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�� ii <br />�� <br />C�ty o�' Roseville <br />Finance Depar�ment, License Division <br />2660 Civic Center Drive, Roseville, N�N SSll3 <br />(651) 792-7036 <br />Massage Therapy Establishment License Appiica�ion <br />Business Name <br />$usiness Add.ress <br />Busin.ess Phone <br />Email Ad.dress <br />�.� �lo�S (�� <br />� . . -v 1-- <br />�o ���v���� <br />�� E 'T <br />� — ��. _ <br />�� � <br />Ferson ta Contact in Regard to Bacsiness L� rrse: <br />Legal Name � <br />Address <br />Phone _ <br />Drivers License Number <br />Date of Birth <br />� <br />� <br />I h.ereby a ly for �he following license(s} for the term of one year, beginning July 1, � 1 , and ending <br />J�ne 31, �,. in tE�e City of Rosevilie, Caunty of Aamsey, and State of Minnesota. <br />��� <br />Massage Th�rapy Establishinent <br />�ee <br />$300.Q0 <br />$150.00 Bac�graund Chec[c <br />(new iicense only) <br />The undersigned applicant makes this application pursuant to al� the laws of the State of Minneso�a and regulatior� <br />as the Councit of the City of Roseville may from cime to time prescribe, incluc�ing Minnesota Statue #l76.182. � <br />ad.dition. the a licant acknowE�d es that ti�e are res onsib[e for reviewin the back round and work hista of <br />thei.r em lo ees includin those that have recei�ed a massa e thera ist license from the Cie . <br />Signature ,� �/ .,1� <br />baCe / . <br />It' completed license should be mailed somewhere other than the business address, please ad�ise. <br />i <br />� <br />