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; . ��� . � <br />I -��� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />New License Renewal X <br />For License year ending June 30,2007 <br />1. Legal Name: Bayete C Hall <br />2. Home Address: : <br />3. Home Telephone: __ <br />4. Date of Birth: � <br />5. Drivers License Number: <br />6. Email Address: <br />7. Have you ever used or been lcnown by any name other than the legal name given in number 1 above? <br />Yes _ __ __ Na If yes, list each name along with dates and places where used. <br />8. Name and address af the licensed Massage Therapy Establishmentthat you expect to be employed by. <br />IIamline Health & Wellness 2151 HamlineAv#L] I Roseville, MN 55113 <br />9. Attach a certi�ed copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course worlc as described in Roscville <br />Ordinance ll 6, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revolced, suspended, or not renewed? <br />Yes No — If yes explain in detail. <br />License fee is 75.00 <br />Malce checics payableto City of Roseville <br />