HomeMy WebLinkAbout07080063 Massage Therapist Application
~" OF CA.l(~
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,
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City of Ca AUGet' W
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
lNDIAtll'-
317 571 2444 phone
3175712499fax
www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
~ORIGINAL PERMIT 0 RENEWAL ~07D'3t00 3
1. APPLICANT INFORMATION
a. EII..?o-ooL
last name
'N,~\, ~
first na e
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middle name
b. qj '&c.\ W, IhtlLlh'ooc* \",-"R-
home address
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city
IV
state
"-II <XJlP -I
zip code
c.
C3(+-) t.{Cf,.:; -sq/}:3
home phone no.
[3/=1-) ~'?;-(9101l-
alternative phone no.
Kp! 1I.,..\n>D/:(i0cpko,COh-]
em ail address
d.
supervisor (if applicable)
business phone no.
business name
e.
city
slate
zip code
business address
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO )if 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.
)liNG 0 YES
Date / Location / Offense
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.
Ji'NO 0 YES
Date I 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;
o NO ~ES
-::tb 15'2-L
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.
D NO
'W; YES
Name of school/ institution \\\.AllVv.,";/ S J"Y)/1('~ ~.Ji';~ TJiDA4f>o.d-M
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
D NO
)l.. YES
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 ~ YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a;)~;iO)7 ~C1q},\\,~;.o~().'<" &,.u.""rrn"" '"?_,clL.+o,. ItJ 4t,0I,4 (%Sl1'1-'6-/3">1
year occupation business name 0 city, state zip , phone no.
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b ~I. Av",~~";""",,, PsAU (~,{,,\\)
year occupation business name
\NhON'fa~~;~' II)
city,s ate Zip
(3R)I"~-,J').~?-
phone no.
c.~ (>.U\.R).'-;,...;O" P6.AU l',h",.do.",
year occupation business name
\rJ.:\{)'N\~"" tl'0
city, sl Ie zip)
[:,IT "f'=;? / -o5'd
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
~ NO
DYES
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 this Application shalf constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
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Signature of \\pplicant
~\\LI S\.~l,rook..
Name printed'
Subscribed and Sworn to before me this q day of ~
,2009'
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J A-M ~~ LL-...-\( L '-\j>(
Name Printed
My commission expires on
20E
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Ad~iS(ntor .
Student FileNo.
[-851
Sl:lleLicemed 1982
,
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American Massage Therapy Association@
Certificate of Insurance
Member ID: 199988
Kelly Ellerbrook
9184 W Paddleboat Ln
Pendleton, IN 46064-8645
Member Classification: STU W
Member Effective Date: 02/01/2007 to 01/31/2908
Administered By:
Healthcare Providers Service Organization
Affinity lnsurance Services, Inc.
I S9 East County Line Road
Hatboro, PA 19040-1218
Insurance Company:
American Casualty Company of Reading, P A
I
~T --~~e~of"Iifsurail~j~:,:;;.- :~~'l\'lasterv PolicflNunllier;,~~-Masterjrolic--'-Effectih~:Daie~~~;\ ~;~~7::tLimits~r--ef' eJlfolled~ meiriber)~":;'
Professional Liability N 0289955556 111/2007 12:01 AM Standard Time $2,000,000 each claim / :
Occurrence Coverage to 1/1/2008 12:01 AM Standard $6,000,000 aggregate Subject to
Time the Master Polic Ag re ate
Coverage is afforded to Enrolled Members for a period of 12 months concurrent 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 terminate 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
$10,000 per proceeding / $25,000 aggregate
$10,000 aggregate
$2,500 per deposition / $5,000 aggregate
$10,000 per incident! $25,000 aggregate
$2,000 per person I $100,000 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 terms"
coverage's, amounts. conditions and exclusions. Please contact HPSO at 1-888-253-1474 directly for a copy of the complete policy.
gJHPSO
lieahhcate rn\\'ider~ Servi~e Organi:atinn-
K#03-00310
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INDIANA i~:!~\iE POLICE
INDIANA GOV'EIRN!M,EN'T~CENTER NORTH
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1 00 NOR T~HS"Si~N<Aa)fE A V E N U E
I N D I A NAP 0 LIS 1l(~;N A 4 6 2 0 4 - 2 2 5 9
, \~~J71 ,
www.sta.te:::/.n.us/Isp
KELLY ELLERBROOK
Date of Inquiry:
Receipt Number:
Amount of Payment:
Entered By:
08/09/2007
6980342
$ 7,00
DEBRl\O 2
TO WHOM IT MAY CONCERN:
A thorough search of our files by NAME, DATE OF BIRTH, SEX, AND RACE ONLY
does not reveal a limited criminal history record on:
Name: KELLY ELLERBROOK
B;,rth Date: OS/26/1976
Sex: FEMALE
Race: WHITE
Results based solely on information provided.
DOUGLAS E, SHELTON, Major
Records Division Commander
Please be advised that the
watermark seal of the
State of Indiana verifies
that this document is in fact
the original obtained on the
above dat.e.
INTEGRITY
.
SERVICE
.
PROFESS I ONA L I 51-,,\
Item
1 of
1
CITY OF CARMEL
PERMIT RECEIPT
OPERATOR:
COPY #
llU~
See: Twp: Rng: Sub: Blk: Lot:
PARCEL ID . .......: MT PERMIT BUSINESS LOCATIO
DATE ISSUED.......: 08/09/2007
RECEIPT #.........: 25963
REFERENCE ID # .... 07080063
SITE ADDRESS ...... WORK DONE IN CLIENTS HOMES
SUBDIVISION ......:
CITY .............: CARMEL
IMPACT AREA ......:
OWNER.... ........: SELF OWNED BUSINESS
ADDRESS.... ......: WORK DONE IN CLIENTS HOMES
CITY/STATE/ZIP ...: CARMEL, IN
RECEIVED FROM .. ..:
CONTRACTOR....... :
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP ...:
TELEPHONE .........
KELLY JB ELLERBROOK
LIC # MT-ELLERBR
ELLERBROOK, KELLY JB
9184 W. PADDLEBOAT LANE
PENDLETON, IN 46064
(317) 485-5923
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC
MT-FEE FLAT RATE 1.00 20.00 0.00 20.00
TOTAL PERMIT :
METHOD OF PAYMENT
CHECK
TOTAL RECEIPT :
AMOUNT
20.00
NUMBER
0.00
20.00
20.00
1522
20.00
I
NEW1 BAL
-----1-----
0.00
0.00