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� � � <br />� � �i <br />City of Roseville <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651)792-7032 <br />Massage Therapy Establishment License Application <br />$����r����� ���� ��� ������� ��- <br />Business Address ��� �� � � �' �� +� �,��,�1 �'_��� � <br />���, ��..�� ��� „���r� <br />t�����.:�:.�� �����,� ���� � :�� J������� .- <br />Person to Contact in Regard tn Business Lice�zse: <br />�_ ���CSx �r���f� �x��s � <br />N:iir v 1����'1 <br />}4rJdI��S ���?��_ �� �� ��r� �`�i��`��, ���'�. ���+! �� f �� ��� <br />Phone _� �� � �-��� Y � � � � _ <br />Drivers License Number <br />Social Security Number <br />«� <br />U.S. Citizen? �Yes No <br />Date of Birth . <br />Naturalized? <br />If yes, date and place: <br />Yes No <br />� <br />I hereby apply for the follo�ving license(s) for the terni of one year, beginning July l, �.�� �� , and ending <br />June 3 l, �_, in the City of Roseville, County of Ramsey, State of Minnesota. <br />License Reauired <br />E�e <br />Massage Therapy Establishment $300.00 � <br />$150.00 Bacicground Checic, <br />(new license only) <br />The undersigned applicant malces this application pursuant to all the laws of the State of Minnesota and regulation <br />as the Council of the City of Roseville may from time to time prescribe, including Minnesota Statue #176.182, <br />, _..� <br />Signature - r'�� <br />D'a[e <br />i, , r- <br />_ ,5 r <br />.-•�h` 4�• �4 �'. <br />Ir � <br />Ifcompleted license should be mailed somewhere other than the business address, please advise. <br />