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Home My WebLink About14050012 Application � . �: ,. � J ",, G�'S`� � � qR'��C'l a ,. � Clt of Car el � _� y ,= Departmenfof Community Services, 1 Civic Square, Carmel, Indiana 46032 rNDIA�P' 317571 ?444phone 31757i ?499faz www.c:vmel.in.gov APPLICATION - nIIASSAGE THERAPIST PERNIIT - $20.00 ❑ ORIGINALPERMIT ❑ RENEWAL 'y�� __. I r�a - - r .u.. i::, r r��r i,�..-., "' " � L' � 1. APPLICANT INFORMATION MAY 0 21014 i'''- a. Ysl�� , rGfa4�� last name first name middle ame b. .S�o/� C�e/ry Jie��,�iy tn�L/ o+vc.�/voli�[ ti✓ a3 home address city �' state zip code �. 3�' �iF�f -/r'JJ�' 3/�' /°8.S`-�3�3 C1an.qrws✓a 4:c �3zirl�. home phoqe no. altema[ive phone no�. em�I address d. 7�nd�w� Q�a4 �'/:� G P�rG� f'O�� 3�/Jlob -/.�D l� business name � supervisor(it appf � til business phone no. e. 1/�2-A FGr� �/6f./� S'J Co-�� .�N ��`�2 business address ciry state zip code 2. APPLICAN7 BACKGROUND INFORMATION a. I am eighteen years of age or older. ❑ NO � YES b. Have you, within the past ttiree (3) years been convicted, or plead Nolo Contendere for any crime of unlawful deviate conduct, deviate sexual conduct or sexual conduct as defined in Title 35 of the Indiana Code. If yes, explain below. �NO ❑ YES Date/Locauon/Ottense c. Have you, within thepasTthree (3) years, had your massage therapisYs license or permit denied or revoked for cause by any governmental entity inthe United States? Ifyes, explainbetow. ��. NO ❑ YES Date/Location/Reason � d. Attached is a copy of my Limited Criminal History.report,which was provided to me by the Indiana State Police no more than thirty (30) days prior to the date on which l am submitting this application to the City of Carmel; ❑ NO ❑ YES ��t^� �� 1 � 1' A 3. MY OUALIFICATIONS: a. I am a graduate of,a school or institution of massage therapy which is accredited by the Indiana Commission of Proprietary Education or similar state agency or commission of a state other than Indiana that required my successful completion of at least five hundred (500) hours of supervised instruction before I was awarded my diploma or certificate of graduation. ❑ NO � YES Name of school/institution 1��-� b. I have attached a copy of my diploma or certificate of graduation from an accredited school or institution of massage ❑ NO � YES c. I have attached proof of my professional liability insurance oi not less than $100,000 per occurrence and $250,000 annual aggregate. ❑ NO � YES 4. MY EMPLOYMENT HISTORY FOR PAST THREE(3) YEARS. o2Dl�1�/�� ra t.��° ��/�v Wr�o lwvse�Va�/ ''FfJ°` �-�/Mc� �riV7��l� 3/JZObf3�l- year occup o� business name �� ciry,state zip phone no. � ,y� / � b �� b��°/ �oi✓ �'�1�' .YU /'BRBt/J /�lp!/i[cL ��n��el„i jN :3i .�..� �.r year occupation business name ciry,state zip phone no. c. year occupation business name ciry,state zip phone no. 5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE I have received a complete copy ot Carmel City Code Section 4-21 ❑ NO ❑ YES State oflndiana ) ) SS: County of Hamilton) I attest that alI ol the above information is true and conect to the best of my knowledge and beliel. I understand that any materially false, misleading, or incomplete statement on this Application shall constitute grounds lor denial of this application and/or revocation ol my Massage Therapist Permit: CZUCn 9 (/r-^,G C.zu.'".� c� ✓� C.>(�� f�/I/C7 Signature of plicant Name printed Subscribed and Swom to be%re me tfiis � day of �� , 20� t-- !� ' -�, NICHOLAS F.MISHLER �/�`-`�,�n� ��< Cou oi Res:NamiRon � j�/�G�TI . �l ;:;i sr,ni, + nh' It '`� My Comm.E�i2s 02-27•2019 Sigr�ture of Notary 1'n�r��F Comm. No.624589 -- - n�,�l�014.� �- M,`s y ►e- Name Printed My commission expi�es on OZ 27 , 20� 5�IJ2074� Details �cl�'t �. . V . ^ � �_ m �— � �9 �3 -! � f J �� ,1��/�/�� :-� ��? �-� � a = �',I, .