Group Home RegistrationDEPARTMENT
OF HEALTH
Addendum to Registration Form Housing With
Services (HWS) Establishment
Applicants for a HWS registration certificate issued by the Minnesota Department of Health
under Minnesota Statutes, Chapter 144D, are responsible for contacting the municipality where
the establishment will be located to inquire about applicable local requirements (M.S.144D.06).
The applicant is responsible for taking all necessary actions as directed by the municipality to
comply with local ordinance requirements (M.S.144D.06). Please document the following
regarding your contact with the local municipality:
Name of City/Municipality:
Date of Contact:
-Z/ //z/
Name and Title of Official:
Official's Contact Information — Phone and Email:
Name of HWS Establishment: (-A 9-� K L�.10 ESOT A L.L c-
Address:
4 2 7 41- D A W 61, D 9-1V F,
City/Zip: F, A 61 h,#)> M N 5 5 l ;23
Name and Title of Person Responsible for Completion of this Page:
K . �4 M/,�-tj � (!)/,/3
Name (Type or Print) (Title)
c 2( 1 6/ Z-0-
(Signature) (Date)
Make a copy of this form for your records and send the completed form with your HWS
Registration Form to:
Minnesota Department of Health
Licensing and Certification Program
P.O. Box 64900
St. Paul, MN 55164-0900
FAILURE TO SUBMIT A COMPLETE APPLICATION MAY RESULT IN DENIAL OF THE
REGISTRATION CERTIFICATE.
5/16/17
To obtain this information in a different format, call; 651-201-4101.