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�� '�� <br />E� <br />� <br />w���- <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapy Establishment License Application <br />(Please Print Clearly) <br />°�New License ❑ Renewal <br />�.� <br />For License Year Ending June 30, � <br />Business Name <br />Business Address <br />Business Phone <br />Email Address <br />Person to Contact in Regard to Business License: <br />Full Legal Name (Please Print) � h �� ���� (� C V�ar i.J� <br />Home Address <br />Telephone <br />,v�...,., .---.,, �-----, .-.-, <br />Date of Birth (mm/dd/yyyy) <br />Driver's License Numbf <br />Ethnicity: <br />Sex: <br />i � �e�'M1� <br />Have you ever used or been lrnown 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 use � <br />-. � n � �mc�� <br />Has the business held any previous massage therapy establishment licenses? If yes, in which city was it licensed? <br />� Yes �o�,v iew� I'�l�l ��� <br />The undersigned applicant makes this application pursuant to all laws of the State of Minnesota and regulation as the <br />Council of the City of Roseville may from time to time prescribe, including Minnesota Statue #176.182. In <br />addition the appiicant acknowledges that they are responsible for reviewin� the back�round and work history of <br />their emplovees includin� those that have received a massa e� therapist license from the Citv. <br />By signing below, the applicant certifies that the above information is correct and authorizes the City of Roseville <br />Police Department to run his/her information for the required background checks. <br />Signature <br />License l <br />Additional �150 background check fee for all first-time applicants <br />Make checks payable to: City of Roseville <br />Date ` t � `� � / <br />