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EA185684 - Building - Commercial/Industrial - Deeply Kneeded Massage - Issued Date 08/02/2023 PERMIT City of Eagan Permit Type: Building ® ® Permit Number: EA185684 3830 Pilot Knob Rd \ \\." °a®°a° Eagan,MN 55122 \""` 4p EAGAN (651)675-5675 * E A 1 8 5 6 8 4 www.cityofeagan.com Date Issued: 8/2/2023 Site Address: 4450 Erin Dr 200 C Lot: 004 Block: 5 Addition: Honey Tree 1st PID:10-33500-05-004 Use: Deeply Kneeded Massage 3 5 QJ 0 Description: Sub Type: Commercial/Industrial Construction Type: Work Type: Massage Therapy License Description: Census Code: - Occupancy: Zoning: Square Feet: 0 Comments: Deeply Kneaded Massage Denise-(952)200-2330 Fee Summary: Massa e Therapy Inspection $0.00 Total: $0.00 Contractor: Owner: - Applicant - Olson Commercial Properties LLC 1585 Thomas Center Dr Ste 101 Eagan MN 55122 This permit shall be null and void if work does not start within 180 days of issuance, or if work is suspended for 180 days or more after started. I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Applicant/Permitee: Signature ssued B : Signature MASSAGE THERAPIST LICENSE EAGAN MA 3830 Pilot Knob Road APPLICATION Eagan,MN 55122 Annual License Fee:$25 Licensing:(651)675-5031 Fax: (651)675-5012 Non-Refundable Background Investigation Fee:$100 License Term:July I to June 30 Name(first,middle,maiden/last): j� D4Z I J Residence Address: l ter` Av ' =HomePhone: (� vS 12, lelo® Alternate Phone:00 ( ) Email Ad ress: kateoAeI 19 Name of Licensed Massage Therapy Establishment where on will b ployed: f OL 6� Areou yancensed2as m age therapist in another community? Yes If yes,where? Have you been denied a massage therapist license by any licensing authority? Yes o If yes,describe: if you have ever used or been known by a name or names other than the true name given above,list such name(s)and information concerning the dates and places used: Are you prese%!;�� �9 � is? es [ NoIf yes,where? 1 Cu rr4Si1 F (�. M Address(es)at which you have lived during the preceding five years,beginning with the most recent: Dates Street eet ( �Cj ty and State _-- t Occupation history for the preceding five years,beginnmg'with the most recent: Occupation Emplo gr dte t +ti L city �Sta ' as 7 y f2v�c 5 e� 1 ;2 0';?o re Have you ever been convicted of any felony,crime or violation of any ordinance,other than traffic? Yes No If yes,please explain: List the names,addresses and phone numbers of three people of good moral character,not related to the applicant or financially interested in the premises,who may be contacted as to the applicant's character: phone Number KNE; i�,ob� goy� �� �! arl�t.5 isrl s 2.5 I, a CA W-, , oeSFW 3. ��G�� ! You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update on the City's website at www.cityofeagan.com/subscribe. Each applicant for a massage therapist license shall furnish the following with the application: a. An official diploma or certificate of graduation from a school approved by the American Massage Therapist Associatio or other similar reputable massage association;or b. An official diploma or certificate of graduation from a school which is either accredited by a recognized educational accrediting association or agency,or is licensed by the state or local government agency having jurisdiction over the school;or c. An official certificate of National Certification for Therapeutic Massage Body Work by the National Certification Boar of Therapeutic Massage and Body Work,an affiliate of the American Massage Therapy Association. If the applicant's diploma or certificate is from a school outside of Minnesota,the certificate or diploma must be a certified copy sent directly from the school to the City of Eagan.Additionally,the school must send the City of Eagan a letter detailing the school's accreditation. Each applicant shall also submit a copy of their Driver's License or State-Issued Identification Card. TENNESSEN WARNING Minnesota law requires that you be informed of the purposes and intended uses of the information you provide to the City of Eagan(the City)during the license application process.Any information about yourself that you provide to the City during the license application process will be used to identify you as an applicant and to assess your eligibility to receive the license for which you applied.If you wish to be considered for a license,you are required to provide the information requested on the license application. If you refuse to supply information requested by the City,it may mean that your application will not be considered. I