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�� . �� �. Finance Department, License Division 266Q Civic Center Drive, Raseville, MN 55113 {651) 792-7036 Massage Therapy Establishment License Application (Please Print Clearly) �New License ❑ Renewal For License Year Ending June 3U, � I I Business Name � i�il-tf ��: ~ 1 � �-1� � Business Address � � l � ��-%Q--- � � j�� -` Business Phone � �. � Email Address �U►�J� � `�1 �" S� �° c.� �`11 Yl fL� i� �� c�G Persan to Contact an Regard to Business License: Full Lega} Name (Please Print� (�,ast) Home Address (Street} (City) Telephone_. _ _ Date of Birth {mm/cid/yyyy) Driver's License Number Ethnicity: Sex: 'i GLt. i � C �-YYl � � a �'" �:.L/ �-i''LQ (Middle} . . � -� � (State) (Zip) �] Cell ❑ Home ❑ Work State of Issuance��1 ^ Have ya ever used or been known by any name other than the legal name given abave? �Yes ❑ No If Yes, List each full narne along with dates and places where used. .r–, P 1 Has the business hatd any previous rnassage therapy establishment licenses? If yes, in which city was it licensed? ❑ Yes � o The undersigned applicant makes this application pursuant io a11 laws af the State of Minnesota and regulation as tha Council of the City of Roseville may from time to time prescribe, including Minnesota Statue #176.182. In additian the a licant ackanowled es that ihe are res onsible t"or reviewin the back ound and work histo of their em lo ees includin those that have received a massa e thera ist license from the Ci . By signing below, the applicant certifies that the above infarmation is correct and authorizes the City o£Roseville Palice Department o n�n hislller information for the required background ckecks. Date / "� � `— � License �ee is �3UQ:00 �t�` "� Additional $150 backgraund c�seck fee far atl iYrst-time applicants Make checks payable to: City of Roseville r � �..