Application For Contiguous Establishment License Form (Page 2 of 2) in pdf

(page 2 of 2)

PRIMARY ESTABLISHMENT INFORMATION

___________________________________________________________________________________________________________

Name of Primary Establishment _______________________________________________________________________________

Shop Location Address ______________________________________________________________________________________

street

city

state

zip

Shop Mailing Address________________________________________________________________________________________

street

city

state

zip

Shop Phone Number _______________________

Home Phone Number __________________

Name of Primary Shop Owner(s) ______________________________________________________________________________

(Please check the appropriate box below and insert the establishment license number)

[ ] Primary Barber Shop - license # BS-________

[ ] Primary Cosmetology Shop - license # CS-_________

I hereby certify that the above named Primary establishment is currently licensed by the undersigned and meets the licensure

requirements as outlined by Idaho Laws & Rules including: a working floor space of not less than 108 square feet for a single station

shop & an additional 50 square feet for each additional station or Contiguous shop; a minimum three (3) foot wide access into all

Contiguous shop areas; toilet facilities, including sink with hot & cold running water, conveniently located & accessible from the

Primary area & within the building where the Primary establishment is located; and hot & cold running water & approved drainage

system separate from the toilet facilities & available to any Contiguous shop not containing said facilities within their licensed area.

I further certify that I authorize the person named, and whose signature appears on the reverse side of this application, to apply for

licensure of and to operate a licensed Contiguous shop within the above named Primary shop.

I further certify that I am familiar with the city/county planning & zoning regulations affecting the shop listed above and that I

assume all responsibility for their compliance.

I further certify that the information recorded hereon is correct to the best of my knowledge and belief.

__________________________________________________

Signature of owner(s) or authorized agent(s)

State of ______________, County of _________________________, ss.

Subscribed and sworn before me this ______ day of _______________________, 20 _____.

(seal)

__________________________________________________

Notary Public official signature

residing at ________________________________________

my commission expires_______________________________

DIAGRAM INSTRUCTIONS

This application must include an accurate and detailed floor plan of the entire Primary & Contiguous shop area on a separate sheet

of eight and one-half inch by eleven inch white paper. The floor plan must include: all inside dimensions, total square footage,

location of all stations, water sources, restrooms, access areas, and entrances. If the establishment is located within a multi-tenet

building or a private residence, please include a drawing of the complete building or residence showing all surrounding or adjacent

rooms and the exact location of the shop area within the building or residence. The floor plan must include the exact measurements

of the Contiguous area to be licensed.

Primary owner note: Clearly designate, by color highlighting, the Contiguous shop area to be licensed. In a different color,

also designate all other currently licensed Contiguous shop areas.

THE APPLICATION WILL NOT BE PROCESSED IF IT IS NOT COMPLETE. THE COMPLETED APPLICATION

MUST BE SUBMITTED WITH THE REQUIRED FLOOR PLAN.

NOTE: The Cosmetology Board has waived the application fee for those Contiguous establishments that change location

(station) WITHIN THE SAME PRIMARY ESTABLISHMENT. Contiguous owners must continue to file the Contiguous

Establishment License Application for such changes prior to such a move. Contiguous establishments that move from one

Primary establishment to another Primary establishment are required to submit both the application and the required fee.

(This NOTE does not apply to applicants for Barber establishment licenses.)

Application For Contiguous Establishment License Form Page 2

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