HomeMy WebLinkAbout14040251 Applicationc2 OF CqR �t
INDhes.
City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
317 571 2444 phone 317 571 2499 fax www.cannel.in.gov
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APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
❑ ORIGINAL PERMIT LI RENEWAL
1. APPLICANT INFORMATION
a.
b.
c.
d.
e.
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last name
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first name
middle name
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home address city state zip code
home phone no. alternative phone no. email adbress
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business name supervi
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business address city
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business phone no.
state zip code
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APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. U NO ES
b. Have you, within the past three (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.
0 ❑ YES Date / Location / Offense
c. Have you, within the past three (3) years, had your massage therapist's license or permit denied
or revoked for cause by any governmental entity in the United States? If yes, explain below.
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 I am submitting this application to
the City of Carmel;
❑ NO YES
3. MY QUALIFICATIONS:
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.
b.
❑ NO
YES Name of school / institution
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of nmassaae
❑ NO
YES
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 aual aggregate.
❑ NO
YES
4. MYEMPLOYMENTHISTORY FOR PAST THREE (3) YEARS.
a. L 0 Lo 2)"11 b�
year occupation business name
b.
c.
year occupation business name
year occupation
business name
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city, state
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city, state zip
phone no.
phone no.
city, state zip
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21 ❑ NO ❑ YES
State of Indiana )
SS:
County of Hamilton)
I attest that all of the above information is true and correct to the best of my knowledge and belief. I understand
that any materially false, misleading, or incomplete statement on this Application shall constitute grounds for
denial of this/application and/or revocation of my Massage Therapist Permit.
Signature,"'" p• i an
Name printed
Subscribed and Sworn to before me this 30 day of
NICHOLAS F. MISHLER
County of Res: Hamilton
My Comm. Expires 02-27-2019
Comm. No. 624589
,20I
Sig jature of Notary
NI'G%p IQ S 1.
Name Printed
My commission expir
on 02-1 1.:7
207
MASSAGE THERAPIST PERMIT
A. Applicant Submittal Requirements
1. A completed application form:
2. A copy of diploma or certificate of graduation from an accredited school or institution
of massage therapy;
3. Proof of professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
4. A Limited Criminal History report provided by the Indiana State Police within thirty (30) days
of application date (phone the Indiana State Police, (317) 233-5424, or their website
www.state.in.us!isp)
B. Processing
1. Application must be date stamped on the date received.
2. Within thirty (30) days of receipt of a fully completed application, a Massage Therapist
Permit will be issued, or the applicant notified in writing of reasons for permit denial.
3. A Massage Therapist Permit shall be effective for a period of twenty-four (24) months,
unless suspended or revoked.
4. The applicant my appeal a denial of a Massage Therapist Permit to the Carmel Board of
Public Works within thirty (30) days from the date of applicant's permit denial.
C. Fees
A non-refundable $20.00 permit fee shall be paid when the permit is issued.
D. For Information or questions:
City of Carmel, Indiana
Department of Community Services
Division of Code Enforcement
1 Civic Square
Carmel, IN 46032
Ph. (317) 571 2444 or (317) 571 2417
Fax (317 571 2499
www.carmel.in.gov ('Aft"
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4/29/2014 Details
11,4.
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Litigation Documents
Digital Certification
Massage Therapy Board
Yuchong Sanders -Holl
Carmel IN 46032
License No: MT21405078
Profession: Massage Therapy Board
License Type: Massage Therapist
Obtained By Method: Examination
Issue Date: 4/24/2014
Expiration Date: 5/15/2017
License Status: Active
r eviavis A cti:
Previous Action - None
No Prerequisite Information
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