Establishment Registration Certificate Application Form - Huntington Beach Police Department
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2HUNTINGTON BEACH POLICE DEPARTMENT
ESTABLISHMENT REGISTRATION CERTIFICATE APPLICATION
/
IMPORTANT INFORMATION: The following items must be completed in their entirety, as is required per 5.24 HBMC. Failure to complete the application or
providing false information will cause delay or revocation of application. Any establishment owner or operator who fails to be in possession of a valid
Establishment Registration Certificate shall be guilty of a MISDEMEANOR, punishable by a fine of one-thousand dollars ($1,000) each day the violation
occurs, or by imprisonment in the county jail for a period not to exceed six (6) months, or by both such fine and imprisonment.
1) BUSINESS INFORMATION:
Name of Business: ____________________________________________ Tax ID #: __________________________
(If applicable)
Address: ______________________________________________________________________________________
Mailing Address: ________________________________________________________________________________
Type of Business: ____________________________Description of All Services: _____________________________
______________________________________________________________________________________________
Are you operating any other business on this premise or adjoining premise?
Yes
No
If yes please describe: ___________________________________________________________________________
2) PERSONAL INFORMATION:
Legal Name
_____________________________________________________________________
(First, Middle, Last):
Other Names Used
__________________________________________________________________
(Last 10 Years):
______________________________________________________________________________________________
Date of Birth: ___________________ SSN: _________________________ Driver’s License____________________
Home Address: _________________________________________________________________________________
Mailing Address: ________________________________________________________________________________
Home Ph: ________________________ Cell Ph: _______________________ Work Ph: ______________________
Email: ________________________________________________________________________________________
Please indicate the best way to contact you
):
Cell Ph
Email
Home Ph
Work Ph
Mail
(Circle one
3) CALIFORNIA MASSAGE THERAPY COUNCIL (CAMTC) CERTIFICATE INFO:
I am certified with CAMTC:
Yes
CAMTC# _____________________________
No, I am not certified *
If establishment owner is not CAMTC certified a valid CAMTC Certificate must be provided for an employee or
independent contractor. List below:
Legal Name
____________________________________________CAMTC# _________________
(First, Middle, Last):
*In addition to above the establishment owner must complete fingerprinting and a background check through
the Department of Justice on forms provided by the City of Huntington Beach Police Department.
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