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Home My WebLink About14050060 Application G�,i.� OF�cA��t o � .. Clt of Ca el � r . .�� Y — Departmeritbf Community Services t Civic Square, Carmel, Indiana 46032 INI�IANQ` (317)571-244a phone (317)571-2499 fax www.carmel.in.gov APPLICATION - MASSAGE THERAPIST PERMIT - $20.00 ORIGINAL PERMIT ❑ RENEWAL 1 5O('j (p � 1. APPLICANT INFORMATION a. , _`�(1(l, t2(� � ast name first name itldle n me e. I�'(1 �oc,l�r �l�c�bles�< <le �r� � home address city state zip code �. 3��- �ll`-� -��3 q�✓�kw�ffr�P rnassaq?� home phone no�. alternative phone no. em � ddress q��'I ��.yl J d ihPC��;n1�� I�PQ �� -€3y�1-ES�6 business name supervisor(if applicable) business phone no. e. l05 1 Sfl��e ��t �ar�e ( �� 32 business.atldress city state zip code 2. APPLICANT BACKGROUND INFORMATION a. I am eighteen years of age or older. ❑ NO 1� YES / � 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. J(�J NO ❑ YES Date/Location/Offense ( � c. Have you, within the past three (3) years, had your massage tlierapisYs license or permit denied ��\or///revoked for cause by any govemmental entity in the United States? If yes, explain below. 1�N0 ❑ YES DatelLOCation/Reason / � � �__._ ._.J ;.ii� .'r1 i i��i��^�� '� /�, �� ' d. Attached is a copy of my Limited Criminal History report�which;was provided�do me,by tlie.lndiana State Police no`more than tliirty(30)days prior to the dateton,which Cam su6mitting this application to the City of Carmel; � . � ,,�, , 1 .` ,��-:� _ . .. �.. . .. ._ — -- NO ❑' YES 3. MY QUALIFICATI�NS: 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��C{Y1CY f G �� hC.�'�I f'�-Y �X i F�)t�� L �e(r��ev�.cS 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 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. year occupation business name city,state zip phone no. b. year occupation business name city,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 of Carmel CityCode Section 4-21 ❑ NO YES State of Indiana ) ) SS: County of Hamrlton) /attest that all of the above in ormation is true and correct to the best of my knowledge and belief. 1 understand th t a materially false, misl ading, or incomplete sfatement on this Application shall constitute grounds for de ial f this a pli ation and or revocation of my Massage Therapist Permit. I ��. � !I�I -� . � � PYIn�'tP(' ��-mann Si at eo\pli ant Nameprinted� Subscribed and Swom to before me this �5 ' � day of , 20�`i' ',P�, PAMEIA K. LUX /� Sf;,�, � County of Res:Hamilton �(f�/W\.PXA- My Comm.Expife5 4•25•2015 na re of Notary �A�" Comm. No.564882 Yv�CL1�- IC- L�-11,L Name Printed � My commission expires o � 20� �B IN�DIANA °d - �"'°:� � " OPERATOR DRIYER LICENSE _ -•. g ��;r�'m9 F.-._-.�- .... � �� ca�� waUi715626-22 � ura09f�f7009mFw 201 }�.� � �Y�BF� �� I p_� I�IIi ` ...";�. � �.�LL� -m� r y .: s618TANOlEWOOD °(+ � 4� NOBLESVLLLE IN' y y�� ..,a�. -"'�\. .O°� . 1�16 s Cffiiy'�,. � � u F � '.� � a�6W N�IE t � tiRlSH011ET`�- pf'�tH! � � �� 008-1�(�3/1�J� . aEYn':BW v. s T'ai�me�d9so3DOtot�i'y,roNav�fB�Q P , , �� , " r //'�/�� . = ' -�«°�."`i" - .. � �=�. Dnlir�e Licei�s�i�g ° T-� E •:' ° -° � iniciai appiication o"PY�-►cense Online Licensing � Renew licenses � AddressChanges Name: Jennifer]. Hartmann Without Renewal Address: 619 Tanglewood Drive � Order License Card Noblesville,IN 46060 r �ogout Your Licenses �I , License MT20901229 License Massage Profession: Massage Numbe_r: Type: Therapist Therapy License Active Expires: 5/15/2017 Issued: 6/22/2009 Status: _�\ .