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k rOA" <br />VA U j <br />;=SiB- I.JILJ <br />V 11 <br />City of Roseville <br />Finance Department, License Division <br />2660 Civic Center Die, Roseville, MN 55113 <br />(651) 792 -7036 <br />Massage Therapy Establishment License Application <br />ON <br />Business Dame <br />Business Address <br />Business Phone <br />Email Address &K <br />Person to Contact in Regard to Business License: <br />Legal. Name. <br />. I Ix <br />Address <br />Phone <br />Drivers License Number <br />U <br />Date of Birth <br />Y.o <br />�[t t , MN ssf ( <br />I hereby ap ly for the following license(s) for the tern of one year, beginning July 1, , and ending <br />June 3l, 2010 , in the City of Roseville, County of Ramsey, and State of Minnesota. <br />Massage Therapy Establishment <br />Tee <br />$300.00 <br />$150.00 Background Cheek <br />(new 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 ille may frorn time to' time prescribe, including Minnesota Statue #176.182. In. <br />addition, the am )l' ant acknowledges that the are responsible fir re ie {ire th.e Background. and work his <br />?p� , ,._ .._._g g ., story f <br />their eDV1oyqes, including those that have received a massage therapist license from the City - <br />Signature <br />Date <br />If completed license should be email. d somewhere other than the. business address; please advise. <br />Ltt,sA rna,�l 4-v o v-t o^4 60-cLvkss: <br />U <br />