Loading...
HomeMy WebLinkAbout14060073 Application Gl,S.; OF�A��t a � .. Clt of Ca el ,� . . � � Y � Department of Community Services 1�Civic Square,Carmel, Indiana 46032 INDIAL`�� 3U)571-2444 hone ( p (317)571-2499�fax. www.carmel.in.gov APPLICATION = MASSAGE 'THERAPIST PERMIT - $20.00 �ORIGINAL PERMIT ❑ RENEWAL '� ���pC�O7 1. APPLICANT INFORMATION a N5 h S< h , -S< o ��l /��l c h last name frst name middle name b ���% [,/ � �1� f� ��i�1 SNy��I l.S �,,� v�Z � �r home address city state zip code c. ��� ' �! 3d y0 �h � s�ap���9n��h GvG ��d�"/�(� home phone no. aiternative phone no.' email address d. �4s1�s� �''�y 3� 7-Y�3 - 3so � business na . supervisor�(if applicable) business phone no. `' , / e. 7'600 L' �C�� '� S �trMc� � lN �/do 3 � business address city state zip code 2. APPLICANT BACKGROUN� INFORMATION a. I am eighteen years of age or older. ❑ NO �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. �.NO ❑ YES Date/Location/Offense c. Haveyou, within the past three (3) years, had your massage therapisYs license or permit denied or revoked for cause by any govemmental entity in the United States? If yes, explain below, ,iw�0 ❑ YES Date/Loca6on I Reason r'.. , _ _.. .. . . _.__ -_..__._� I X�i ; .'t:�_��p.'^c �'-"'.:: d. Attached is a copy of my Limited Criminal History report, whichrwas�p�o,yided�to.me by tfie,lndiana State Police no more than thirty(30)days prior to the date on`which I,am sutimitting�this application to the City of Carmel; �� ,,,;,:i�� _�. r,i.� �_ `E � . � �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. ,,'� NO ❑ YES Name of school/institution �c�n,�C �✓o� .Shc,oc,� 6d /�Sl/t�.c f�' Y�� b. I have attached acopy 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.2o�� i''1s s . `7'lu.r.P�'rY /`/! 1s1s�c LnJf . .����„cl /✓✓ `��3z 3�7��'73-�4' �f year occupa6 business name city,state zip phone no. b,Z0�3 G'ilun3c�Jr Prin�c� I'6.•:{.f5 f�r✓. Cad�. /✓1 ��1 .11/✓ � c year occupation business name� city,sCate zip phone no. c. OJ �w�Sd-r<.i��U�'�. N.IQ� �J�4�'-�r�1� S�Of� /�.Jy �� 70 �O . .. year occupation businessname 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) 1 attest that all of the above information is true and correct to the best of my knowledge and belief. 1 understand thatany materially false, misleading, or incomplete statement on fhis Application shall constitute grounds for denial of this application and/or revocation of my Massage Therapist Permit. �G-�� �j�,, - Seo� ��IGr15Ll� Signature of Applicant Name printed Subscribed and Swom to before me this I ��y1 day of ��AxMA_ , 20� � PAMELA K. LUX `���� ���� s�y � County of Res: Hamilton Signature ofNotary � My Comm.Enpires 4•25-2015 Comm.No. 564882 '�i��L/� K . ��X Name Printed My commission expires on �-� , 20�� , ,, _ � v . � Indiana x���OV , � Professionel � ,�.< ,:.y, � � � w' �censing' Agency ..«:.:_, .. _._.. R 144 4�,/'�� 4� � � `� STATE OF INDIANA 9;� - .,;- i� '-^�'�° '� 1lichrcl R. Pencc InJiam�Piqln�iunal Lii�ruvot AL'enr� .. '...�� 102 1\'.N'avhin�lmi ti1. Ronm\\'O'2 ���� InJiana�>ulis.1\Jti:W � �a.. ``�— Ph�mr:131'�2S2-M90 Fuii(3 U 123S-A236 versonaf in�ormation: Name: Scott Allen Hansen Address: 1131 Darby Lane Indianapolis, IN�46260 Date of Birth: 10/16/1967 License.Information: I�VIfI�/C� aiJYGY IIILVJ�GJV�J License Type: Massage Therapist Status: Active Issue Date: 09/15/2009 EYOiration Date: OS/15/2017 Obtained By: Grandfathered Disciplinary Action: None Valid as nf: Mne lim 09 10:51:12 AM EDT 701d New Search �