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_ � ;��� �- -�'�r - ` ` <br />`, .�..� . "' .' <br />Tinance Department, Li�ense T3ivi�ian <br />2660 �iv�c C���er 1]�iv�, �asevil:le, MN 55113 <br />(651} 7�2-7034 <br />�Vi�ssag� Ther�p��i License <br />New I.,ieerise X Renewal <br />For License year ending 7une 3Q, 2A{�6 <br />1. Legal. Name: �a ete C. IIaII � k <br />2. Home Addxess: -`k', �►!�k -` <br />3. Home Telepl7one: ---_ <br />4. Date o�L'irth <br />S. Drivers License N�.unUer. ..u� <br />G. Ez��aii Address: - � ' � <br />�. ��� tra+ rrntt ever used ox been known by any narrze other than tl�e Ieg;ai na�e g%ven in numbe� � abave? <br />Yes Nc If yes, �isi eac� r�ar.�e aloz�g wzth dates and places w�Zere used. <br />&. Nar�e and address of �e lieensed Massage `�he�°apy Establisla.ment ihat you expeet tn be ��played by. <br />�aml�ne Heal� & Wellness 21.51 Haml�e Av #111 Roseville MPT 55113 <br />9. Attaah a certi�ed oopy of a diplonaa or c:ert�ficate a�' �'aduation fx`o� a schoal of.tzaassage therapY <br />ine�udin� a mini�nt�an o�60Q hoi.�rs in successfully cofnpleteci cnurse wor� as described in Rnseville <br />Ordinance 116, massags Tt►er�py Establzsl�ments. <br />� Q. Have you h,ad any ps�eviaus massage ttzerapist lieense tl�at was �evaSced, s�spended, or not res�evved? <br />Yes_ No X Iiyes ea�ptain in d�fiail.. <br />Licensa fee is 7S.b0 <br />Make checks payable to City o;F�t.oseville <br />