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, ��,�w'k���y', :� <br />�:. <br />Finance Depari;ment, L�cense Di�ision <br />2G60 Civic C�nt�r Drive, Rosevgile, MN 55�.13 <br />(651) 792-7034 <br />Niassage Therapist License <br />New Lice��se Renewal � <br />For License yeax endi�ag June 3p �,r�c��i <br />l. Legat Name � ��1 �0.��R.. �►+c"1'a�..1'� <br />.-- <br />2. Home Address _ <br />3. Ho�ne Telep�o•� _._ <br />� <br />4. Uate of �irt� _ <br />t <br />S. 1]ri�ers License Numb <br />6. �mail Adc�ess '�`" <br />�� <br />_.,w _ � <br />7. Have ynu ever used ar bee�n kna/wak by any name other than tY€e Iegal name given in number 1 abave? <br />Yes No �/ If yes, list eac� name along with dates and ptaces where used. <br />8, Name and address af t�ae �fcens�d Massage T'hera�py Establi ment that you expect ta ernployed b <br />�r�������s �- h��. `� �1��y °��o � t��.�.: ��zk-��� qo� ���. �,,C�j_ <br />����1le ��l �5it�i a��-[��; ~-i�"13ca <br />9. At�ac� a certi%ed copy of a diplozna or certificate of gracluat'ron frocn a school of massage therapy <br />including a minimum af S00 hours in successfuily caznpieted cnuz-se wark as described in Ras�ville <br />Ordinance I16, massa�e T`berapy �siablishments. �,��. ��Q. <br />1�, Have yau had a�1y pzevious zn�a `5age therapist Iiccnse tk�at was revoked, suspended, ar not renewed? <br />Yes Na r�' Tf yes explain u� detail. <br />Licezase f�e is 75,Q4 <br />Make checks payabie to City of Roseville <br />