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Home My WebLink Aboutmassage therapy licenses/applications r - '.. � . State of Minnesota License No: 2011-02 County of Hennepin City of Orono Fee: $250.00 '¢'�.�' , 0 �'. '� ,�� .;�._ � Massage TherapY License ,� ��r�; ;�'�-�;��`�y,� G��%' ,�9�.E§H�'S�`'�'�� Upon investigation and satisfactory evidence of the qualification of the licensee, this license is granted and pursuant to application and payment of fee thereof, and is subject to all the provisions and conditions of the regulations and ordinances of the City of Orono and City Code Chapter 31 pertaining to such; and subject to revocation according to law for violation thereof. This license is not transferable except by consent of the issuing authority. Licensee Name: Seidou Salon Spa, Inc. Trade Name or DBA: Seidou Salon Spa Applicant: Lauren Patnode Address: 3502 Shoreline Drive Commencing: June 28, 211 Terminating: December 31, 2011 Approved Massage Meryl Verkins Therapists: Issued by authority of the City Council of the City of Orono, Minnesota June 27, 2011 _��t��_ _ Attest: Lili Tod McMillan, Mayor � �-- - • l_�-�- -- - -- Linda S. Vee, City Clerk ' 2750 Kelley Parkway„-P.O. Box 66,`Crystal Bay, MN 56323 Phone: (952)249-4600 l Fax: (952)249-4616 l www'ci.orono.m�.us f � �� 7 O� p � p CITY of ORONO - Municipal Offices `'3 "� � Street Address: Mailing Address: '1',� Gti,�' 2750 Kelley Parkway P.O. Box 66 � .� Orono,MN 55356 Crystal Bay,MN 55323-0066 �kESHog' July 27, 2011 Lauren Patnode Seidou Salon Spa 8706 Hillswick Trail Brooklyn Park, MN 55443 RE: Massage Therapy License 3502 Shoreline Drive At their June 27th meeting, the Orono City Council approved the granting of a massage therapy license to Seidou Salon Spa. Attached is your original license. According to City Code Section 26-36, this license must be displayed in a public location within the salon. Referenced code sections are enclosed for your information. As noted on the license, the following massage therapists are covered under the Seidou Salon Spa massage therapy license: • Meryl Verkins Any individual who provides massage therapy services must be covered under the current license. Please be aware, performing massage therapy services without a license is a violation of City Code Section 31-11. If you wish to add new massage therapists to your license prior to the annual renewal date1 the individual must complete the attached Application for Massage Therapy License, Part III and return it to the City of Orono. There is no charge to add massage therapists to the current license, but the attached application must be submitted and approved for each new massage therapist prior to conducting massage services. Please feel free to contact me at 952.249.4620 or cmattson@ci.orono.mn.us if you have any questions regarding massage therapy licensure or any other City related matter. Sincerely, CITY OF ORONO U�J � Christine Mattson Planning Assistant Attachments Telephone(952)249-4600 • Fax(952)249-4616 www.ci.orono.mn.us . . �- �_�, State of Minnesota License No: 2011-02 County of Hennepin City of Orono Fee: $250.00 g�� O O � ;�k �k }. �', IVlassage Thera License � .�,� �� }. G�, pY ��9kES4H�'.