| (1) |
Name of the Massage Parlour/SPA, if any: |
Latest passport size photo of the applicant Self Attested |
| (2) |
Name of promoters with full postal address: |
| (3) |
Status of owners/promoters, whether company (copy ofmemorandum and Articles of Association may be furnished):
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(a) |
Partnership firm (if yes, copy of Partnership Deed andcertificate of registration under Partnership Act may befurnished):
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(b) |
Proprietary concern (if yes, give name and address of thepromoters):
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(4) |
Location of the centers alongwith full address: |
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| (5) |
Details of Location- |
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(a) |
Area: |
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(b) |
Title (whether outright purchased) if yes, copy of theregistered lease deed should be furnished:
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Yes/No |
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(c) |
Survey number: |
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(d) |
Village, Taluka and District: |
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(e) |
Distance from nearest town: |
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(f) |
Distance from nearest railway station: |
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(g) |
Distance from nearest airport: |
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| (6) |
If center is attached to a hotel/resort/hospital: |
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| (7) |
Details of the building- |
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(a) |
Plinth area (floor-wise): |
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(b) |
Building number: |
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(c) |
Details of building license from local body (attach blueprintof the building and copy of building license):
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| (8) |
Details of facilities- |
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| (9) |
Details of equipment- |
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(a) |
Massage table (number and size): |
Yes |
No |
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(b) |
Gas or electric stove: |
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(c) |
Medicated water facility: |
Yes |
No |
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(d) |
Facilities for sterilization: |
Yes |
No |
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(e) |
Facility for steam bath: |
Yes |
No |
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(f) |
Others, if any (please specify): |
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| (10) |
Details of personnel- |
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(a) |
Number of male masseurs: |
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(b) |
Number of female masseurs: |
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| (11) |
Quantity of medicine and health programmes- |
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(a) |
The firm that supplies medicine (with full address): |
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(b) |
The health programmes offered (specify length of eachtreatment programme):
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| (12) |
Acceptance of the regularity conditions: |
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| (13) |
Application fees (details of DD) (a demand draft for Rs.1,000/- drawn in favour of–
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The Director,Directorate of Health Services,Governmentof Goa,Campal, Panaji – Goa403 001), is to beenclosed with the application:
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| (14) |
I am aware of the conditions prescribed by the Directorate ofHealth Services for the Massage Parlour/SPA and wish to confirmthat I shall abide by the same and such other conditions as maybe laid down from time to time by the Directorate of HealthServices for the Massage Parlours/SPA.
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(Name)Address____________________________________________________________________________________________
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