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��'� <br />Finance Departme ' , L►cense ivisian <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651j 792-743b <br />Massage Therapy Establishment License Application <br />(Please Print Clearly) <br />� New License ❑ Renewal . <br />For License Year Ending June 30, <br />BusinessName i(',t/YIp�S'�lAh�DQ �-LC <br />BusinessAddress �1ij�P��_��Lh_�_�__,_i�prx/;t' �j�2�'p�9i%{,e. �lN ,�jJ`��/3 <br />�J <br />Business Phone <br />Emai1 Address <br />Person to Contact ift Regartt to Busifzess Lfcense: <br />Full Legal Name (Please Print) 1� Vt . ,��►'�-Q <br />ir ,...t� / .....s\ /T�i;.�.liPl <br />Ho�ne Address <br />` (Streetl <br />Telephone_ <br />Date of Birth (mm/ddlyyyy)_ <br />Driver's License Nurnber <br />Ethnicity: <br />5ex: <br />(CitY) <br />// - <br />(5tate) ("L�}S) <br />❑ Ho���e ❑ Wark <br />State of Issuance G% <br />Have you ever used or been known by any name other than the legal name given above? <br />❑ Yes (� No �f Yes, List each full name along with dates and places whera used. <br />Has the business held any previous massa�e therapy establishment licenses? If yes, in which city was it licensed? <br />❑ Yes <br />/� i <br />The undersigned applicant makes this application pursi�ant to all laws of the State of Minnesota and re�ulation as the <br />Council of the City of Roseville may from iime to tiine prescribe, including Minnesota Statue #176.1$2. In <br />addition the applicant acknowledges that thev are responsible for reviewine the background and work history of <br />their em�loyees including those that have received a massa e� therapisY license from the Citv. <br />By signing 1Zelow, the applicant certifies that the ahor+e information is correct and authorizes the City of Roseville <br />Palice Departmen# to run his/t�er informatian for the required background checks. <br />Signature ��' 1 � � <br />License Fee is $300.00 <br />Additi�nal �150 background check fee for all first-time applicants <br />Malce checks payable to: City of Roseville <br />Date D�j-��j,� <br />