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Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792 -7036 <br />Massage Therapy Establishment License Application <br />Business Name fg 7.* / ��� 1p 577:; <br />Business Address <br />Business Phone 1" % <br />Email Address <br />Person to Contact in �g rd to Business License: <br />Legal lance <br />Address <br />Phone Date of Birth <br />Drivers License Number <br />I hereby apply for the following license(s) for the term of one year, beginning July 1, wZ4 Z T and ending June <br />14) , in the City of Roseville, County of Ramsey, and State of Minnesota. <br />License Required Fee <br />Massage Therapy Establishment $300,00 <br />$150.00 Background Check (new license only) <br />The undersigned applicant makes this application pursuant to all the laws of the State of Minnesota and regulation as <br />the Council of the City of Roseville may from time to time prescribe, including Minnesota Statue # 176.18 . I <br />addition, the a lic nt acknowledges that they are responsible for reviewing the background and work histojy of their <br />errs to es including those that have received a massa a thgra ist license from the Qty. <br />I have attached a certificate indicating Workers Compensation coverage, and the appropriate fee(s). <br />Signature <br />Datefi <br />If completed license should be mailed somewhere other than the business address, please advise. <br />