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Attachment A <br />� <br />V q-Lj1U.L J�E <br />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 .. 5 4 e- Y^(' 42L l.. 6- C <br />Business Address /I Le X.v1. # 4.4c <br />Business Phone � r) t --- ! G q --- ( I I Z. <br />Email Address -�c c <Cli�U /f �? j ` �. ca•.. <br />Person to Contact in Regard to Business License: <br />Legal Name <br />Address <br />Phone Date of Birth <br />Drivers License Humber <br />I hereby apply for the f ll vAn license for the term of one ym, beginning July , h , and ending June <br />1,'L 01 , in the City of l Roseville, County of Ramsey, and State of Minnesota. <br />License Requie Fee <br />Massage Therapy Establishment $300.00 <br />$150.00 Background Check (nevi 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 #176.182. In <br />addition, the ap lit acknowledLyes that the; are responsible for reviewing the background and work hest r of'their <br />mplgyees., including those that have received a massaize, thera i t license from the Ci . <br />Z have attached a certi sate i 'eating Workers omp nsation coverage, and the appropriate fee(s). <br />Signature <br />Date 3 <br />If completed license should be mailed somewhere other than the business address, please advise. <br />