� ;; ,t�•� Online Licensing J � � :I � _ . . New Search Person Information Litiaallon Documents GU8n9 Yang I Diaital Certification Address Information Massaae Thereov Board I Indianapolis IN 46237 license Informatdon License No: MT20900168 Profession: Massage Therapy Board �icense.7ype: Massage Therapist obtained eyMethod: Grandfathered Issue Date: 3/20/2009 6cpiration Date: 5/15/2017 License Status: ACti�e Previous Action IPrevious Acdon- None II Related Lice�ses No Prerequisite [nfom�ation II Mtps://m�license.in.godeVerificationlDetails.aspX?agency_id=1&license_id=1336573& 1/1 G�,S.1 OF CAR,y��,f iii � INDIA�e' ��'�� tl �� City Of Carmel, Indiana RERMIT #: 11910129 ISSUED TO: YANG, GUANG PERfvIIT ISSUE DATEc 11/30/2011 ISSUED BY: � "' �aN�'� Ji 'm'Blanch d; DepartmenCofCommunityServices -Permitshall expire two'(2):years irom issuance date,.unless suspended or revoked. -This permil does not create�a proprietary interest, and maynot be'transfeqed or sold. . , � . : �� - O \ � � �' � � �� o � N � \ n -p O Q d) N I � � � � \ � � v= N � N N M '1 �� U w � � \ � � (�� a � `✓ ` � � � � ` � �� N �.` � N \ •�� Tt hJ ` � "j V N � a � � � ' \ � L� \ �j •��i, � c ,� � � ° . � � � U iz � m� � � � �— � m � .� o v � Y \ � � ` �o Y o ,o �o o �� \ o •' < g.3 O �� ' � i � y Ih 4= � o � j� � �� ` p . � : (O U l ]/1 ��, Q � ( � ��.�, ' � Uvu \ v \ , � 6� ' `J =g � N � �'� \ � �. v N r. `a �� ♦ � � .�� o � � � � \ � zc � � � Z � �� \ � � ~ Z � � � � � � � �, � � ` � c � � ` 4-- � ` _ ' � i^, �� W � U . � � � � � .o � w � L \ � U O � O � U , } °- � ; V� � Z . i � C � ° � , .��Mv'...-,��_"q��i �� '� � o - � ^ .._� � � ��t: � � �� .� � w � � � � 'J. � � � �T�� .r... Vl s � � � ^ ^ - W r - � � � N � . ,) -,r�, C Y :r� •pq O ? V � � T j _ � � � � � � �L � j � f'� •� fl z .� ' � C � Q � c � ,� ,•.� � - rp�! ^� - _ � _ � � � '� rn 1� � O � .",J, .J � :11 � � U � C � GJ .^ V �� Vi � ,� � � J a'a � ,� �1 � � C C V � � � � J � .� � ? � r E `� I � > � .� � L � � � ' o � Q c Ci � � � � ...� � a � � � �� J � � � � �� a, � .? v � � � � � �� .� � � = � � � � �� _ k ' � .\`��p��ll`� •�� .. � ` � � � � ! � �„ ' � � ' � `� � a _ .� � � 11 � 9 � ,'� C f � I p ,o _. � F _ � � � � r = A\ � � � � •i/ � �H �I. ^ ;� � c O '�..� � _ � � � � v: � � 1 L^' � ~^ , = I( Q� L I _ :i :1 ` J � I � � W � R y C M .. � � � x i � ,�_ � � � _ � � � ! j c � W ` � :. 0 I � � � � � : � � ^ �, � � � -d � _ = � � ` � = � � ? I i � � �� ^ - , � .� � � s 4-a I` � . � ` � � .r � � - r J I o � = � � � •� � .� .� � � l � � � J ` � I � � l O � I_l l. .` =(. J � W / I � � � - - m � w � ,. ._ = � . �.�y 'r = c u � I ' � � �, ` M =- ^ � � �/ � � •`— Ff,d � - . N W � � ` , a � �� I .� �" � � �;, E N � � d � � � = ^ � -� � Lcc � J L� � ^ 1�f' fI� J r � , `_`� � � � � � � � - _ � � � � v ^ •� c � `n � � � ^ - ^ C N y _� � J Y � { a � ^ z � Q i � � � _ A � � � I ; ,�, � � o � . _ � � ' o � a W ► � � �� __ _ _ ----------- � i ir T r � ir ,1; ir T T v � % 1��+��%� ��N/%:��u��%:�� a , d� Fwd: Your Indiana YroTess�onai 1,icense nas ueen'ttenewcu - �b� • �- - r Fwd: Your [ndiana Professional License Has Been Renewed Mon 6/10/2013 7:2II PM From: yangmassage To: jane@carmel.woodhousespas.com __.......__.. ..,........ _. _.....,,._.._ I'rnu�im��AnAi u:J�ihuur uu'I'-hlubil��'fhe fu..l u:aionohAv 4tl uule:nrl<. -------Original messagc------- Subject:Your Indiana ProFessio�al License Has Been Renewed �rom:lndiana Professional Licensing Agency<PLA@pIaJN.gov> To:ya ngmassage@yahoo.com Cc: � —'- _':— =- - - � . - - -. .��I� � e �a' e ' 0 ' Congratulations Guang Yang! Your Massage Therapist (Iicense or permit or registration) number MT20900168 has been successfully renewed by the Indiana Professional Licensing Agency. Your license will now expire on 05l16/2017. � DO NOT REPLY DIRECTLY TO THIS EMAIL–IT IS FOR NOTIFICATIONS ONLY AND IS NOT MONITORED. DIRECT CONTACT INFO FOR YOUR LICENSING BOARD IS ON EACH BOARD'S WEB PAGE. Go to www.pla.in.yov(http:llwww.pia.in.gov)and use the "Find your profession" link. Verify Your License Online Your license can be verified online using our free public Search 8 Verify (htips:l/cxtrar.et.in.gov/we�lookup/) site. The Indiana Professional LicensingAgency does not issue pocket license cards or wall ceRificates as part of the licensing process. If your profession has a posting requirement in order to remain in good standing, see the 'Order License Cards" section below for instructions on obtaining copies of your license. Other professions may order also. htto://maiLcarmel.woodhousespas.com/Main/frmMessagePrint.aspx?popup=true&message... 6/11/2013