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��� -iJL � <br />F� J <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville,lVNi 55113 <br />(651) 792-7036 <br />NTassage Therapy Establishment License Application <br />❑� Nevv License ❑ Renewal <br />Business Name Welispring Massage Therapy <br />For License Year Ending June 30, 2016 <br />Business Address � 935 W COUnty Rd. B2, Suite 185 (in Roseville Chiropractic Center Office) <br />Business Phone 763-957-9296 <br />r-,ma�� aadress toni@wellspringmassage.net <br />Person to Contuet in Regnrd t� Brtsiness License: <br />Pull Legal Name (Please Print) <br />Home Address <br />(Street) <br />Telephone ( <br />Date of Birth (mm/dd/yyyy) <br />Uriver's License Ntunber <br />Ethnicity: <br />Sex: <br />Thorson <br />(Last) <br />� Cell <br />Tonia <br />(First) <br />(City) <br />❑Home ❑Woi-k <br />Lynn <br />(Middle) <br />(State) (Zip) <br />State ofIssuance M N <br />Have you ever used or been known by any name other than the legal name given above? <br />� Yes ❑ No If Yes, List each full name along r��th dates and places where used. <br />Has the business held any previous massage therapy establishment licenses? If yes, in which city was it licensed? <br />❑ Yes <br />C . <br />The infot�nation that you are asked to provide on the application is classified by State law as either public, private or <br />confidential. All data, with the exception of driver's license numbers, will constitute public record if and when the license is <br />granted. Our intended use of the infiormation is to perform the backb-ound check procedures required prior to license issuance. <br />If youu refuse to supply the information, the license application may not be processed. <br />The undersigned applicant makes this application pursuant to all laws of the State of Minnesota and regulation as the Council <br />of the City of Roseville may fi-om time to time prescribe, includino Minnesota Statue #176.182. In additio«, the applicant <br />acknowledQes that they are responsible for reviewing the background and work history of their employees, including those that <br />have received a tnassa�e therapist license from the Citv. <br />By signin� below you certify that the above information is correct and authorize the Ciry of Roseville Police Department to run <br />your information for the rzquired background checks. (Note: Baekaround checks may take up to 30 davs to complete.) <br />Signature ��...- i Date '� � ( ' � `� <br />License Fee is �300.00 <br />Additional �150 background check fee for all fu•st-time applicants <br />Make checks payable to: City of Roseville <br />