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CITY OF ROSEVILLE <br />FINANCE DEPT, LICENSE D M S I O N <br />2660 CIVIC CENTERDR, ROSEVILLE,MN 55113 <br />(651) 490-2212 <br />MASSAGE THERAPIST LICENSE APPLICATION <br />APPLICANT' S NAME : <br />DATE OF BIRTH: <br />� ��� ���.�� <br />��� f { <br />1���1 (1VIIDDLE) <br />RESII�E�f�� 1�L?F.��; �� ��� �� �►'� <br />� �r{7 ��� t ��. ��} "�`� <br />RESIDENCE TELEPHONE: `'' � <br />BV IJ11 VLIJIJ L-1L�IWIJIJ. �` � 5 �"� � <br />BUSINESS TELEPHONE: <br />NAME & ADDRESS OF THE LICENSED MASSAGE THERAPY ESTABLISHIV�NT THAT YOU <br />�� {] l�F �[NPLC? E#Y- <br />. � r _� ��1� � �, <br />� i � � F � <br />��1..���.� -" ._ - - . T <br />I hereby apply for the following license for the term of one year, beginning July 1,2002, and ending June <br />30,2003, in the City of Rosevill�, County of Ramsey, State of Minnesota. <br />LICENSE 1 C <br />MASSAGE 'I'I�RAPIST <br />FEE <br />$75.00 <br />The undersigned applicant makes this applicationpursuant to all the laws of the �ra��n� l�'� <br />regulations as the Council of the City of Roseville m��r ��ri �ini� � t � pr�ribc, irrcludio� <br />Statue#176.1$2, _ � �,� � �_ , � <br />���nature <br />D�ate � � �f J � <br />ar�d <br />�ot� <br />**If completed license should be mailed somewhere other than the applicant's residence address, <br />please advise. <br />Receipt #� <br />