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Attachment A <br />L�i� <br />�� <br />City of Roseville <br />Finance Departme�t, Lieense Division <br />2Gb0 Civic Center Drive, Roseville, MN SS1.13 <br />(651) 792-7434 <br />Massage Therapy Establishment Ilicense Application <br />Business Name 1 e ��1 + 1� <br />Business Address ��. /�' � � iv .S <br />Business Phone <br />Emai3 Address <br />Pe�'son to Co�uact rn Regard to f3usiness Lfceftse: <br />Legai I`�ame f"F ✓tl'I'R_. <br />Address <br />Phone <br />Drivers License Number <br />n <br />� _ <br />Date of Birth <br />I hereby apply for the following ]icense(s) for the term of une year, beginning luly 1, �C)d , and ending <br />3une 31, )� , in the City of Rosevifle, County of ]�anzsey, and State of Minnesota. <br />I.icense Required <br />Massa�e 'Fherapy Estahlishment <br />Fee <br />�300.00 <br />$150.00 Background Check <br />(new Iicense only) <br />The undersigned applicant makes this app3ication pursuant to all the taws of the SEate af Minnesota and regulation <br />as the Cauncil of the City of Roseville may from time to time prescribe, including Minnesata Sta[ue #176.182. In <br />addition, the.a�piicant acknowled�es thaE they are responsible for reviewin¢ the backtrround and work histor�of <br />iheir em lo �ees incl�dinQ those that have received a nlassa e thera ist ]icense frotn the Cit . <br />c -� � <br />Si�nature <br />Date --- - ! ! ! (� /� � <br />If completed license shouId be maiied somewhere other than the business address, please advise. <br />