Free 45242.pdf - Indiana

APPLICATION FOR ESTHETIC SALON LICENSE
State Form 45242 (R2 / 9-01) Approved by State Board of Accounts 1993

LICENSE FEE: $40.00

Indiana Professional Licensing Agency 302 West Washington Street, Room E034 Indianapolis, Indiana 46204-2246 Telephone: (317) 232-2980

Social Security number or Federal ID number *

* Social Security number is requested by this agency in accordance with IC 4-1-8-1, and is mandatory that it be given. Social Security numbers are available to the Indiana Department of Revenue.

APPLICANT INFORMATION
Name of salon applicant

Address of applicant (number and street, city, state, ZIP code)

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

Address of salon (number and street, city, state, ZIP code)

Telephone number of salon ( )

Telephone number of residence ( )

County code (see listing) Supervising esthetician license number

Name of supervising licensed esthetician [six (6) months active experience as an esthetician or cometologist prior to application] Nearest highway number (if salon is located on Rural Route) Location of salon

Business
For direction from main highway, please indicate the N / S road and E / W road "hundred" numbers in appropriate spaces below: ____________ North ____________ Name of road (if applicable) ____________ South ____________ ____________ East ____________ Name of nearest town

Residential
____________ 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

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

M

T

W

TH Yes

F No

S

Yes
If yes, explain the nature of the separation:

No

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

SALON REQUIREMENTS 1. Number of work units: 2. Operable sterilizers: must have one (1) cold sterilizer and either one (1) steam autoclave or 3. Hot and cold running water. 4. Number of covered waste receptacles [one (1) for every work unit]: 5. EPA registered disinfectant. 6. Lancet safety device waste container. 7. One (1) cabinet or drawer for storage of clean towels, linens, and headbands. 8. One (1) covered hamper for storage of soiled towels, linens, and headbands. 9. One (1) facial bowl or facial sink. 10. One (1) facility treatment chair or hydraulic chair. 11. One (1) utility chair or one continuous counter top. 12. One (1) esthetician stool. 13. One (1) hands free magnification lamp. 14. Twelve (12) spatulas or tongue depressors. 15. Twelve (12) pair rubber gloves. 16. Twelve (12) clean towels. 17. Twelve (12) drapings. 18. Esthetics will be provided in a separate room which is used exclusively for esthetics services. (Continued on the reverse side)

one (1) dry heat sterilizer.

SALON REQUIREMENTS (continued) 19. 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 an esthetic salon. 20. A change in salon ownership or location will require the filing of a new salon application. 21. Any person providing esthetician services in the salon must possess a valid esthetics license issued by the Board of Cosmetology Examiners. If the 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 esthetic salons as required by the State Board of Cosmetology Examiners, and ensure that all employees comply with all requirements. (If esthetic 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 esthetic salon will be under the personal supervision of expiring , license number ,

, who holds an esthetician license under IC 25-8-12.5 and has at least six (6) months experience as an esthetician

under IC 25-8-12.5 or 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? If yes, please describe the act on a separate sheet of paper and attach to this application.

Yes

No

STATE OF COUNTY OF

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SS:

I, , having been duly sworn on oath, say that I am the above-named, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of applicant / corporate officer / partner Signature of Notary Public

Printed or typed name of applicant / corporate officer / partner

Printed or typed name of Notary Public

Date subscribed and sworn to Notary Public

County of residence

Date commission expires