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'�j Nc�a License <br />��,5��,��5 ��n,� <br />���7r�"��� <br />� <br />Finance Department, License Uivision <br />2b60 Civic Center Drive, Roseville, MN SS113 <br />(651)792-7036 <br />Massage Therapy Establishment License A�plication <br />❑ Renewal <br />c5 E/� d� �� i1 Q't� � t-1 T <br />Por License Year Ending June 30, 2��6 <br />rn ASS�? �c <br />ButiinessAddres�__2!-�0_� __F�RV��I�I- �!� -- ./� -- P�.c'S�i�� �Ylt� Tj � I (S`'"-r� � <br />---____w_ _.:.—__._ _'�_�____ _ . �__��__._._ _ --- <br />s��s;�,�,s �n�,��t ��b3 ,_222—�i�3S <br />Email Address _ �tJi_ ��C�1=5 � ��"1 � L • �-O n"1 <br />Person to Contact r�t Regard to l3usii►ess I.icense: <br />f ull Legal Name (Please Print) ___��"��LS <br />( I_ast ) <br />Home Address <br />(StrreU <br />Telephone ,—_ --_-- <br />Date of Birth (mn�/dd/yyyy) <br />Driver's License Number_ <br />Ethnicity: <br />Sex: <br />__....__. �Cell <br />(City) <br />❑Home ❑Work <br />El.i 2A-i3`-rr.� <br />_-�� (Middlcl�-- <br />(St�ue) (Zip) <br />S[ate of Issuance M t n n�S o T� <br />Have you ever used or becn known by any name other than the legal name given above'? <br />�j Ycs ❑ No If Yes, List cach full name along widi dates and places wherc used. <br />{-�ciD� �U���'r� S��n�t7E� ��5� �n �i�-i� �J�C- ����Z -e� �u��� z��� <br />Has thc business held �u�y previous massagc therapy estab(ishment liccnscs`? If ycs, in which city was it licensed'? <br />❑ Ycs �, No <br />'The intbrmation that you are askcd t�> provide on the application is classiticd by State law as either public, privatc or <br />confidential. All data, with the exception of driver's license numbers, will constitute public record if and when thc license i� <br />granted. Our intended use of the informativn is to perform thc b�ickground check procedures reyuircd prior to license issuance. <br />If you refuse to supply the information, the license application may not be processed. <br />The undersigned applica��t makes this ��pplication pursuant to all la���s of the State of Minnesota and re�tQati�n as the Coimci) <br />of the City of Roseville may from tiinc to time prescribe, incluciing Minnesota Statue #176.183. In addition, the ap licant <br />acknowledees that thev are responsible for revicwing the background and work history of their ei�lovecs including those th•it <br />have recerved a massa e�therapist license from the Cit� <br />By signing below you certify that the ab�ve infonnation is correct and authorire the City of Roseville Yolice Department to run <br />your information for thc required backgroimd checks. (Note: Back�round checks mav t•ike up to 3Q days ro complcte.) <br />Signattu�c ��k� ����_� <br />u���� �L`� � � 2� t S <br />License ree is $300.00 <br />Additional $150 background check fee for all first-time applicants <br />Make checks payable to: City of Rosevitle <br />