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Home My WebLink About14050025 Application G,,�,� °�"r�,y�r . C �t of Ca�e1 � � Y �epartment of Community Services 1 Civic Square,Carmel, Indiana 46032 �INDIAN� (317)571-2444 phonc (317)571-2499 fax www.carmel.in.gov APPLICATION - MASSAGE THERAPIST PERMIT - $20.� ❑ ORIGINAL PERMIT ❑ RENEWAL I �fif�a 5 1. APPLICANT INFORMATION a _�e'��' , /��ICId tlAf/��U1� lastname firstname middle�n me b. z�v G Ma�h SF. �fa��1� � yGl�$ home address city state zip code �. �lZ ZHY <314�i � �bua 1t!-¢ 92�� qMbil.C� home phone no. alternative phone no. email a�tl ess — �— d. Woo�rw� ba« SPa Laur> �,�cf ��- - �D� - 13n� business name supervisor(it applica le) business phone no. e. -zl�ZA E. 11l��'S* �ar`v��l � t1 �ll�o3Z business address city state zip code 2. APPLICANT BACKGROUND INFORMATION a. I am eighteen years of age or older. ❑ NO �7 YES b. Have you, within the past three (3)years been convicted, or plead Nolo Contendere for any crime.of unlawful tleviate�conduct, deviate sexual conduct or sexual conduct as defined in Title 35 of the Indiana Code. If yes, explain below. NO ❑ YES Date/Location/Offense c. Have you, within the past three(3)years; had your massage therapisYs license or permit denied or rev ked 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 ceitificate of graduation. ❑ NO �YES Nameofschool/institution I�,�Ialt'a. �,Q/�LflU/h'L Y�'I(�$��WI b. I have attached a copy of my diploma or certificate of graduation from an accredited school or institution of massage '�I NO ❑ YES c. I have attached proof of�my professional liability insurance of not less than$100,000 per occurrence and $250,000 annual aggregate. ❑ NO ❑ YES 4. MY EMPLOYMENT HISTORY FOR PAST THREE(3)YEARS. a.zo� sc � ,�- Won'�ho� l��qa Ca rm�-1 ;IN y�o3z s��-�-r� year occupa�i n business name city,�s[ate zip phone no. b.Z�i� Mass�,� � m ssa�,� �� plai�cl�l ��N Nb�1o8 3t�- B3q-G year occupa on business na -city,�state zip phone no. Cl1CSY0�N+ FirY� C�s1iU. . . �."tp�2 u •�,. Churt.�. Da,�cu � Rrr-t;1411� �I��3`f �t�z � N°l3-uvt year occu ation business name city,state zip phone no. 5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE I have received a complete�copy of Carmel City Code Section 4-21 ❑ NO �YES State of Indiana ) ) ss: Counry of HamiltonJ I attest that all of the above information is true and correct to the 6est of my knowledge and belief. I understand thaf any matenally false, misleading, orincomplete statement on this Application shall constitute grounds for denial of this.application and/or revocation of my Massage Therapist Permit. � Al�� e�- r �Signature of Appl ant Name printed Subscribed and Sworn to before me this Z�a day of a , 20� PAMELA K. LUX �S��yy�Q1�L�-�� 5� � County;of Res: Hamitton Signature of Notary My Comm.Expires 4•25-2015 �/� M L L L�-t/X Gomm.No.564882 Name Prinled �� My commission expires on , 20 : - - -, In�uiwi'n,e� �� X�U�,,, I��lo 1`�'c.IVJ(C!N:: �� wm H J �U'N N I�WI 1.(I 1 , /). �.11l�l u . . �T. �° MASS�GET:HCRAP-1_ � , . - �'� - �,,AI'1'�1i11.15=F� ; 11�115121117: -� . s. � c� �- AlIC18 �C[t � . , . � 4 ,; ,, f � �� . r_•�� C�,, . _. .. . � ;Stirc . - _.�_-----�-'— • . �$iyy!, _ '��r Ju�C'�.V'� / ,�w_:illll �VII a�� <.f��.�.� �x � . '��.`�m�� '� � iK�,,' � ,� - .xt�„�e,I NaL��.NE3 .,—� , , — - _ 7nrJ.A-�i-.i�-S_.MW�. � il � _� '- . .00HUM� � 9 Q�3e5'_. t t � EnL�.t��('�� i Fes . �F = F a ��a �. � _ l �a�. F �P tyiTliy'1' q'43 � ' O�l�+4t,V3610a� t" � � y�kV40RN � �_ �I t��Gt�c-B�n� � � ��_�� .,� � � �,• � .la/ I� pi a ��';��u3178-82-0�1331id'+�� . a}(xsUIIn71^ott .m1E e121�1 � t4 - � ` .lETTm�lun �G�i�h� ��n- �� i�l � AUCIA KAYLEN„E��. � ��'� ��--I�� l��o-,cE�i��-'r_"`',��Ilg"fl [ II¢,N' ean�swsrnrenonoaaai ,�� °a � - " ' � ��Gaaza.irt+aiaao� fAli �- � �.o� 1 ,e�e 1�31f��992 � i;��fert.er.prsn081911]1100001