�''�v„ O Upon investigation and satisfactory evidence of the qualification of the licensee, this license is granted and pursuant to application and payment of fee thereof, and is subject to all the provisions and conditions of the regulations and ordinances of the City of Orono and City Code Chapter 31 pertaining to such; and subject to revocation according to law for violation thereof. This license is not transferable except by consent of the issuing authority. Licensee Name: Seidou Salon Spa, Inc. Trade Name or DBA: Seidou Salon Spa Applicant: Lauren Patnode Address: 3502 Shoreline Drive Commencing: June 28, 2011 Terminating: December 31, 2011 Approved Massage Meryl Verkins (6/28/11) Alfredo Lopez (11/02/11) Therapists: Bess Bost (9/29/11) Phillip Gore (9/29/11) Terrance Orris (9/29/11) Lauren Patnode (9/29/11) Issued by authority of the City Council of the City of Orono, Minnesota on: June 27, 2011 Updated: September 29, 2011, November 2, 2011 (seal) Linda S. Vee, City Clerk 2750 Kelley Parkway,P.O. Box 66,Crystal Bay, MN 55323 Phone: (952)249-4600/Fax: (952)249-4616/www.ci.orono.mn.us ._, _-- _, • State of Minnesota License No: 2011-02 County of Hennepin City of Orono Fee: $250.00 � � K �� , � O ' O� 1 4 4�.1 � ,5 ,� ,� .` t ,� 1 � a` � �. .'d . � .. .. � ` r . ` { ��" ' !�Y ��Il��sa�ge=�7.� ��ra.�y `��' ` � ,�,�� ,�� , , ce=r�s� �� ; ,�� `��k p�a��, pti!"� '� `^ �t �`IS;i��g,�, r ' _ i�i �kESHO s,r r.' �., ; ' �� ' . : : ' � p _..__. .. . . . . . , ., _—�— C... ��.,w�u ...._.w.v-��.n�`w,R_.��..�....,.�.�.._�..,.....�.a.?.:_u�n-,,..,.�.d�3 a..,.>_-, ...V ... .�F.....t k . .u� r .r.r�� ...._-. ... ., .�c�� Upon investigation and satisfactory evidence of the qualification of the licensee, this license is granted and pursuant to application and payment of fee thereof, and is subject to all the provisions and conditions of the regulations and ordinances of the City of Orono and City Code Chapter 31 pertaining to such; and subject to revocation according to law for violation thereof. This license is not transferable except by consent of the issuing authority. Licensee Name: Seidou Salon Spa, Inc. Trade Name or DBA: Seidou Salon Spa Applicant: Lauren Patnode Address: 3502 Shoreline Drive Commencing: June 28, 2011 Terminating: December 31, 2011 Approved Massage Meryl Verkins (6/28/11) Therapists: Bess Bost (9/29/11) Phillip Gore (9/29/11) Terrance Orris (9/29/11) Lauren Patnode (9/29/11) Issued by authority of the City Council of the City of Orono, Minnesota on: June 27, 2011 Updated: September 29, 2011 �� d� L� Linda S. Vee, City Clerk r �, .�. , � � � q� �,. � 2750 Kelley Parkway ,P 0 Box 66 Crystal Bay,'MN 55323,� s ,;; x ; ;, - „ `�Pho�e.�:(952)249-4600/TFax (952)249-4616/www ci.orono mn us' ' �: ' r �: p , ; _ ;..- .,_ 9,,� ��a � .�;�.... � � � .. _.�_._ __..,,_:. ..,:._�.. ,.. . �.s_>.�� .,.__ �w.�_. ' ` _..—�^ :'• 1 State of Minnesota License No: 2011-02 County of Hennepin City of Orono Fee: $250.00 ��1tr�, ��O,�r, p�� :�� , � ��s��f ��.. �� Vlassa��e Thera�pY ��c�nse � �: � �� t�� ti l �� } ti �`'� `vS,� �,t�"t�'�,G%�, ��kEsHo4� _._— . �,.�,.,,. .. . . , } Upon investigation and satisfactory evidence of the qualification of the licensee, this license is granted and pursuant to application and payment of fee thereof, and is subject to all the provisions and conditions of the regulations and ordinances of the City of Orono and City Code Chapter 31 pertaining to such; and subject to revocation according to law for violation thereof. This license is not transferable except by consent of the issuing authority. Licensee Name: Seidou Salon Spa, Inc. Trade Name or DBA: Seidou Salon Spa Applicant: Lauren Patnode Address: 3502 Shoreline Drive Commencing: June 28, 211 Terminating: December 31, 2011 Approved Massage Meryl Verkins Therapists: Issued by authority of the City Council of the City of Orono, Minnesota June 27, 2011 �:.Q - ��.