpeg,.png,.tiff,.bmp,.pdf,.txt,.rtf,.csv,.doc,.docx,.xls,.xlsx,.ppt,.pptx, .zip files under 50 MB. check total requried

The system allows you to upload a maximum of 20 documents with your application. You may upload more documents via case manager after you submit.

Add another related document

I hereby consent to the stipulated conditions.
Massage or Public Bath Permit Conditions

Enter Full Legal Name