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Finance Department, License Division <br /> 2660 Civic Center Drive, Roseville, MN 55113 <br /> (651) 490-2212 <br /> Massage Therapy Establishment License A pp lication <br /> Business Name W o (Z.I<.0 u.-V P K <br /> B us in ess A dd r ess � -c' P n (�k*�-V 55 1 ) <br /> incss thane <br /> Person to Contact in Regard to Bialness License: <br /> Name <br /> Address <br /> Phone �D a to of Birth <br /> Drivers License Number <br /> Social Security Number <br /> 0 � -065aLll ('O <br /> �(>d ID <br /> U.S. Citizen? Yes No Naturali7-ed? Yes No <br /> If yes, date and place: <br /> I hereby apply for the following license(s) for the term of one year, beginning July 1, ,and ending <br /> June 3 1, , in the City of Roseville, County of Ramsey, State of Minnesota. <br /> License Required Fee <br /> Massage Therapy Establishment (300.00 <br /> 50.00 Background Check <br /> (new license onl <br /> The undersigned applicant makes this application pursuant to all the laws of the State o =- eso a and regulation <br /> as the Council of the City of Roseville may from time to time prescribe, including Minnesota Statue #176.182. <br /> Signature <br /> �'- <br /> Date <br /> If completed license should be mailed somewhere other than the business address, please advise. <br /> For office use only: <br /> �atl■/q+' 4-�. 1: tit J i <br /> ecerP �'�•'�+:-�`•' *ate:iS-=�,ai►•�• .�:rT:��•!: <br /> , <br />