� �� Attest: Lifi Tod McMillan, Mayor �� / �� Linda S. Vee, City Clerk Y _._. y _ �__ _ _ . _ _ ..� ,_ r ,.�-� 2750 Kelle Parkwa P.O. Box 66, Crys;al Bay, MN 55323 �:� �P�hone: (952)249-4600!Fax: (952)249-4618/www:cl.orono.mri.us ` �, ` �� „ � State of Minnesota License No: 2012-02 County of Hennepin City of Orono Fee: $100.00 '¢O'�' 0 0 � ��rr�� Massage Therapy License 'S•� � � .; _' pti�' L9kESH�g'w Upon investigation and satisfactory evidence of the qualification of the licensee, this license is granted and pursuant to application and payment of fee thereof, and is subject to all the provisions and conditions of the regulations and ordinances of the City of Orono and City Code Chapter 31 pertaining to such; and subject to revocation according to law for violation thereof. This license is not transferable except by consent of the issuing authority. Licensee Name: Seidou Salon Spa, Inc Trade Name or DBA: Seidou Salon Spa, Inc Applicant: Lauren Patnode Address: 3502 Shoreline Drive Commencing: January 24, 2012 Terminating: December 31, 2012 Approved Massage Lauren Patnode Phillip Gore Therapists: Meryl Verkins Kali Mason Bess Bost Alfredo Lopez Terrance Orris Issued by authority of the City Council of the City of Orono, Minnesota on: January 23, 2012 Updated: February 21, 2012 � � _..� � / (seal; �i1�"_��i�--- -- �i Linda S. Vee, City Clerk 2750 Kelley Parkway,PA.Box 66,Crystal Bay, MN 55323 ' Phone: (952)249-4600/Fax: (952)249-4616/www:ci.orono.mn.us �� State of Minnesota License No: 2012-02 County of Hennepin City of Orono Fee: $100.00 'Q"�'1�' - . _ O O ;r' - � � ��;, j�� f� as:sa��e T��e.rap� :L�ice:nse , , �'� k�,� �; ,;� �� :. �� t�'��a 4w�~� �� „ , 9kESH0- � : , ;�_ , w � ,., r. ,�- � •... . > _ : � . �� :� ; . v �' --— < _.�a�.� ,..�.�.M�,�_ .....r ..._.�..� .�__ � .... .,_.��....� . .W ..�_�.� .; ��._.,....� ��..r.� Upon investigation and satisfactory evidence of the qualification of the licensee, this license is granted and pursuant to appiication and payment of fee thereof, and is subject to all the provisions and conditions of the regulations and ordinances of the City of Orono and City Code Chapter 31 pertaining to such; and subject to revocation according to law for violation thereof. This license is not transferable except by consent of the issuing authority. Licensee Name: Seidou Salon Spa, Inc Trade Name or DBA: Seidou Salon Spa, Inc Appiicant: Lauren Patnode Address: 3502 Shoreline Drive Commencing: January 24, 2012 Terminating: December 31, 2012 Approved Massage Lauren Patnode Phillip Gore Therapists: Meryl Verkins Bess Bost Alfredo Lopez Terrance Orris Issued by authority of the City Council of the City of Orono, Minnesota on: January 23, 2012 Updated: a`,�- ' t`�`��.(�N'�.�.� —--- Attest: Lili Tod McMillan, Mayor � / ��✓� ��-z– Linda S. Vee, City Clerk , y AV 2750�Kelley Pa�kway,=P.O.:Box 66,C.rystal Bay,�MN .55323 = ?� �, �; � .., .'' r:m m��~. Phone: (952)249-4500/:Fax: (952)249-4616/www.ci:orono:mn.us , - . : ., , ..t'+ . ' Feb 23 2010 12: 18PM Unidale 651 -224-5320 p. l �c Rd CERTIFICATE OF LIABILITY INSU °"'��'""'°�^', ..1 RANCE oznsr�o,o �i" 1.1 CERTIFICATIO 13.9UED A8 A TTER pF INFORMA UNlOALE IN8URANCE AOENCY ONLY AND CONFER8 NO RIOHT8 UPON TH� CERTIFICATE 676 uNIVERSITY AVE HOLD�R. THIB CERTIFICAT! D0�9 NOT AMHNO, EXTEND OR SAINT PAUI,MN 55103 AL1'�R THE COVERAG�AFF�RDED BY TH�POLICIES BELOW. IHSUR6R8 A�FORDING COVERAOE NAtC M �Se1C0U SalO�9p8 �NBURER A: Pesrbp0 1110emnity Insuranoa C0�►Ipdfly 3So2 3harollns D�Ive inisuaeR e: Hav�ya-S�eurlbr