have read and agree to all ordinances associated with this Massage Therapist License.I certify that I have read the a questions and/that t answers are true and correct to the best of my k owled e. 5 Signature Date Execu this da f ' ,20 KATHERINE J.CARLETON M Notary Public-Minnesota ` My oomm"W Expirn Jen 31,2027 No Public Amount paid: Date background check completed: V—o01 3 investigating officer: - Conclusion: Complete a separate Authorization Form for each owner with greater . . , than a 5 percent interest in the establishment and for the on-premise manager. E AG A N 3830 Pilot Knob Road Eagan,MN 55122 AUTHORIZATION FOR RELEASE OF INFORMATION FOR BACKGROUND CHECKS A photocopy/facsimile of this authorization is valid as original. Name:(flrst;middle,last) Please Print Other names used(if any) C100 �ddress: IM` Street �- C' State lip Code 7 Date of Birth: D / I Driver's License Number: ^(7 5 I S� - d` State A photo copy of driver's license is required The Eagan City Code addresses the requirements for back ground investigations as follows: • Chapter 5.02 -liquor license applications. • Chapter 6.34 -tobacco license applications. • Chapter 6.39 -massage therapy establishments and massage therapists. • Chapter 6.35- premise permits for pull-tabs With my permission,the Eagan Police Department may disclose to the Eagan City Administrator,City Clerk,Deputy City Clerk,and City Council all information collected as a result of the background Investigation done for the purpose of evaluating the attached license application. I understand that my records are subject to the State of Minnesota's Data Practices Act and become public documents unless otherwise provided for by State or Federal Law. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. Signature must be notarized. Signature of person authorizing release KATHERINE J.CARLETON Executed this day of ,20� M No Wic-Minneaota y C-Mftion Expbee Jen 31,2027 *16) Public MASSAGE THERAPY ESTABLISHMENT EAGAN LICENSE APPLICATION 3830 Pilot Knob Road Eagan,MN 55122 Annual License Fee:$300 (651)6ityofeagyofeag 0 Non-Refundable Background Investigation Fee:$300 cltyclerk@can.com License Term:July 1 to June 30 Applicant Name(sole proprietorship,8mi ed liability company name or corporation name): 'Ot V�� � �5� Name of Massage Therapy Establishment: 10 Establishment t rens: //'� G q450 Cir n Dr l�Q, a�0 l.. Business Phone: (� t tAA 0 Alternate Phone: ( ) Name and home address of all owners with a 5 percent or greater interest in the establishment(first,middle,maiden/last}: Name: O Address: I 00KAI Name: Address: Name: Address: Attach an additional sheet ifnecessary. Email Address: i Minnesota Tag Identifica ou Number: q-7.3- 1? Federal Tax Identification Number: '-/7&-17 — ly/ Have the owners ever been convicted of any felony,crime or violation of any ordinance,other than traffic? ❑Yesklo If yes,please explain: Have the owners had a massage therapy license revoked or suspended by any licensing authority? 0 Yes�60 If yes,describe: List the names,addresses and phone numbers of three people of good moral character,not related to the applicant or financially interested in the premises,who may be contacted as to the applicant's character: 1. Name �d Y W ess e-,? j� 5-5 67 � P a6�b er 2. 1.Q 50YAe. 51 rtenwMN G 3S� 3. i�l,c;,� OrJ Nio��-51AXAJ450y? & cokA LA4 Worker's Compensation Insurance Insurance Company Name (Not the insurance agent) Policy Number Dates of Coverage: to OR I am not required to have workers'compensation liability coverage because: I have no employees I am self-insured I have no employees who are covered by the workers'compensation law(these include:spouse,parents,children and certain farm employees) You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update on the City's website at www.cityofeagan.com/subscribe. Each owner and the on-premise manager shall submit a copy of their Driver's License or State-Issued Identification Card. TENNESSEN WARNING Minnesota law requires that you be informed of the purposes and intended uses of the information you provide to the City of Eagan(the City)during the license application process. Any information about yourself that you provide to the City during the license application process will be used to identify you as an applicant and to assess your eligibility to receive the license for which you applied.If you wish to be considered for a license,you are required to provide the information requested on the license application.If you refuse to supply information requested by the City,it may mean that your application will not