Laserfiche WebLink
�,��' ,. ,.� ���� ,..�r, <br />� <br />Finance Department, Lice�se Division <br />2b60 Civic Center Drive, Rvse�il�e, MN 55� 13 <br />�r�z� ��z-�o�� <br />Massage Therapis� Licen�e <br />New I.,icer�se � Renewal <br />For �,icense year ending June 30 ,____�� �y� � <br />��Ctbt . : !�l c%,O <br />l. Legal Name � ,`� - <br />2. Horne Address_ •- �-� ____,� _ _ <br />3. Hame Te1ep�Zane�° � <br />4. Date of Birtli <br />S. Dravers License Number <br />6. �mail Address <br />7. I�ave you ever used or been knnwn by any 3iame other tEaan the legal name given in nuznber � above7 <br />Yes Na X�� I£yes, Iist eaeh name along with dates and places where used. , <br />8, azne and address of the licensed Massa�e �'�erapy Establishment that you expeet to he employed by. <br />�i� ( !�� �Y��a'SC�S�, r�i15 el%��`p �,G�� <br />9. Atiaci� a certi�ed copy of a diptarr�a a�• certi�cate of graduati€�n frae�r a schpp! of massage thez•apy <br />includin� a�ninimum oi 6�0 #�aurs in st�ccessft�lly co�npleted course worlc as described in Rose�vilIe <br />Ordinance 116, xraassa�e Theragy Est'ablishme�3ts. <br />10. Have you had atay �revious mass��e the�•apist lice��se that was revoked, suspexlded, or not renewed? <br />Yes �o � If yes explaii� in detaiI. <br />�.ice�sse fe� is 75.00 <br />Make checks payable ta City of Rosevzlle <br />