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itsv <br />MOU-ND VIEW <br />2401 Mounds View Boulevard * Mounds View MN 55112-1499 <br />(763) 717-4000 * Fax (763) 717-4019 <br />info@moundsviewmn.org * www.moundsviewmn.org <br />APPLICATION <br />THERAPEUTIC MASSAGE: THERAPIST (INDIVIDUAL) <br />[� THERAPEUTIC MASSAGE: ENTERPRISE <br />This is a renewal application only. The information shown below is information on your original <br />application that may change from time to time. All other information on the original application is <br />kept on file. Please review the information below and make any corrections in "red" ink if <br />possible and answer "yes or no" to any questions that are asked. <br />Business Name <br />Eric Roy Massage <br />Eric Rautio <br />Applicant <br />Address <br />8373 Groveland Court <br />City <br />Mounds View <br />State <br />Minnesota <br />Zip <br />55112 <br />Phone 1 <br />a- S <br />Phone 2 <br />Email: <br />eric@ericr"oy.com <br />Change in residence in the last ear? <br />Convicted of a felony in the last ear? <br />Have there been any changes in ownership or partnership in the last ear? <br />Have all real estate and personal property taxes that are due and payable for the premises <br />been aid? <br />Has the location in the building where the massage services are to be conducted changed in <br />the last ear? Vl <br />✓ If the business is to be conducted under a designated name or style other than the full <br />individual name of the applicant, attach a copy of the certification required by MS <br />Chapter 333. <br />✓ Please attached or forward a valid Certificate of Insurance good through the entire <br />license period. <br />I hereby certify that the information provided I this application is true and correct and I <br />understand that any misrepresentation made herein may be grounds for denial of this <br />application for a business license. <br />Applicant Signature: <br />