Ineuranoe comp�rry Orcno,MN 668$1 It�URER G, It�UREq 0: iroauaeR�• cover�►oEs P uC1�8 OF INSU �ISTEp BELOW EN ISSUED TO UREp NAMEO AB R 7Hfi POLICY INqCATED.NO ANDINO ANY RECWREMENT,TERM OR CONDI7lON OP/WY CONTRACT OR pTF1ER DOCUMENT 1M7N RE6PECT TO WHICN TMIa CER7IFICATE MAY BE 188UED OR MAY PERTAIN,THE IN9URANCE/4FFORDED BY THE POLICIE9 OESCRIBED NEREIN IS SUBJECT TO ALL THE TEAMB,E](CLUSIONB AND CONDITIONS OF SUCH POlICIEB.AGpREOATE LJMITS SHOWN MAY HqyE BEEN REDUCEO BY PND CLAIM$. �r�� M!GF INSIJRANf� Pa.icr Nu� e �o�r ex� � �N�'�� 4ppzge7�3q OZM6/ZD10 02115/2�1i E1c�-iooeuRRewCE i 1,000,000 A X COMMERdAL0EN8RALUAe�LriY : GU11NB MAOE �p(',�IR MED D(P ens erwn) i PeRsowl AADV INJURY S 1,OOO,D00 O�f+IERALAAOqEOA7E i �.000,�00 GENtAOGREOAreuMqTAPPUEBPER: PRCOUcrB-DOMP/OPAOO 6 y,Q00,000 POUCY PFiO. �� ' A{f7'OIIO�si LM�ILIT► �rn�uro �aNa��r�c�uat� ,: �u owNeo,�uto� �M�� BOdLYfNJURY , ! 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Nonbowt.Eo alJT09 �.Y�e!Y i • PROPERTY QAYAc�E : (Pa.a/d.r+U �M��V�� /UJTOONLY-EAACCIOGP(T � afVY AUTO QTM�RTHAN EAACC 5 AU7'O ONu^ AGO S QGll�/YMSIt�Lj,A UAB11JTy EACH OCCURRENCE { OCCUR �CU►�MS MAOE AOL�iREGa7E 6 S GEDUGTIBLE a RETENTI i WORIC�11i GO�yPQ'�M110NN0 B iMKOYW'w►el.lTv WC4OOZB9T499 O2I1GP2O�O O2I1O/2011 x T R Vp ANTPROP(iETOR/PARTNEIiIDmCUTNEa � EL.�qChIAOCIDEkT ; 1�,000 pINCQ4MBABER EXCWDHD7 ��^�0ry�^NN� QL.DI9EA9E-EA EMPLOYE = 500,000 d��Cfb 1M1 EL.qS�SE-POLICY Uh11T 0 10Q 0�0 �� 02I16/2010 07115l2011 z0 000 Llmlt A Bu61r1ee9 Perwnal PropKly 4�� o�aarnoN or ore�enna+a��.ocn�oNs�vK►r�■r�xcu,�oNs�oeo eY a�ooRe�r�a�cu��RoniroNs C H LDER C,pN Baard ot Cosmetdopt�t ExAminws BNOUt,C ANY OF T1E AGOvi o�p��r0�1!!S!CANClLLED GEpO(�7M�uw�4np� a►h Y►+�e�aR,n�ssuura ineu�ae Nnu er�avoR ro w►a. �0 DA�YMi0T1iN 2829 UI'11Ve1sUy AVe11U6 9E 9ulta 79 0 NOTIC!TO TM!CEq71DICATi XOLD�R NAMID Tp TI�I.�RT,81RFAIWRE 70 D0 W lNALL Mln�eapoNe,MN a641� wOs!NO OSL�7Af10N Olt LL�wurl or ANY qN�UPON 7!i!INAUI�R,171�o�t9 ae n�aeer�rRnv� wu�xo� nerRe ACOf�za(znoerw� �1668-2aos�coRe cpRPORqt�ON. All rlahts ro�onrad. Ths ACORD name end lopo ar�rplst�r�d ma�,s ot ACaRD P:: �� . Board of Cosmetologist Examiners 2829 University Avenue SE, Suite 710 * �;� b�A BOARD OF Minneapolis, MN 55414 OLOGIST EXAMINERS 651-201-2742-612-617-2601(fax) www.bceboard.state.mn.us- bce.board@state.mn.us Salon license Application -MAKE A COPY OF THIS APPLICATION FOR YOUR RECORDS- THE BCE IS ON A THREE-YEAR LICENSE CYCLE. A LICENSE CANNOT BE ISSUED FOR MORE THAN THREE YEARS. THUS,YOUR INITIAL LICENSE MAY EXPIRE IN LESS THAN THREE YEARS. Please complete all of the following questions. Failure to have a complete application will result in a delay of your safon license as the application will be returned. A Salon License attaches to a single owner or business structure and is not transferable under any circumstances. Owning and operating a salon under another person or business license is illegal. "The data which you furnish on this application will be used by the BCE to assess your qualifications for licensure.Disclosure of this information is voluntary. You are not legally required to provide this data,however if you fail to do so,the BCE may be unable to process this appliwtion. Disclosure of your Social Securiry number is required by Minnesota Statutes 270C.72 and your Social Security number may be requested by and released to the Min�esota Commissioner of Revenue. Then BCE may use your Social Security Number for revenue recapture as authorized by Minnesota Statutes,Chapter 270A.After