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Male Female

Yes No

Yes No

Yes No

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Have you ever been refused/denied a Massage Establishment Permit or any such permit or have had a permit revoked? 
If YES, indicate date(s), location(s) and detailed nature of the offense(s)

Street Address

On-Site Manager Information

Last Name

Have you ever been convicted of violating Municipal Ordinance in any town?
If YES, indicate date(s), location(s) and detailed nature of offenses(s).

Phone #

SSN #

Have you ever been convicted of a crime?
If YES, indicate date(s), location(s) and detailed nature of offenses(s).

Email

Place of Birth

Height

Sex

State

ZIP

Email

City

Phone #

Conviction(s)/Denial Reason

Date of Birth

Convictions/Violations/Revocations

Business Owner Information

Address

Fax #

ZIP

First Name

First Name

Weight

State

City

Last Name

Fax #

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Fees

or

The following documents must be submitted with this completed application: • Signed, notarized letter from the company which owns the establishment, authorizing you to act as representative. If you are the company owner, submit a notarized letter stating so.
• Photocopy of Applicant’s current driver’s license.
• Photocopy of Owner’s current driver’s license.
• Photocopy of On-Site Manager’s current driver's license.
• Two (2) photographs of Applicant at least 2” x 2” (head and shoulders against plain background, in color)
• Complete set of Applicant’s fingerprints need to be submitted. (Separate fee applicable)

Pay By Credit Card

Massage Establishment	Fee
Application Fee	$145
On Renewal (For every Month After January 31st)	$53/Month Late

Attachments

Total Fees

Payment Method

I do solemnly declare and certify, under the penalties of the law, that the foregoing information is true and correct and that the business conducted will be in accordance with the ordinances of the Borough of New Providence.
I herein authorize the Health Officer and the Chief of Police of the Borough of New Providence, or their authorized representatives, to seek information and conduct an investigation into the truth of the statements set forth in this application and the qualifications of the applicant for the permit. I understand that the health Officer and/or the Chief of Police may require, and I agree to furnish, any other identification and information necessary to discover the truth of the matter hereinbefore specified as required to be set forth in the application.
I further understand that, if the Borough of New Providence issues a Massage Establishment Permit to me, that this permit is not transferable to any other person, company or entity and that the fee paid by me is non-refundable.

Business Owner Signature

In order to receive your permit, you must first pay the above Application Fee.

If you'd like to pay now by Credit Card, Select Pay Now from the Preferred Payment Method click Pay Now button below.

Certification

Pay Later