BOARD
OF HEALTH
| For Office Use Only: | |
| Permit #: | |
| Approval Date: | |
BOARD
OF HEALTH
CITY OF
Applicant’s Name:______________________________________________
Applicant’s Home Address:_______________________________________
Applicant’s Telephone #:_________________________________________
Business Address:______________________________________________
Business Owner’s Name:_________________________________________
Business Owner’s Telephone #:___________________________________
Please answer the following questions:
If now engaged in the practice of massage, state where:_________________
What particular form or kind of massage do you wish to be licensed to practice:
Facial_____ Scalp_____ General Body ______
Do you wish to be authorized to treat men exclusively or women exclusively, or persons of both sexes?___________________
Do you wish to be licensed to conduct an establishment, office, or room of your own for the reception and treatment of patrons?_______________________
Number of rooms to be used for the accommodation or treatment of patrons:________
What facilities are provided for securing hot and cold water?_____________________
What arrangements are made for assuring the cleanliness of towels, robes, sheets, or other coverings used in connection with the treatment of patrons?______________________
_________________________________
What toilet facilities are available for the accommodation of patrons of each sex?
_________________________________
Number of rooms to be used for the accommodation or treatment of patrons:__________________
On what floor or floors are the rooms located?________________________
Are the rooms above described used or to be used for any other purpose than for the giving of massage treatment?_______ If so, for what purpose(s)?_____________________________
What education, training and experience have you had to qualify you to practice massage? (Attach certification from an approved and accredited program).
_____________________________________________________________________
References:________________________________________________
________________________________________________
________________________________________________
I, the undersigned, applicant hereby certify that I am at present free from any communicable disease of any nature or description whatever, except as stated below, and agree that so long as I hold a license to practice the business or businesses applied for herein I will at any time furnish such evidence regarding any health and my fitness in all other respects as the Board of Health may desire. Exception as to communicable disease________________________________________________________________
I further certify that the declarations and answers made by me to the above questions and to the questions, which apply to the business or businesses for which I wish to be licensed are true; that I have read the Regulations of the Health Department governing the practice of massage, and that the name which I have signed below is my true name.
Notes to Applicant:
All applications for Massage Licenses must be approved by the Board of Health. The Board usually meets once a month.
Massage license fee is $50.00.
Attached is the City of
If you have any questions, please call the Board of Health at 978-374-2325.