be considered. I have read and agree to all ordinances associated with this Massage Therapy Establishment License.I certify that I ba a read the above questions and that the answers are true and correct to the best of my knowledge. M -,� 1,�LA 7 9-1 Establishm t Owner's Signature Date jvV= rmnv�Executed this day of ,20 ETONesota 31.1027 No Pubic Note:The City of Eagan requires massage therapy establishments to designate an on-premise manager.The on-premise manager may be one of the establishment owners. Name of On-Premise Manager: On-Premise Manager's Mailing Address- Business Phone: 0 3\, �\00 tom, --01 M ty :S Vs- Alternate Phone: On-Premise Manager's Email Address: Haste n-premise manager ever been convicted of any felony,crime or violation of any ordinance,other than traffic? ❑ Yess"o If yes,please explain: Has the on-premise manager had a massage therapy license revoked or suspended by any licensing authority? ❑ Yes No If yes,describe: List the names,addresses and phone numbers of three people of good moral character,not related to the on-premise manager or financially interested in the premises,who may be contacted as to the on-premise manager's character: 1. a� ice' obfnsonSy rk adr�s, per��1�1 ©7S Phone hl� 9(r� 3. 10 f ►� 2 lit N v 1vZ TENNESSEN WARNING Minnesota law requires that you be informed of the purposes and intended uses of the information you provide to the City of Eagan(the City)during the license application process. Any information about yourself that you provide to the City during the license application process will be used to identify you as an applicant and to assess your eligibility to receive the license for which you applied.If you wish to be considered for a license,you are required to provide the information requested on the license application. If you refuse to supply information requested by the City,it may mean that your application will not be considered. I have read and agree to all ordinances associated with this Massage Therapy Establishment License.I certify that I have read the above questions and that the answers are true and correct to the best of my knowledge. Furthermore,I consent to(1)take full responsibility for the conduct of the licensed premises,and(2)serve as the agent for service of notices and other process relating to the license. emisc Manager's Signature bate Executed this day of v 10 l ,20 er If=RLETON nnesota No Pu lic �31'�' a Amount paid: To be completed by the Police Department Date background check completed: e781&1/1-cr2? Investigating Officer: 66xwo Conclusion: A& ,1 S ,e j, To be completed by Building Inspections Date of Inspection: 9 1 — -:Zo.�3 Building Inspector. Conclusion: Additional Forms (https://www.ncbt DENISE L COOK mb.org/additional- (HTTPS://WWW.NCBTMB.ORG/B forms-2s Score Report CTHERAPIST/UNITED- Request STATES/MN/BLOOMINGTON/OT (https://www.ncbt mb.org/forms/Scor HER/DENISE-L-COOK/) e-report-requests Exoires: May 12.2024 Payment History Program Status :Certified (https://www.ncbt mb.org/account/pa C Click here to edit your free Directory listing yment-historys (https:/Avww.ncbtmb.org/directory/membership-signup/? pid=44870934) Tools (https://www.ncbt mb.org/certificants /tools-actives MTAC Application (https://www.ncbt mb.org/application s/massage- therapy- assessment- exam-for- certification- applications A o o � � b co� o � N 4 • Iy J V Q 7 k4 rn O � z:s Z:s to ° CYI Q w �► � o 4 � Q f C/) 7 E § . / § 3 = 0 2 7' ) ° 0 2 ƒ ? c ■ \ 7 $ c Q F 0 q o m � g 0 kƒ , 7 ( k C cn k B 2 0 3 / k / CD 0 � 2 0 0 = o ■ k g � � m ■ 7 0 � M 0 _ 0 -0 a Q = § § E 0 E ° E 2 0 2 E \ c 3 k § 3 m w 0 3 . % / ■ 2 k § g _£ w N k 2 \ ƒ C 2 / 0 %` C @ QL §. m @ § c k a \ @ _ = 5 m Ein ° F. ? 0 \ \ 0 QL \ k _ 0 . \ g . o . 2 � ® \ \ \ / \ � ` Icr . � d � A a OF r' O rh o, tq T !"� OmmmK cr � tsL o o- tv �, ,•.. !O � O rr � rte( Uk ux Rt t G CO „ to to ��►- N � O tA � O O *-MO- � h r•- m A Ux m ux � q ..». tot N� M O MtNN@SOTA a VERT . COOK 2 DENISE LOUIS e BLOOMINGTON, MINGT N,14 BLOOMINGTON, 1726 Id DL*H8(8-0J�V 622, iss2020 ai Dos 03) 98 ie 9-AV202,4 9 CLASS D 9SENDNONE DOlbit `' iSBEX F i i,`'Y700 tif)Ih kms— to MOT y ,9EVEsBRO DeYp19 VM or cmftueon W to Is.=9u.GVftl1tlWM IIE611!Con.Lewes City of Eagan Cash Receipt Receipt Date 7/24/2023 Receipt Number 242430 Denise Cook MASSAGE ESTAB BACKGROUND 1101.4239 300.00 Massage Estab background Total Receipt Amount 300.00 159470 11:50:32 City of Eagan Cash Receipt Receipt Date 7/24/2023 Receipt Number 242431 Denise Cook MASSAGE ESTAB FEE 0401.4064 300.00 Massage Estab Fee Total Receipt Amount 300.00 159470 11:51:01