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Massage Therapy Establishment License Application <br />Business Name � l�� �.� �� �_ �-�: �` � �`�� =� ��- 4 �' � �� � �.� � (- f. <br />Business Address • -I �-i_ l C{ <br />Business Phone <br />� IL- <br />Per son fo Contact in Regard to Business ,kern' c: <br />Address <br />Phone <br />Drivers License Number <br />Social Security Number <br />unre of Birt', <br />C. r r r <br />U.S. Citizen? L I ds No Naturalized? Yes I 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 31, , in the City of Roseville, County of Ramsey, State of Minnesota. <br />License Required <br />Fee <br />Massage Therapy Establishment $300.00 <br />150.00 Background Cheelc <br />(near license only) <br />The undersigned applicant makes this application pursuant to all the laws of the State of Minnesota and regulation <br />as the Council of the City of Roseville may from time to time pre1cribe, includi g,11Winnesota•Statue # 1 76.192. <br />Signature r <br />�.-- <br />ate 2 -1 — C) L <br />If completed license should he mailed somewhere other than the business address, please advise. <br />Fo?- o0ce use only <br />• 'rkti `rrtrS •�`v •�� -�,r: '���+fF -FYI � ,gc •� •� _�_ � 3°���hC_a. ; <br />S�" y - • r '�' t� S 21ry���{yJ:# 'k.• tiS"v °�,y� �r <br />N! 7 r r;.: '•fyl�.. elf :� { ��� k.� � �f •+r <br />. is. <br />- v <br />