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1� <br />City of Roseville <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, SIN 55113 <br />(651) 792 -7036 <br />Massage Therapy Establishment License Application <br />Business Name ��'� �� �� � � C CL �-e' <br />Business Address r���� _ �'� � `n ��- �.t�S��s ��i � WA-,! 13 <br />Business phone <br />-F ev� <br />Emal l Address tx <br />Person to Contact in Regard to Business License: <br />Legal Name <br />Address �� ._ - -- �" � -_ U # <br />1 <br />Phone t ' ` � - Date of B irth <br />Drivers License Number <br />I hereby apply for the following l icen se(s) for the terra of one }year, beginning July 1, O , and ending <br />June 31 a , in the City of Roseville, County of Ramsey, and State of Minnesota. <br />Massage Therapy Establish -neat <br />$300.00 <br />5150.00 Backerround Check <br />(new license only) <br />The undersigned applicant makes this application pursuant to all the laws of the State of Mj nnesota and regulation <br />as the Council of the City of Roseville may from time to time prescribe, in.cludin l�IInnesota Statue #1 76.182. In <br />addition, the applicant acknowledges that the are responsible for revi.ewir the �ac round and -- - - - —P.p �' p - -- � �..__ - work history of <br />their employees, inc lu ding those that have received a massage therapist license from the C its - <br />i ornature <br />Date <br />/ / - -)- & /0 S- <br />If completed license should he mailed somewhere other than the business address, please advise. <br />