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an <br />City of' Roseville <br />Finance Department, License Division <br />26160 Civic Center Drive,, Roseville, MN 55113, <br />(651)1792-7036 <br />0 <br />Massage Therapy Establishment License Application <br />'711 IsA 6&t <br />100 <br />Business Name lox <br />Imm <br />my - M' �# <br />A A - 01 <br />Person to Contact in Regard to Business License,* <br />Legal Name <br />Address <br />Phone Date of Birth— <br />Drivers License Number I X, I' �T- ACV- <br />,%WWI % <br />1, hereby apply for the following license(s) for the, term of one year, beginning July, 1, - .:k 0 t and, endini� <br />E04F <br />June 31 in the City of Roseville, County of Ramsey, and State ofMinnesota. <br />Massage Therapy Establishment <br />I <br />$3001.00 <br />$,150.00 Background, Check <br />(�new, license, only' <br />The unders,igned 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 ftom time to time prescribe, 'Including, Minnesota Statue #1,7'61.192. In <br />addition, the 4pplicant acknowledges ffiat. they are responsible for reviewing the ackffoiund and work historvi ol <br />tYeir e.wT)Iove-psine][udins-those��� ad-a—massage therapist..1 i cense from the <br />Signature -A /V W" <br />N...Oe <br />Date <br />If completed license should be mailled, somewhere o er than the business address, please advise. <br />