Massage Establishment Ownership Information Form

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Massage Establishment Ownership Information Form
A. Establishment Information:
File # (applicants only):___________________ License #: MM _____________
Establishment Name: _______________________________________________________
D.B.A: ___________________________________________________________________
Address: _________________________________________________________________
B. Type of Ownership:
Corporation
Individual
Partnership
Other
If you selected Corporation, you must attach a copy of the Articles of Incorporation on file with the Florida
Secretary of State's Office.
C. Does the corporation have more than $250,000 of business assets in this state?
Yes
No
If "Yes", submit a formal opinion letter from a Florida licensed Certified Public Accountant (CPA) affirming the
corporation had more than $250,000 of business assets during the previous tax year; or in lieu of a formal
opinion letter from a CPA you can submit a copy of your Florida Corporate Income/Franchise Tax Return
(Form F-1120) from the previous tax year.
D. List the owner(s) of the establishment and all officers of the corporation as applicable.
Each person listed below having an ownership interest in the establishment including officers and
members of the board of directors must submit to the background screening requirements under
s. 456.0135, F.S., unless you answered "Yes" to C, pursuant to 480.043, F.S.
If C is "Yes", please list the owners below and only submit fingerprints for the owner, officer, or individual
directly involved in the management of the establishment. If C is "Yes" and the prints are on file with DOH
and available to the Board of Massage Therapy the requirement to submit the prints for this person is met.
Attach additional sheets if necessary.
Date of
Owner/ Officer Name - Title
Mailing Address
SSN
Birth

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