issuance of a license,all information contained in this application,except your Social Security Number,will be public information pursuant to Minnesota Statutes,Chapter 13." Pursuant to Minnesota Statutes 604.113 and 609.535 the BCE is authorf:ed to charge a service charge of 530.00 for any check that is retumed for non-su�cient funds. License Fee• • $143.00 License Fee Total (Payable to the BCE,Credit Cards Not Accepted) ■ $130.00 Application Fee ■ $13.00 Office of Enterprise Technology License Surcharge Fee�nnN sess�o��w zoo9:cnapter ios,Art.2,Sec.59,Subd.3) Check Tvae of Salon License In order to obtain a Cosmeto/ogy Sa/on License,your sa/on must have a floor p/an that includes all Cosme[ology Services including shampoo bowls and hair service stations. If you do not have a,tloor plan that indudes those services,but p/an to offer manicurist and esthetician services,please comp/ete both a Manicurist and Esthetician Sa/on Application and submit together. Cosmetology Salon o Manicurist Salon o Esthetician Salon Check Tvpe of Business Structure � Individual Proprietor o Partnership Corporation o Other Business Structure � Salon Information �/zoo9 Salon Name(DBA—Doing Business As) Salon Legal Name ��`�� _S'�. c� Owner Last/Corporation Name Owner First Name �10 =-� �.2�?��'� For Office Use Only: Staff Initials: Check/MO/Receipt Number: Amount Paid: Application Number: License Number: Date Processed: Additional Aunlication Information Check one of the following and answer any additional questions: � New.Never Been Licensed Salon oChanae of Ownershin(Currentiv Licensed Salonl Previous Salon License Number Previous Salon Name Previous Salon Address Previous Salon Owner oSalon Relocation Previous Salon License Number Previous Salon Name Previous Salon Address OBusiness Structure Chan¢e Previous Salon License Number Salon Nam �� Salon Leg�4�Vame S Salon Address ��..V �-' (A�� , City State Zip Code � �� Salon Phon � er � � _ County of a on Locatio R Social Security Number or Fede ID(T r I�. /� Email Address y Salon Manager Last Name Salon Manager First Name Salon Manager MN License Ty,e of Manager License Number CosmetOlogist � ' / / O Manicurist �'t O Esthetician Please check the following days the salon is o en: O Monday Tuesday Wednesday �Thursday Friday Saturday O Sunday Is this saton open y appointment onl : Is this salon in a residence? O Yes� No If Yes,list one day per month salon is open: O Ye5 f�No l Number of Practitioners Working in Salon Total Square Feet of Salon, Required Cosmetology Salon Manicurist Salon Esthetician Salon Square Feet 1- 120 1- 100 1- 110 Per Practitioner Add 50 for each additional licensee Add 50 for each additional licensee Add 50 for each additional licensee 3 Insurance Information Professional Liability Insurance (Required for All Salons)—General Liability will not be accepted Name of Insurance Company , i ��!�� /�� ....�,� - Policy Number � � ., , � f ,� �� Attach a Certificate of Insurance to the Application that indicates: • Certificate Must Show: o $25,000 coverage/each claim o $50,000 coverage/each policy per operator • Certificate Holder Must Be: o Minnesota Board of Cosmetologist Examiners, 2829 University Ave SE,Suite 710, Minneapolis, MN 55414. o Name of Insured must be the owner and DBA of the salon and assigned to the salon's address. Workers Comnensation Questions 1. Will this salon employ individuals? �Yes � No 2. Will this salon have only independent contractors with MN Manager Licenses? oYes Q No You must complete the following Workers