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� ����/ ., �..�(�„�� � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapy Establishment License Application <br />�New License ❑ Renewal For License Year Ending June 30, �� �, � <br />Business Name <br />Business Addres� <br />Business Phone <br />Einail Address <br />[�erson to f,ontact a�z [tegard to Lfusiness License: <br />Full Legal Name (Please Print) <br />�Iotne Address <br />re«...,,.�� <br />Telephone � <br />Date of Birth (mm/dd/yyyy) <br />Driver's License Numbex <br />Ethnicity: <br />Sex: <br />C�-v�� �°1 i�1Y� f � <br />(Last) � �i-}_ (Fii <br />(City) <br />,�Cell �3ome �ork <br />��-- <br />(Middlel <br />(State) <br />State of Issuance �" V' 01 <br />Have ou ever used or been known by any name other than the legal naine given above? <br />�Yes '❑ No If Yes, List each full name along witl� dates aud places where used. <br />YY���.I �[`�� ���`�-�-1� �,�,��~ l� � <br />Has the business held any previous massage therapy establishment licenses? If yes, in which city was it licensed? <br />❑ Yes �o <br />(Zip) <br />The information that you are asked to provide on the application is classif ed by State law as either public, private ar <br />confidential. All data, with the exception of driver's license numbers, will constitute puUlic record if and when the license is <br />granted. Our ivtended use of the information is to perform the background check procedures required prior to license issuance. <br />If you 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 from time to time prescribe, including Minnesota Statue #176.182. In addition, the applicant <br />acknowledees that thev are responsible far reviewin� the background avd work historv of their emplovees includin� those that <br />have received a massaee theranist license from the Cit,� <br />By signing below you certify tl�at the above information is correct and authorize the City of Roseville Police Department to run <br />your information for the required backgr und checks. (Note: Backgrouvd checks inay take up to 30 days to complete.) <br />.�� m �� <br />Signature Date <br />License Fee is $300.00 <br />Additional $150 background checic fee for all �rst-time applicants <br />Make checics payable to: City of Roseville <br />� <br />