Free 38924.PDF - Indiana

APPLICATION FOR COSMETOLOGY SALON LICENSE
State Form 38924 (R4 / 7-99) Approved by State Board of Accounts 1992 Your Social Security number is requested by this agency in accordance with IC 4-18-1. It is not mandatory that it be given. Social Security number are available to the Indiana Department of Revenue.

Indiana Professional Licensing Agency 302 W. Washington St., Rm. E034 Indianapolis, IN 46204-2700 Telephone: (317) 232-2980

Social Security number or Federal ID number

LICENSE FEE: $40.00

APPLICANT INFORMATION
Name of salon applicant (owner)

Name of salon (not more than 29 characters including spaces) Address of applicant (owner) Address of salon

City, state, ZIP code Telephone number of salon ( )

City, state, ZIP code

Telephone number of owner (residence) ( )

County of salon

Name of supervising licensed cosmetologist (six (6) months active experience under IC 25-8-9 prior to application) If salon is located on rural route, give nearest highway number

License number of supervising cosmetologist

Location of salon (check one)

Name of road (if applicable)

Business

Residential North

For directions from main highway, please indicate the N/S road and E/W road "hundred" numbers in the appropriate spaces below.

Name of nearest town

South

East

West

Give specific directions to salon (exact location with respect to a residence or surrounding building)

Approximate opening date

Normal salon hours

Check days open

Sunday

Monday Yes

Tuesday No

Wednesday

Thursday

Friday Yes

Saturday No

Is this salon connected in any way with residential living quarters?

If Yes, is the salon separated from the residence by a substantial floor to ceiling partition with a separate entry?

If Yes, explain the nature of the separation

SALON REQUIREMENTS 1. Number of work stations ______________ 2. Operable sterilizers on premises - must have at least one (1) wet and one (1) dry 3. Operable sterilizers at each work station - must have at least one (1) wet and one (1) dry 4. Hot and cold running water 5. Shampoo bowl or shampoo sink 6. Number of covered waste receptacles one (1) for every two (2) work stations 7. 8. 9. Eight (8) combs Three (3) brushes Effective disinfectant

10. One (1) cabinet or drawer for storage of clean towels 11. One (1) covered hamper for storage of soiled towels 12. Twelve (12) towels

A. Salon shall have sanitary requirements and all licenses posted and a sign visible at the main public entrance of the salon, stating the name of the establishment and that the establishment is a cosmetology salon. B. A change in salon ownership or location will require the filing of a new salon application. C. Any person providing cosmetology services in the salon must possess a valid cosmetologist license issued by the Board of Cosmetology Examiners. D. Cosmetology salon leasing or subleasing to an esthetician under IC 25-8-12.6-7, shall maintain a separate room for such practice which is used exclusively for esthetics services and comply with Rule 2, sanitary requirements for estheticians as established by the board. E. Cosmetology salons providing electrology shall maintain a separate room for such practice which is used exclusively for electrology services, and comply with 820 IAC 3-1-12, sanitary requirements for electrologists as established by the board. If salon is owned by a corporation or partnership, list the name, title and address of the officers of the corporation or partners of the partnership. NAME TITLE ADDRESS

AFFIDAVIT I will operate establishment in compliance with the rules governing the sanitary requirements of cosmetology salons as required by the State Board of Cosmetology Examiners, and ensure that all employees comply with all requirements. (If cosmetology salon is owned by a corporation or partnership, this application must be signed by an officer of the corporation or a partner of the partnership.) The cosmetology salon will be under the personal supervision of ______________________________________________________________________ License number _________________________, expiring _____________________________________________, who has at least six (6) months active experience as a cosmetologist, under IC 25-8-9, before the application was submitted.
Have you ever committed an act for which you could be disciplined under IC 25-8-14?

Yes

No

If the answer is Yes, please describe the act on a separate sheet of paper and attach to this application.

I swear of affirm that the above statements are true and correct to the best of Signature of applicant / corporate officer / partner my knowledge and belief. NOTARY CERTIFICATE

STATE OF COUNTY OF

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SS:

Subscribed and sworn to before me on this __________ day of ____________________________________, ________________.

Signature of Notary Public Printed or typed name of Notary Public

Notary's county of residence

Date Commission expires