Compensation Insurance section if you answered: • Yes,to Question Number One or • No,to Question Number Two Workers Compensation Insurance (Required for All Salons Employing Individuals) Name of Insurance Company v /)„ ` , � l Policy Number ; ,�� , s � � -tl1 Required documentation to be submitted to the BCE • Certificate Must Show: o Workers Compensation Coverage • Certificate Holder Must Be: o Minnesota Board of Cosmetologist Examiners, 2829 University Ave SE,Suite 710, Minneapolis, MN 55414. • Contact the Minnesota Department of Labor and Industry regarding workers compensation questions at 651-284-5005. 4 /'� � . '�� CERTlFICATE �F LIABILITY INSURANCE °"��' w�°°°cER TIf13 CERTIFiCATION IS tSSUED AS A MATTER OF iNFORMATION UNIDALE INSURANGE AGENCY ONLY AND CONFERS NO RiGHTS UPON THE CERTIFICATE 575 UNNERSITY AVE HaLDER. TH1S CERTtFFCATE DOES NOT AMEND, EXTEND OR SAINT PAUL,MN 55103 ALTER'i'HE COV£RAQE AFFORDED BY'fHE POLICIES BELOW. INSURERS AFFORDING COYERAGE NAlC� iNSURED INStk2ER A: PeeAess Indemn' insurance Com a Seidou Salon Spa �Y p try 3502 Shorebne Drive ��R� Ha�eYe-SearnY Inswance Company Orono,MN 55391 �� INSUftER R MiSIItER E: � COVERAGES THE POUCIES OF INSURANCE USTED BELOW HAVE BEEN iSSUED TO THE INSURED NAMEO A80VE FOR THE POUCY PERIOD INDICATED.NOTVVITHSTANDIMG ANY REQUIREMENT,TERM OR CONDiTION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TtiIS CER77FICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRlBED HEREIN IS SUBJECT TO ALL TNE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE UMRS SHOWN MAY HAVE BEEN REDUCED BY PAtO CUUMS. INSR ADO �PO�UCY EPPE P�OL�ICY EXMRAT�ON� LJ11T8 LTR.INSR 7YPE OF INS�AIICE POL�NIMIB�i ! G��'W� �qpp�67434 02/15/2010 02H 5J2011 �H ocxuRRErrCE 8 1,000.000 � o A � x COMIAERC�AI.GENBRAI LIA&Lt1Y i PREMISES amae�oa S CW MS MADE �O(�lNt MED E%P(My atre pwson) S P�soNnl.aqpvlWt�r S 1,000,000 cENEwu ncor�c�aTE S 1�O00.000 OEN'L AGGREGATE UMR APRlES� PROOUCTS-C�#IP/OP Ati(i S 1,000,000 Poucr ,�a �oc s �ur�w►su.n,r ANYAUTO COMBINEDSINGLELIMR s (Ea eaident) Atl OVYNED AUTOS BO�IY INJURY SCI�IEDlR.E0AUT0S (�P�) � WRED AUi� 80DILY INJURY S FlON-0WNED AUFOS (P��) ��nr oa+�ncE s (Pe►�cadeM) f i GARAGE LWBILITIr AUTO ONLY-EA ACGDENT S j nNY AUtO FAACC S � OTHER TltAN t AUTOONLY: Ap�, 5 i EXCESS!UYBRQLA LIABILiTY E/1CH OCCURREN(CE S j�OCCUR �CWMS 1M�E ACaYiREGATE S S �� S RETENTION S S � WORKERS COMPENSAT101J ANp Q2J1S/2�7� ��175/2011 x TO LI AITS ER B eear�.oreRs•uneiurv Y/N 'VVC.4OOYBB74SB � Awr wtoartlerowpnR�wo�mve�--� E.��nc�oEntT � 4 100,000 OFF�CER�MEMBER OCCLUDEO? LJ �Mandatory in NH) EL DISEASE-EA EMPLOYE S $OQ.UU� f ye6,Cesaiba under E,�,as�sE_p�t�w urt1T S 100,000 A i oTM� 4002667434 02/15J2010 02/i5/2011 �.ppp� � Business Pers�tal Property oescRmnoN oF��rsanoNs r�ocanoius r veHic�es r ptexusroNs aooEo eY p+oorts�ee�tT��cu►i�toviswt�s CERTIFICATE HOLDER GANCELLATION Board of Cosmetoiogist Examiners s�o��AeO�°Escn�aE°vou°�s e�c�wc�u.�o EXPIRRT1pN on�n��n+E essur+c wwn�wa.��oenv�e ro Maa 'i0 pars wrtmEn 2829 University Avenue SE S�dte 710 ��TME c�rt�ca��o�HA�o ro.Me�eurFAw�r�m oo so aHwu. Minneapolis,MN 55414 B�OSE NO OBUliR710N OR UABRrtY OF ANY KMD UPON 7ME WSUt�R,IT3 AOENTS OR R�RESBiTATIVES. au�+owz�rt�r� ' � �'/'�l DISCLOSURE OF COMPANY OWNERS, PARTNERS, OFFICERS R / � NAME OF SALON: C� GL �-G-L .lJ� An applicant for a Salon license must include the following information: . Individual Proprietor: Provide the name and address of the Owner • Partnership: Provide the name and address of all General Partners and Limited Partners • Corporation or ILC: Provide the name and address of ali elected Officers,Directors,Governors,Members, Shareholders owning 10%or more of company stock,and any Managers/Employees with authority to exercise control in policy or management of the company If any owner or partner is also business entity,you must complete this form to disclose the owners/partners/offlcers/shareholden of that business eMity as well. Last Name Firstt Name Middle Init'al �/�' �� L_�-li(itN! v� �� Residential Address Primary Telephone Number �� ` Cs o� �� State . � � � Title check one) 100%Owner General Partner Limited Partner Elected Officer(title: ) Director LLC Governor/Member Shareholder(Percentage of Ownership: %) Manager/Employee with controlling authority Last Name First Name Middle Initial Residential Address Primary Telephone Number ��tY State Zip Code Title(check one) 100%Owner General Partner Limited Partner Elected Officer(title: ) Director LLC Govemor/Member Shareholder(Percentage of Ownership: %) Manager/Employee with controlling authority Last Name First Name Middle Initial Residential Address Primary Telephone Number City State Zip Code Title(check one) 100%Owner General Partner Limited Partner Elected Officer�title: ) Diredor LLC Governor/Member Shareholder(Percentage of Ownership: 96) Manager/Employee with controlling authority This form may be photocopied if additional forms are needed. 5 Buildine and Zonin�Compiiance Check the appropriate box below,and attach�equired documentation: (Applicant must check one) oThe building in which this salon is located is new construction. 1. Applicant must attach a copy of the signed,dated Certificate of Occupanry issued by the City or County in which the building is located. 2. Applicant must attach statement from Zoning Official that salon is in compliance with zoning ordinances,or obtain signature below: Signature of Zoning Official Title Date Print Name of Zoning Official City or County Name Telephone Number � The building in which this salon is located is an existing building. The Applicant has made improvements or changes to the salon which require building permits and zoning approval. i. Applicant must attach a copy of the Building Permits issued by the City or County in which the building is located. 2. Applicant must attach statement from Zoning Official that salon is in compliance with zoning ordinances,or obtain signature,belo 3. �� I�1/�hQi�/ �1`i�zd� Signa re of Zoning Title Dat�e � � � - v 2(,,�►n I�rn o✓ C� rcrvi o �� Z Z �(�t- y� 23 Print Name of Zoning Official City or County Name Telephone Number � The building in which this salon is located is an existing building. No Building Permits or Zoning Approval were required by the City or County in which this salon is located. Signature of Zoning Official Title Date Print Name of Zoning Official City or County Name Telephone Number Generel Diredions to Salon Draw a Diagram to Salon 6 Salon Floor Plan (can submit blue arints or formal drawin�l NAME OF SALON Total Floor Space (from salon floor plan below) squarefeet �IculateanyReception,RestroomandSupplyareas which are part of the salon floor space: Reception Area= sguarefeet TOtal R2t1UCt10�5 (from caiculation at right) '�squarefeet RestroomArea= a feet Supply Area = s arefeet Total Work Space(raaipoorsPaoe►minus[ra��) = square feet Total Reductions= squarefeet Prepare a diagram of the salon floor plan,using the Sample Floor PI an attached. Each square below equals Fve square feet. If your salon is larger than 50 feet by 50 feet,a I c e e oor lan. 1 �� c:t � � � .