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Home My WebLink About 14090139 ApplicationCl*ty of C Department of Community Services 1 Civic Square, Carmel, Indiana 46032 (317) 571-2444 phone (317) 571-2499 fax www.carmel.in.gov APPLICATION - MASSAGE THERAPIST PERMIT - $20.00 ❑ ORIGINAL PERMIT 1. APPLICANT INFORMATION RENEWAL 1 ` )q Q 1 �-a(0-11 a. last name firsf name middle name home address ci y state zip code C. 3r7- qqd -- (321 home phone no. 1 Z - �O - � q eq yaha,-U�,, date of birth eriiail address d. MQ ✓L ONel C317) .73 37o business nalne superv' or (if applicable) business phone no. e. A&d business address city state zip code 2. APPLICANT BACKGROUND INFORMATION IMI rm�s!r-p� aa. I am eighteen ears of a e or older. ❑ NO dYES yg 1 2 1018 b. Have you, within the past three (3) years been convicted, or ple 4olo Contendere for -Inf irime of unla ul deviate conduct, deviate sexual conduct or sexual con I�as defined in rtlp �� f he Indi na Code. If yes, explain below. NO ❑ YES Date / Location / Offense c. Have ou, within the past three (3) years, had your massage therapist's license or permit denied or r oked for cause by any governmental entity in the United States? If yes, explain below. NO ❑ YES Date / Location / Reason d. Attached is a copy olply Limited Criminal History report, which was provided to me by the Indiana State Police no e than thirty (30) days prior to the date on which I am submitting this application to the City of mel; ❑ ❑ YES A 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 211YES Name of school / institution 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. s�d a. 6 U�S41 e J a C (Oti3 z (7 - q73 -3rM year occ ation busin—es—snapfie city, state zip phone no. b. C. year occupation business name year occupation business name city, state zip city, state zip 5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE I have received a complete copy of Carmel City Code Section 4-21 ❑ NO f/ YES State of Indiana ) ) SS: County of Hamilton) phone no. phone no. I hereby swear or affirm under the penalties of perjury, that the statements made in this application are true, complete and correct. I understand that any materially false, misleading, or incomplete statement on this application shall const' ute groun s for denial of this application, revocation of my massage therapy permit, and rosecuti n nde a able law. Si nature of Applicant Name printed Subscribed and Sworn to before me this day of , 20 Signature of Notary Name Printed commission 8/25/2017 Details (41ndiana Online Licensing New Search - Litigation Documents Amanda Dawn York Digital Certification Massage Therapy Board Indianapolis IN 46234 License No: MT20902753 Profession: Massage Therapy Board License Type: Massage Therapist Obtained By Grandfathered Method: Issue Date: 8/18/2009 ` Expiration Date: 5/15/2021 License Status: Active No Data Available No Data Available No Prerequisite Information r https://mylicense.in.gov/everification/Details.aspx?agency_id=1&license id=1360169& 1!1 CITY OF CARMEL ITEM 1 OF 1 PERMIT RECEIPT OPERATOR: ajohnson COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: PARCEL ID ........: MT PERMIT BUSINESS LOCATIO DATE ISSUED.......: 10/08/2018 RECEIPT #.........: BC000016618 REFERENCE ID # ...: 14090139 SITE ADDRESS .....: WORK DONE IN CLIENTS SUBDIVISION ...... CITY CARMEL IMPACT AREA ...... OWNER ............: SELF OWNED BUSINESS ADDRESS ..........: WORK DONE IN CLIENTS HOMES CITY/STATE/ZIP ...: CARMEL, RECEIVED FROM ....: AMANDA YORK CONTRACTOR .......: YORK, AMANDA DAWN LIC # MT-YORKAMA COMPANY ..........: YORK, AMANDA DAWN ADDRESS ..........: 10930 PUTNAM CT CITY/STATE/ZIP ...: INDIANAPOLIS, IN 46234 TELEPHONE ........: (317) 490-1327 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ------------------------------------------------------------------------- MT-FEE FLAT RATE 3.00 60.00 40.00 20.00 0.00 ---------------------------------------- TOTAL PERMIT 60.00 40.00 20.00 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 2O.00 --------------- TOTAL RECEIPT 20.00 77 MASSAGE THERAPIST PERMIT City Of Carmel, Indiana PERMIT #: 14090139 ISSUED TO: 09/26/2016 PERMIT ISSUE DATE: $APPL NAME ISSUED BY: Jim Blanch . d; Department of Community Services - Permit shall expire two (2) years from issuance date, unless suspended or revoked. - This permit does not create a proprietary interest, and may not be transferred or sold.