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Massage TEstablishment License Application <br />.. .... . . .. <br />i <br />Business Marne XA� - 1A e N C4 s. - <br />Business Address t (. e, <br />C <br />Business phone 611- -� - -I-"3 Cf- — 8 -7 S- z_ <br />Person to Contact i ri Regard to Business L icepise: <br />Name <br />Address <br />Phone <br />Drivers License Number <br />Social Security Number <br />U.S. Citizen? Yes 9 No <br />Date of Birth <br />Naturalized? � x Yes <br />If yes, date and place: <br />o <br />I hereby apply for the following 1 icense(s) for the term of one year, beginning July 1, , and ending <br />June 3 It } in the City of Roseville, County of Ramsey} State of Minnesota. <br />License: Required Fee <br />Massage Therapy Establish -meat 5300.00 <br />$ 1 50.00 Background Check <br />(new license only) <br />The undersigned applicant males this application pursuant to all the laws of the State of Minnesota and regulation <br />as the Caunril of the City of Roseville may from time to time prescribe, includ' g Minnesota Statue #176.182. <br />Signature <br />Date '- <br />If completed license should he mailed somewhere other than the business address, please advise. <br />Foi• office ice use only: <br />