Type Full Name :
Sign With Hand
Please note that if you choose 'License Type' to be 'Temporary', then fee for one day is $25 and for each additional day is $10.
Establishment Information
Establishment Type
{[ADDR]}
{[CITY]}, {[STATE]} {[ZIP]}
{[APHONE]}
{[AWEBSITE]}
# of Vending Machines
How do you intend to pay? Note: There is a 3% surcharge if paying by Credit Card and a $.25 fee if by eCheck. *
# of Massage Chairs
City *
Email *
Emergency Phone #
{[PNAME]}
State *
Total Fee
Late Fees
Application Type *
State *
License expires May 31st of every year.

Late fees will be applied if application is an Annual renewal and application is submitted on or after June 1st. Food Licenses are subject to proration if application type is new and it is applied for after January 1st.

Certification
ZIP *
If Massage & Bodywork Therapy Establishment License:
Ownership Type *
Phone # *
Emergency Contact
Vending Machine Fees
Signature *
City *
First Name *
Phone # *
Address *
ZIP *
How do you intend to pay? Note: There is a 2.65% surcharge ($1.50 minimum) if paying by Credit Card and a $1.50 fee if paying by eCheck. *
# of Days (only for Temporary)
Does your establishment serve/sell food products? *
Address *
Business Name *
# of Massage Tables
# of Shower Fixtures or Rooms
Last Name *
Emergency Contact Information
Email
Emergency Email
Application Fee
License Fee
Payment must be received on or before the deadline in order to avoid a late fee. A license WILL NOT be issued until payment has been received and application is approved by the Health Department.
Owner Information
License Type *
If 'Yes' enter Certified Food Safety Professional
Category *
Preferred delivery method for license
Number of Employees
{[CNAME]}
Specify Address where establishment resides *