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�4Y. <br />����. <br />City of Roseville <br />Finance Department, License Division <br />�66b Civic Center Drive, Roseville, MN SSll* <br />(651) 792-7034 <br />Massage Therapy Establishment License Application <br />�415LfLC55 �19Jf7C �� �� �� ����.��� _ .. <br />�u5�s��r��� _. �_. �. � � � ���.�,r��� � ����. �.��'d' �� � <br />f � _�_� � � ., . , <br />I�tisi n��� PI ��r�: <br />�mail Address <br />Person to Contact in Regara'to Business License: <br />� <br />Legal Name � '/C/ �� <br />Address R � <br />Phone � � ��-�_ Date of Birth <br />Drivers License Number _ ,.. <br />I hereby apg]� for the fol[ow€��g Iicense(s) for the term of one year, beginning July I, ,� �� �_, and ending June <br />31, ��� , in the City of Roseville, County of Rarnsey, State of Minnesota. <br />License Reauired Eee <br />Massage Therapy Establishment $300.00 <br />$150.00 Bacicground Claec�C <br />(new license only) <br />The undersigned applicant malces this applicatio�� pursuant to all the laws of the State of Minnesota and regulation as <br />the Council of the City of Roseville �nay from time to tim� prescribe, including Minnesota Statue #17G.182. <br />Signature �� ��X�� <br />�' <br />I ],i•.� ..����� ._ <br />If completed license should be mailed somewhere other than the business address, please advise. <br />