HomeMy WebLinkAboutCustom Cuts, Inc. - 12/31/1986APPLICATION FOR MASSAGIST PERMIT
1. Business name:( , Cl, ]S7O y) (_1 L1 % _3 C_' ,
2. Business address: %tg �EpE' %h�� Telephone:
3. Applicant's full name: JiLC6P. �}tJ )fgrgY'eQy/eSNickname:
4. Address: tL3 (�1Qre, _3L le 33?--300
5. Two (2) previous addresses prior to present address:
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6. Social Security Number; ('2 -3.2 3 ��/iD S � � Date of birth:
7. Weight: / / Height: ,� ! 7 d Color of hair: /% c?(f,)12
Color of eyes: 6 y'e w o Sex: /%)Ci lr-
8. Statement of all convictions for any felony or misdemeanor or violation of a
local ordinance.
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9. Recognized schools attended:
Name
M
Address
Date attended
-- %Y6 7
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10. Massage or similar business history and experience prior to date of application
for past ten (10) years.
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11.
12. Please attach to this application:
a. proof of age
b. fingerprints (to be taken by Police Department)
c. two (2) front -face portrait photographs taken within thirty (30)
days of application date and at least 2" x 2"
d. copies of diploma or certificate of graduation showing applicant
has completed not less than seventy (70) hours of instruction
e, a medical certificate signed by a licensed physician within seven (7)
days of application date. The certificate shall state that the
applicant was examined by the certifying physician and the applicant
is free of communicable disease.
13. Please attach the names, current addresses and written statements of at
least five (5) bona fide permanent residents, other than relatives, that
the applicant is of good moral character. If possible, the statements should
be furnished from residents of the town.
14. I hereby authorize the town, its' agents and employees to seek information
and conduct an investigation into the truth of the statements set forth in
the application and the qualifications of the applicant for the permit.
15. I hereby certify that the information contained in the said application is
true and correct.
P� Aure if
Bristol, ss. Massachusetts
January 30, 1986
Notary Public
December 28, 1990
My Commission Expires
BANCROFT SCHOOL OF MASSAGE THERAPY
50 Franklin Street
Worcester, Massachusetts 01606
(617) 757-7923
(617) 753-9757
The BANCROFT SCHOOL OF MASSAGE THERAPY does hereby certify that
Elizabeth Hargreaves
has completed the following course of study
CERTIFIED MASSAGE THERAPIST
COMPLETED
SUBJECT
HOURS
GRADE
101
Massage Techniques
203
94
102
Anatomy/Physiology
115.5
96
103
Advanced Massage
101.5
95
Therapy
--
104
Hydrotherapy
10.5
94
105
Health
23
Pass
106
Business
21
Pass
107
Psychology/
20
Pass
Philosophy
108
Nutrition
15
Pass
July 3, 1985
Date of Graduation --
Rat ryn 4Hnyrk. tar y
Director f Academic Curriculum
Karen L. adas
January 27, 1986
ate
MANSFIELDHEALTH E TER
a unit of Sluay Mernonal Hospital, Inc.
200 Copeland Drive I Mansfield, MA 02048
Telephone (617) 339-4144
January 29, 1986
To Whom It May Concern:
Elizabeth J. Hargreves was seen and examined by
me at the Mansfield Health Center on January 24, 1986.
At that time, she was found to be free of
communicable diseases.
Copies of her complete physical examination are
on file at the health center.
Sincerely,
Charles Gibbs M.D.
BOARD OF HEALTH
TOWN HALL
50 WEST STREET
MANSFIELD, MA 02048
TOWN OF MANSFIELD
Date OdJ 1 11 E�
PLEASE PRINT
I hereby make application for a
for my business conducted at
under the_ /
name of ( � �wll
owned by
type of business
Signatu
Address
Telephone C
- ---- -- ----
Date Paid
No.
New ( ) Renewal ( )
License
1
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