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<br /> STATE OF MINNESOTA (For o.p..rtm..-,( U.. Only) <br /> DEPARTMENT OF COMMERCE <br /> 133 EAST SEVENTH STREET , <br /> ST. PAUL, MINNESOTA 55101 <br /> (612) 2~31g '. e <br /> , <br /> tJ'(}(L~, <br /> ~~~~~ <br /> ~ ~ -,.} <br /> ... ~ ...~ <br /> ->>';'c~~fi' LICENSE NUMBER I DATE PROCESSED <br /> COSMETOLOGY SALON DA TE PROVlSiONAL ISSUED <br /> LICENSE APPLICATION <br /> A. TYPE OF LICENSE <br /> o Individual Proprietor <br /> o New o Partnership <br /> o Late Ren........I o COf]loration <br /> o Ltd. Uability Co. <br /> o Check jf salon is Jo.:ated in OUf home o Busines. Trut:t <br /> B. APPLICANT INFORMA TION , <br /> Salon Na".... ~N......(1t~.....) <br /> Al\.-...S, 'DOGO <-._, - <br /> Salon Street Addresa ,PI \ I ~ SlalAl Zip Code <br /> 3(, L.e...'IiVlC'-tO'1 Ave.)J. v\ tv' S /2 b <br /> County of Salon L~tion Salon T Ilepnon,e Numbet' ~T..I.D. Number - <br /> LA.S,.A ( r;.l 2. ) -'1=t-11 31-(,5 TS , <br /> O.<ignatOjl Uc.nS<<! Mana~ploY"d by s"lo<l (.. l appears on~) <br /> ) G. \) -r E. N <br /> ."1ana~e"'$ LicenS4 t-;wmbet' :::;.. Managi~~ ~0c) - <br /> . l~'" C' S <br /> 7:><J <br /> - <br /> C. OWNER INFORMATION - <br /> Lt<, Namel<) and Addre"r.s) of Ownerls) and Officer(s) (attach additional paqes if needed). S... instruction ItS and 1/.7, <br /> O....ner's Name ~. AddtIl:N - <br /> I-i L\ lv' ( ~ tJ C" <J 'i t::-!J . . . ... ~hl.f\-lJi HI<.! SSIZ<. <br /> I. '--11:'0 f!..AH-N R..u 6"0 - <br /> J'.-mer's Nam. a---. Addt_ <br /> - <br /> - <br /> D. COMPLETE THE FOLLOWlNG IF THIS APPLICATION IS DUE TO RELOCATION, NEW OWNERSHIP, ANDIOR <br /> STRUCTURE CHANGE - <br /> ;CfTntr Name o.f Saloon lJconoo Numbo< - <br /> ( <br /> ~ ::;;rme; Adcfe-s.& of Salon C't:f. Stat.o - <br /> - <br /> INSURANCE INFORMATION - <br /> -. <br /> ,he applicant mu<t provide evidenee of th. .alon'. coverage by PROFESSIONAl liability in<uranee at at lea.t S25.000 for each _.- <br /> :Iaim and S50.000 total Covera . for <lach oli ear for each 0 era tor. NOTE: This I. not Men/lI.blll insurance , <br /> I <br /> "ROFESSIONAL Nam. or I ,uran~ Compony (NOrth. insuranc. agency) Policy or Binder Number -\ <br /> -'ABILITY , ~~.,-, J. G;- ( 2- <br /> \lSURANCE: p I ~. . <br /> VORKERS' Name or In.uranee Com pony <br /> :OMPENSATION <br /> \lSURANCE: <br /> 'I <br /> i <br /> . EV. 6195 (OVER) <br /> - <br />