� ��2 � � � �� , - �x t� �� t " � � � i �� 4�-�-�"�:� � �0�� 8 SAMPLE FLOOR PLAN outside �, '� � L �,� � � C� � � A � Residence Area � L � (Laundry Room) B F � FreshA�Vent � B L G � Exhaust � Fan � � � I 18 I �a�Y feet H Salon Area � � H � R J � � � A ( Residence Area -- -- -- 15 — - --- ---� (F�nilyRoom) feet ( � ' 1 i � Residence � � D �IIV Are-- H H � U pstairs) Outside CODES T4 BE USED A. Chair L Ventilation (designate type of ventilation) B. Sink M. Air Conditioner C. Covered Meta)Container (soiled towels) N. Heater (hot water) D. Counter (station) O. Desk E. Dryer P. Fire Extinguisher F. Cabinet {clean linen) Q. Waste Receptacle G. Cabinet (supplies) R. Coat Radc or Goset H. Chair (waiting) S. Dispensary with Sink I. Table � T. Toilet Facilities J. Table (manicure) U. First Aid Kit K. Entrance/Exit (specify the area that V. Large Covered Metal CoMainer for Disposal of Garbage the door leads to) W Pedi Spa 7 Salon Licensee Resconsibiliri Ownina A Salon o Salons are limited to offer cosmetology-related services to the type of license held. If a salon is found to offer services that fall under the BCE regulation and are not licensed to offer those services,the Salon can be assessed civil penalties up to$2,000 per violation found. o A salon must have a current designated manager with a current license. o The salon must ensure all practitioners working in the salon are currently licensed. If a salon is found to have unlicensed or expired practitioners, civil penalties of up to$2,000 per violation may be assessed,to the salon manager and owner or loss of licensure may result. o The current salon license, salon manager license, and all licenses of employees and independent contracts must be posted conspicuously at the salon. Renewals - Renew Online! o Your salon license will expire on December 31�`of your three-year license period. If you fail to renew on or before that date,you will be considered expired and not eligible to offer services. Additional renewal fees will apply if you fail to renew on-time. The Board makes every effort to mail renewal notices to each licensees, but it is your obligation to renew your license on-time whether you receive a notice or not. Mana�erChan�e o If you change your manager,you must notify the Board immediately. Address Chanae o If your salon moves locations, you must complete and submit an entirely new Saton Application and complete all the requirements for a new salon. Online License Verification o To verify the license status of persons performing services at your salon, use the Online License Verification at www.bceboard.state.mn.us. Cosmetolo�v Laws and Rules o Copies of Cosmetology Laws and Rules are available from the Minnesota Bookstore at 651-297- 3000 or www.leg.state.mn.us. 9 CERTIFICATION OF APPLICANT 1 certify rhai the information submitted with this application is rrue and correct 1 also certify that this document has not been altered or changed in any manner from the form odopted by the eoord of earber and ,� Cosmetologist Examiners. � �` � �/ Signatu e of Owner#1 Date Subscribed a �rn to bef re me This day of 20 � �. � � Notary Seal � RHEA S SMY Signature of Not N07qqypuBAl�SKi 'a-,,,�• M MINNESOTq Y Commla�bn cxp�res�an.31.�1P My Commission Expires`��'� Signature of Owner#2 Date Subscribed and Sworn to before me This day of , 20 Notary Seal Signature of Notary My Commission Expires Signature of Owner#3 Date Subscribed and Sworn to before me This day of , 20 Notary Seal Signature of Notary My Commission Expires 10