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� <br />-�' <br />Finance Dep tme'� t, License Division <br />2660 Civic Cente '�Dri' e, Roseville, MN 55113 <br />( "1) 7i 2-7036 <br />Massage Therapy Esta�ishment License Application <br />❑ New License �Renewal For License Year Ending Ju�e 30, �� <br />Business Name �}4 (��QT S D/k (�I,C (� oD t� f�'0211' F� dL �k� W► � I1 J h�'�. � S P l 02l `[' <br />i <br />Business Address � 'ZZO � ,L.eX i n�za N /�� E /�. �w�'re '� (o � �sEu�u-C� SS1 ! 3 <br />Business Phone (� 5 �—� � Z—�.3G s� ' <br />Email Address e(` 1 G!� $ h��r. r`�" S ipR r� � G� W�. �b ►�. C O"� <br />Pe�son to Contact in Regard to Business License: <br />Full Legal Name (Please Print) .�(��jL�'`��C L IZ\ G� CPCIZLL�a l.r �( l� (`t�l�� <br />.r __�. ..-:.__�. .,,,�.aa,_� <br />Home Address <br />(Streetl <br />Telephon <br />Date of Birth (mm/dd/yyyy) _ <br />Driver's License Number <br />Ethnicity: <br />Sex; <br />(City) (State) <br />'�Cell ❑Home ([�Work, <br />State of Issuance Wti Y1 <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 with dates and places where used. <br />�`12. t G f�F G A�2 l.l+�" A3 E 'p a( N 1�1,Q_ <br />Has the business held any previous massage therapy establishment licenses? If yes, in which city was it licensed? <br />❑ Yes [�No <br />(Zip) <br />The information 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 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 a�plicant <br />acknowledges that they are responsible for reviewing the background and work history of their emplovees, including those that <br />ha�e received a massa eg therapist license from the Citv. <br />By signing below you cei�tify that the above information is correct and authorize the City of Roseville Police Department to run <br />your information for the required background checks. (Note: Back�round checks may take up to 30 davs to complete.) <br />Date <br />License Fee is $300.00 <br />Additional $150 background check fee for all first-time applicants <br />Make checks payable to: City of Roseville <br />