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J'OerjArfo' _qq� <br />4WO <br />City of Roseville <br />Finance Department, License Die vi io n <br />2660 Civic Center Drive, Roseville, MN 5511 <br />(651) 792 -7034 <br />Massage Therapy Establishment License Application <br />Business Name ( 0' t i <br />Business Address <br />Business Phone <br />1097 <br />S F / �3 <br />Email Address ' ' in <br />Person to Contact in Regprd to Business License: <br />Legal Name <br />Address <br />Phone . <br />Drivers License Number <br />r <br />;Ll�ti 13 <br />Date of firth <br />I hereby apply for the following license for the term of one year, beginning July 1 2-6) 09 and ending <br />June 31, , in the City of Roseville, County of Ramsey, and State of Minnesota. <br />License Required <br />Massage Therapy Establishment <br />Fee <br />$300.00 <br />$1 50.00 Background Check <br />(new license only) <br />The undersigned applicant makes this application pursuant to all the laves of the State of Minnesota and regulation <br />as the Council of the City of Roseville may frorn time to time prescribe, including Minnesota Statue # 17 6.18. In <br />addition. the amfl icant acknovvled Res that they are resnan sihle for reviewi ne the hack 2 rou nd and work history of <br />their eMplgyees, including those that have received a massage therapist license from the City. <br />Signature <br />Date <br />If completed license should he mailed somewhere other than the business address, please ad vise. <br />