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�i�� <br />� <br />City of Roseville <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(b51} 792-7036 <br />Massage Therapy Es�ablishrnent License Application <br />Business Name <br />SY�7�mf ��'1 c . <br />Business Address ``f {s� G ,� � �„� SS'j/3 <br />Business Phone <br />Email Address <br />- --� r-_ - <br />Person to Contact in Regard to Business License: <br />./ _ <br />Legal Name _ <br />�ddress <br />Phone <br />Drivers License Number <br />� -- - � <br />. , � - - <br />_ � <br />Date of Birth _ <br />I hereby ap ly for the following license(s) for the term of one year, beginning July 1, �, and ending <br />June 3I ,�,,�, in the City of Roseville, County of Ramsey, and State of Minnesota. <br />�.icewse�toc�ed ree <br />Massage Therapy Establishment $300.00 <br />$150.00 Background Check <br />{new license only) <br />The undersigned applicant makes this application pursuant to all the ]aws of the State of Minnesota and regulation <br />as the Council of the City of Roseville may from time to time prescribe, including Minnesota Statue #176.182. � <br />addition the applicant acknowledges that they are responsible for reviewing the hackground and work history of <br />their ern.ployees, includin�ose that have received a massa eg therapist license fro;n the Ciri. <br />Signature <br />Date �l% // .s"" � <br />If completed license shotild be mailed somewhere other than the business address, please advise. <br />