Florida Cosmetology Salon License Application by PermitDocsPrivate

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									                                   INSTRUCTIONS FOR COMPLETING
                                      BOARD OF COSMETOLOGY
                                   SALON LICENSURE APPLICATION

                                       Application begins on page 2

If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.

The following information will assist you in completing this application. Please review it CAREFULLY.

    1. Rule 61G5, Florida Administrative Code, provides that a salon application must be filed,
       appropriate fee paid, approval granted by the department and a license issued prior to a salon
       opening for business. A new salon application must be submitted for a change of location or a
       change of ownership for a fixed location salon. A new salon application must be submitted for a
       new mobile unit or change of ownership. Any of these changes voids the previous license.

    2. Attach to this application your check or money order for $105. Make the check or money order
       payable to the Department of Business and Professional Regulation (DBPR). This fee consists of
       the $50 licensure fee, the $50 non-refundable application fee and a $5 unlicensed activity fee.
       Mail to the address below.

    3. Upon approval, all salons will be inspected, except salons located in flea markets, which will
       require an inspection before the application is approved.


APPLICATION CHECKLIST:

TRANSACTION                APPLICATION REQUIREMENTS

                                 Pay $105 application fee which includes a non-refundable application fee
                                 of $50, a $50 licensure fee and a $5 unlicensed activity fee (make check
Salon Initial                    payable to the Department of Business and Professional Regulation)
Licensure                        Complete DBPR 0020 – Master Organization Application form
Application
                                 Complete DBPR CL-4402 – Salon Licensure Application form




                Please send your completed application, documentation and required fee(s) to:

                            Department of Business and Professional Regulation
                                        1940 North Monroe Street
                                      Tallahassee, FL 32399-0783


                                          www.MyFlorida.com/dbpr




2008 March                                        Page 1 of 6                              Cosmetology Salon
DBPR 0020 – Master Organization Application

                                                             STATE OF FLORIDA
                                                        DEPARTMENT OF BUSINESS AND
                                                         PROFESSIONAL REGULATION


                                ORGANIZATION INFORMATION
Federal Employer ID Number/Social Security Number*

Organization/Applicant Name

Doing Business As (D/B/A) Name

Ownership: Proprietorship Corporation Partnership Joint Venture Agreement
            Trust Agreement Estate Professional Association Other
                                     MAILING ADDRESS
Street Address or P.O. Box



City                                                                                                    State                           Zip Code (+4 optional)

County (if Florida address)                                                               Country

                                                                 CONTACT INFORMATION
Contact Name

Primary Phone Number                                        Primary E-Mail Address

                              RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address



City                                                                                                    State                           Zip Code (+4 optional)

County (if Florida address)                                                               Country

                                                           BUSINESS LOCATION ADDRESS
Street Address



City                                                                                                    State                           Zip Code (+4 optional)

County (if Florida address)                                                               Country



                      ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number                      Fax Number

Alternate E-Mail Address

*Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance, Social Security numbers are
mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections 455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are
used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers
must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317.




2008 March                                                                      Page 2 of 6                                                           Cosmetology Salon
DBPR CL 4402 – Salon Licensure Application

                                               STATE OF FLORIDA
                                         DEPARTMENT OF BUSINESS AND
                                          PROFESSIONAL REGULATION
                                            1940 North Monroe Street
                                           Tallahassee, FL 32399-0783

                              NOTE – This form must be submitted as
                                    part of an application packet
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.

                                                   SALON INFORMATION
Name of Salon                                                 Salon Phone Number                       Contact Phone Number

Salon Locale (Check only one)
   Stand Alone Building                                      Shopping Center/Mall
   Office Building                                           Department Store
   Residence                                                 Flea Market
   Mobile (complete descriptions below)                      Other: (Describe - _______________________)
Category (Check only one)                                                              Square Feet of Floor Space:
   Full Service Salon (all Cosmetology services)              Facials Only
   Full Specialty (Facials and Nails)                         Nails Only
Mobile Salons select type (check only one)
   Motor Vehicle               Other Mobile Type             (i.e. travel trailer)
Description of vehicle or other mobile type                                              Identification Number Required:

   SALON OWNERSHIP (Check Only One Of These Choices and provide information requested)
   Sole Ownership
   Name of Owner                                                            Social Security Number*

    Mailing Address                                             City                    State                   Zip

   Partnership (Application requires both signatures. Please use additional pages if necessary.)
   Name Partner #1                                          Social Security Number* (partner #1)

    And Partner #2                                                          Social Security Number* (partner #2)

    Mailing Address #1                                          City                    State                   Zip

    Mailing Address #2                                          City                    State                   Zip

   Corporation
   Corporation Name

    Corporation Identification Number

    President                                                               Social Security Number*

    Vice-President                                                          Social Security Number*

*Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In
this instance, social security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections
455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants
and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers
must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant
to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317.



