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k 4 <br />V TI-JI A <br />Vi <br />Finance Department, License Division <br />2 & <br />2660 Cmr- Center Drive, Roseville, MN. 55113 <br />(651) 792-7036 <br />Massage Therapy Establishment License Application <br />ANew Licease 0 Renewal (Please Print Clearly) <br />For License Year Ending June 30, <br />Business Name LL. r-7- <br />Business Address <br />Business Phone 0 <br />Email Address <br />Person to Contact in Regard to Business License: <br />Full Legal Name (Please Print) CLL*rl n I <br />il 0300+1 <br />Home Address. <br />(street) <br />Telephone. <br />Date of Birth (mnVdd/yy <br />� yy)_ <br />Driver's License Number— <br />Ethnicity: <br />Sex: <br />nil <br />(City) (State) (zip) <br />6Cell Ll Home 0 Work <br />State of Issuance M N <br />Have you cvcr usod or been known by any name other than the legal name given above? <br />[ Yes 6 'No If Yes, List each frill name along with dales and places where used. <br />Has the business held any previous massage therapy eslRblishmeiit hoenscs? If yes, in which city was it licensed? <br />tA' j <br />K Yes L~ZX, P <br />I 1 - rA(.3rN t, LJ No <br />ne undersigned applicant makes this application pursuant to all laws of the State of Mimesota and regulation as the <br />Councit of the City of Roseville may from time to time prescribe, including Mimiesula Statue #176.182. In <br />addition, the applicant acknowled ges that they are responsible for reviewingthe -backi-gowda, work - histy of <br />ud <br />their employmincluding these that have received a rnassag,,e theranist license from the - <br />By signing below, the applicant certifies that the above information is correct and authorizes the City of Roseville <br />Police Department to Tun bi.kAcr information for the required background checks. <br />Signawre Date 4. <br />Liceme Fee is $300.00 <br />Additional $150 background check fee for all first-time applicants <br />Make checks payable to: City of Roseville <br />