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Home My WebLink About07060157 Application ~<{ OF CA.ltAt: G' , ~( il lNDIAr<i" City of Carmel Department 01 Community Services 1 Civic Square, Carmel, Indiana 46032 3175712444 phone 317 5712499 fax ''f ORIGINAL PERMIT 5 0 RENEWAL O~OI 7 ~ Le II \/, I;~ . ,.", I 1T~-$20;OO:::i ill: i: JUN 2 0 2007 1Ui j Ii! APPLICATION - MASSAGE THERAPIST PE , 1. APPLICANT INFORMATION a. ~,"r.\-~-r- I~ame ~. first name ~~~~ middle name b. '-Ie; ~ r~.'\t'.\."- C-I- tome address (' <..."-",,,-<.-1 city ..-LA state tJ0.<J'? . zip code ~ - c. --?/7- ':'-7/- o7~2 home phone no. 3/ '7 -3 '7 <-/- :3 332 aJternative phone no. rJc.."~ D"~ ~c.re email adtlress >13"-..J 1-.1,..(.,.... d. business name supervisor (if applicable) business phone no. e. business address city state zip code 2. APPLICANT BACKGROUND INFORMATION a. I am eighteen years of age or older. 0 NO / (3 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. "yes, explain below. ~ 0 YES Date I Location I Ottense 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. ~O 0 YES Date I Location I 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; , o NO G;)"VES ~(2-0/cilb KB ~v~.f' l,/bD OIL <pvI. KJ), t.,~J..R,1 p.vl. ,'3.,,{ 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. ~ES D NO Name of school I institution Kc.pi...^ C D / I "-j C'" ~ b. I have attached a copy of my diploma or certificate of graduation from an accredited school or institution of massage ~ D NO c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and $250,000 annual aggregate. D NO ~ES 4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS. a. 0";--7 5:<,1<-,> P.-o (-01 C. .A/"h/",~:II<:...., .L'1 year occupation business name city, state zip il (:;,'0 "Go Q b. 0/- <;- A#51"~"f year QCCupalion A,^ j <;'J :11..1 business name ---c..A ?J!,' ....".......'Ou/>S -'-'\ City, state Zip 517 . 77C~' </> <-. _ phone no. (~_ ~ u~l,-s;' 0'>:) ~4 phone no. c. year occupation business name city, state zip phone no. 5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE f have received a complete copy of Carmel City Code Section 4-21 D NO .p. YES State of Indiana ) ) SSe 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 fhis Application shall constitute grounds for d al of thl plication and/or rev ion of my Massage Therapist Permit. ~ ~<''^ e Name printed ~""-+"( , Subscribed and Sworn to before me this ;;;""'0 t\-.day of --.::::,.~ ^<? , 20 0 sl~!f-lr7YfJL PA-hiE-L-II- Y-;. Lu){ Name Printed My commission expires on 4/.:::;,5 ,205 ::OUl:I:-on~m '" . .. ~J>;r:.lO ~;:;~~~:UGlg n -l~!il3C::UZ -I tOllIl'T'l;Dol'T'I 0: O;~ 0li'!"""~"tJ ~ O,~ UI;j! zr;f~ -1Olif~n-f "' UI",Q)-I1'T'l ~ IJ:'I~~: 2 ::0 !ij ~ii ~~N . ~, i ~~ g~ ~ CtIl p,J~ ~.3:1/) _- x : ~~ '"" ON COO ~g mo Xr "z ~-- :;:ex> .", -- "... ~cn Nex> ~. 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T ^1o'n'lrl 1"ITTnTT'lo..."fT American Massage Therapy Association@ Certificate of Insurance Member ID: 204109 Dane Porter 49 Granite Ct Carmel, IN 46032-1296 Member Classification: STU W Member Effective Date: 05/01/2007 to 04/30/2008 Administered By: Healthcare Providers Service Organization Affinity Insurance Services, Inc. 159 East County Line Road Hatboro, PA 19040-1218 Insurance Company: American Casualty Company of Reading, P A ''E,>>,,,,..t!ft)f:lliSura,nceV1I11Mastera~olic''~;Num6e~Maste'rjl?oIic-~>EffectivelDate~KztJ~~~:a;ciImtsi("~'e'r~'enrolleafmemhelH~j%~ Professional Liability N 0289955556 1/1/2007 12:0] AM Standard Time $2,000,000 each claim / Occurrence Coverage to 1/l/2008 ]2:01 AM Standard $6,000,000 aggregate Subject to Time the Master Polic A re ate Coverage is afforded to Enrolled Members for a period of 12 months conCUlTent with the Enrolled Member's effective date or until membership is terminated or expires. If the Master Policy is non-renewed or cancelled. the Enrolled Member's coverage under this policy will tenninate upon the expiration of the Certificate Period and will not be renewed. The Master Policy A re ate ma be reduced b claims aid on behalf of other insureds. Additional Coverages (included in Professional Liability Limits specified above): . Personal Injury Liability . Good Samaritan Liability . Malplacement Liability . Workplace Liability . Fire & Water Legal Liability (subject to $250,000 sub limit) Coverage Extensions License Protection Defendant Expense Benefit Deposition Representation Assault (excluding Texas) Medical Payments First Aid Damage to Property of Others Coverage Extension Limits $\ 0,000 per proceeding / $25,000 aggregate $10,000 aggregate $2,500 peI deposition / $5,000 aggregate $ ] 0,000 per incident / $25,000 aggregate $2,000 per person / $] 00,000 aggregate $2,500 aggregate $500 per incident / $10,000 aggregate This material is intended to provide a general overview of the products and services offered. Only the policy can provide the actual temlS, coverage's, amounts, conditions and exclusions. Please contact HPSO at \-8R8-253~ 1474 directly for a copy of the complete policy. ltHPSO He~lthcar~ Providers SecviceOrgao"at;o,,- K#03-00310 /" / I) If[aplan QIoIkB~ ~ ~noiam:tpolis ~ ~noimm ( BlSClTE lI1 <~~~~I~~~ '<ITlfiz aI-ertifi-ez '<ITlfat ~ane ~orter ~az zatizfaclorillI x:omp12teo tIr~ x:nurz~ of ztuolI pr~zcrih~o for Braouatinn ano iz tIr~r~fnre ~nti&o tn tIriz ~iploma tn iBlassage mberapp @tben tbtS' S'txtb bap of 1une, 2007 ~. ):! 4/ f ~ir1::;::2 ~ ~irl'cl.or