2008 March                                                   Page 3 of 6                                          Cosmetology Salon
Indicate the maximum number of licensees you intend to employ for the following categories. The number
of licensees you employ should coincide with the square footage of your salon (refer to Rule 61G5-
20.002,(4),(5), Florida Administrative Code)
Mobile Salons only need to indicate how many cosmetologists/specialists are currently employed
Nail Technicians __________________________
Facialists        __________________________           *BARBERS MAY NOT WORK IN A SALON
Full Specialists __________________________             UNLESS A COSMETOLOGIST IS ALSO
Cosmetologists __________________________                     WORKING IN THE SALON.
*Barbers          __________________________
                                           SALON REQUIREMENTS
Does the salon have the following:
1.   Adequate ventilation?                                                                   Yes      No
     What type of ventilation (air conditioning, etc.)?
2.   A closed container for depositing hair?                                                 Yes      No
3.   Running water where cosmetology services are being performed?                           Yes      No
          Shampoo bowls with:
                  Hot running water?                                                        Yes       No
                  Cold running water?                                                       Yes       No
          Sink or lavatory with:
                     Hot running water?                                                      Yes      No
                     Cold running water?                                                     Yes      No
4.   A closed container or cabinet for clean/disinfected articles?                           Yes      No
5.   A closed dustproof linen cabinet?                                                       Yes      No
6.   A closed receptacle in the cosmetology services area for soiled linens?                 Yes      No
     OR an open receptacle in an area separated from the public?                             Yes      No
7.   Containers for waving lotions and other types of such preparations?                     Yes      No
8.   Wet sanitizers?                        With covers?        Without covers? ______       Yes      No
9.   Toilet and lavatory facilities:
     a.    Are they in the salon?                                                            Yes      No
           Are they on the premises, in the same building, and within 300 feet of the
     b.                                                                                      Yes      No
           salon?
     c.    Do the facilities have:
          1.   Toilet tissue?                                                                Yes      No
          2.   Soap dispenser with soap or other hand cleaning material?                     Yes      No
          3.   Sanitary towels or other hand-drying device?                                  Yes      No
          4.   Waste receptacle?                                                             Yes      No




2008 March                                        Page 4 of 6                            Cosmetology Salon
10.   Separate, well-ventilated area for extending and sculpturing nail services?                  Yes      No
      Is any other business being operated in the same licensed space, in accordance
11.                                                                                                Yes      No
      with Rule 61G5-20.002, Florida Administrative Code?
      a.     If yes, what type of business?
             If yes, how are the businesses separated? (Permanent walls, separate and distinctly marked
      b.     entrances, etc.) ____________________________________________________
12.   Residential Salons - Answer the following additional questions if the salon is also a residence.
         Is the salon separated from the living quarters by permanent wall
      a.                                                                                       Yes     No
         construction?
         Is the entrance to the salon separate from the entrance to the living quarters
      b.                                                                                       Yes     No
         of the residence?
         Is the toilet and lavatory facilities' entrance for the salon separate from that of
      c. the living quarters?                                                                  Yes     No

13.   Mobile Salons - Do your facilities have:                                                     Yes      No
      a.     Self-contained, flush chemical toilet with holding tank?
      b.     What is the clean water storage capacity? __________________
      c.     What is the waste water storage capacity? __________________
If this application is based on a transfer of ownership or a change of location or mobile vehicle, please
complete the areas below and include the original salon license with this application.

 1.   Name of Previous Salon:
 2.   Permanent Business Address or Location of Salon:
      City                                              State                      Zip Code
 3.   Phone Number (w/Area Code) of Above Location:
 4.   Previous Owner(s) Name(s):
 5.   Previous Salon License Number:
 6.   Is the previous salon currently operating?                                    Yes       No     Unknown
 7.   Has the owner of the proposed salon ever held any other salon licenses in Florida
      for salons which have been transferred, relocated, or closed, and which should be            Yes      No
      deleted from our licensing records?

If yes, provide the following information (use additional sheets, if necessary):
      a.     Salon license number:
      b.     Salon name:
      c.     Salon address:
      d.     Date closed:




2008 March                                          Page 5 of 6                                Cosmetology Salon
8.    Has the owner of the proposed salon ever held a salon license in Florida that has
      been revoked, suspended, fined, placed on probation, or otherwise been acted                  Yes      No
      against?

If yes, provide the following information (use additional sheets, if necessary):
     a.   Salon license number:
     b.   Salon name:
     c.   Salon address:
     d.   Date closed:
                                  INSPECTION CONTACT INFORMATION
9.    Does the owner of the proposed salon hold a Florida cosmetologist or specialty
      license? (Being licensed to practice cosmetology or a specialty in Florida is NOT a           Yes      No
      requirement for owning a salon.)

     a.   If YES, provide license number                       and licensee's name __________________
          If NO, has the owner of the proposed salon ever held a Florida cosmetologist or specialist
     b.
          license?                                                                             Yes   No
     c.   If YES, provide license number                       and licensee's name __________________
                                            CERTIFICATION
I hereby authorize any individual, company, or institution with whom I have been associated to furnish the
Florida Department of Business and Professional Regulation with any information which they have on
record or otherwise concerning my qualifications for professional registration and licensure in Florida, and
do hereby release the individual, company, or institution and all individuals connected therewith from all
liability for any damage whatsoever incurred by me as a result of their furnishing such information.

I further certify that all information furnished by me on this application and on all attachments is true and
correct to the best of my knowledge and belief, and that I have read, understand, and agree to comply
with the statutes and rules applicable to the practice of my profession in Florida.
Signature of Sole Salon Owner or Corporate Officer      Signature of Partner (if applicable)


Print Name of Sole Owner or Corporate Officer           Print Name of Partner (if applicable)


Date Signed                                             Date Signed




2008 March                                        Page 6 of 6                                   Cosmetology Salon

								
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