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18. Are you directly or indirectly interested in other establishments iu the City of Little Canada to <br />which a license of the same kind has been issued? Yes " No <br />19. Dave you had any previous massal;e therapist license that was revoked, suspended, or not <br />renewed? Yes J No <br />If yes, explain in detail: <br />20. T-Iave you ever made application for a massage therapist license or similar activity and had <br />such application denied? __ Yes _ ~~ No <br />Tf yes, explain in detail: <br />I understand that the information provided in this application may be considered private or <br />confidential data. T further understand that I may not be requhed by law eo provide such information. <br />The purpose of providing such information is to aid the City of Little Canada in its determination on <br />my application for a permit. I acknowledge the providing, or failing to provide, such information <br />may affect the City's determination on my application. I understand this information will be made <br />available to the City of Little Canada, its City Council, agents and representatives, as well as the <br />Minnesota Department of Revenue, or any other person or enfity authorized by law to receive said <br />information. I release the City of Little Canada from aziy and all liability for its receipt and use of <br />data received pursuant to this application. <br />STATE OF MINNESOTA ) <br />COUN'T'Y OF ~~~'JS~) <br />~/~/ ~~/Q ~y7/~- l ,being first duty swozn, upon his/her oath, <br />deposes and says that helshe is the person who has executed the above application, and that the <br />statements made therein are true of his/her own knowledge and belief. <br />r /%'~'~ <br />Sig tore ,-- <br />1~1~55 y~ue~ I he~'~ r»`~ ~ <br />Title <br />