"Application for Barbershop Licensure" - Florida

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Application for Barbershop Licensure is a legal document that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida.

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State of Florida
Department of Business and Professional Regulation
Florida Barbers’ Board
Application for Barbershop Licensure
Form # DBPR BAR 5
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Complete all sections of this application.
Barbershop
Pay $130 fee. (Make check payable to the Department of Business and
Licensure
Professional Regulation.)
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Instructions
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.
Application Instructions (by section)
a. Section I
i.
Select the barbershop type you are applying to license.
ii.
Indicate if you are applying for a new barbershop license, a location change, or an
ownership change.
b. Section II
i.
Fill out each section completely.
ii.
Sole proprietorship/individual ownership may not be required to obtain a Federal
Employer ID Number.
iii.
Indicate the barbershop business type.
iv.
If the barbershop is a business type other than sole proprietorship, indicate the ownership
name.
v.
Business ownership: Provide the name, Social Security number, address, and the
percentage of ownership for all persons holding greater than or equal to a ten percent
ownership interest in the business.
Fla. Stat. § 559.79.
vi.
If the barbershop will be owned by a corporation, each Officer, Director, Chief Executive
or other person who is able to directly or indirectly control the operation of the barbershop
must provide their name, title, Social Security number, and an address.
Fla. Stat. §
559.79.
c. Section III
i.
Indicate whether or not the barbershop meets all safety and sanitation requirements
outlined in Rule 61G3-19.011, Florida Administrative Code, described in “GENERAL
BARBERSHOP SAFETY AND SANITATION REQUIREMENTS”, with such requirements
to continue in full force and effect for the life of the barbershop.
ii.
Answer the questions regarding any prior discipline.
d. Section IV
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
General Information
a. Barbershop Operation
i.
A license must be issued and available for posting before the barbershop can open for
business.
DBPR BAR 5 Barbershop Licensure
Incorporated by Rule: 61-35.006
June, 2015
1 of 8
State of Florida
Department of Business and Professional Regulation
Florida Barbers’ Board
Application for Barbershop Licensure
Form # DBPR BAR 5
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Complete all sections of this application.
Barbershop
Pay $130 fee. (Make check payable to the Department of Business and
Licensure
Professional Regulation.)
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Instructions
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.
Application Instructions (by section)
a. Section I
i.
Select the barbershop type you are applying to license.
ii.
Indicate if you are applying for a new barbershop license, a location change, or an
ownership change.
b. Section II
i.
Fill out each section completely.
ii.
Sole proprietorship/individual ownership may not be required to obtain a Federal
Employer ID Number.
iii.
Indicate the barbershop business type.
iv.
If the barbershop is a business type other than sole proprietorship, indicate the ownership
name.
v.
Business ownership: Provide the name, Social Security number, address, and the
percentage of ownership for all persons holding greater than or equal to a ten percent
ownership interest in the business.
Fla. Stat. § 559.79.
vi.
If the barbershop will be owned by a corporation, each Officer, Director, Chief Executive
or other person who is able to directly or indirectly control the operation of the barbershop
must provide their name, title, Social Security number, and an address.
Fla. Stat. §
559.79.
c. Section III
i.
Indicate whether or not the barbershop meets all safety and sanitation requirements
outlined in Rule 61G3-19.011, Florida Administrative Code, described in “GENERAL
BARBERSHOP SAFETY AND SANITATION REQUIREMENTS”, with such requirements
to continue in full force and effect for the life of the barbershop.
ii.
Answer the questions regarding any prior discipline.
d. Section IV
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
General Information
a. Barbershop Operation
i.
A license must be issued and available for posting before the barbershop can open for
business.
DBPR BAR 5 Barbershop Licensure
Incorporated by Rule: 61-35.006
June, 2015
2 of 8
ii.
A new barbershop application must be submitted for a change of location, name or
ownership. Any of these changes void the previous license.
iii.
All barbershops will be inspected, with the exception of flea market barbershops, after the
license has been issued. Flea market barbershops must be inspected before a license
can be issued.
iv.
Fee: $130. (Make check payable to the Florida Department of Business and Professional
Regulation.)
DBPR BAR 5 Barbershop Licensure
Incorporated by Rule: 61-35.006
June, 2015
3 of 8
State of Florida
Department of Business and Professional Regulation
Florida Barbers’ Board
Application for Barbershop Licensure
Form # DBPR BAR 5
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.
For additional information see the Instructions at the beginning of this application.
Section I – Barbershop Type and Transaction Type
CHECK ONE OF THE BARBERSHOP TYPES
Shop Type (check only one)
 Commercial [0304/1030]
 Residential [0304/1030]
 Flea Market (will be inspected prior to licensure) [0304/1031]
 Other (describe _______________________________________________) [0304/1030]
CHECK ONE OF THE TRANSACTION TYPES
Initial Barbershop
Location Change
Ownership Change
Section II – Barbershop/Owner Information
BARBERSHOP INFORMATION
Name of Barbershop
Federal Employer ID Number
MAILING ADDRESS (License will be mailed to this 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
BUSINESS LOCATION ADDRESS (Actual address of barbershop.)
Street Address
City
State
Zip Code
County (if Florida address)
Country
ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number
Fax Number
Alternate E-Mail Address
DBPR BAR 5 Barbershop Licensure
Incorporated by Rule: 61-35.006
June, 2015
4 of 8
Section II – Barbershop/Owner Information – continued
BARBERSHOP BUSINESS TYPE
 Sole Proprietor
 Corporation or LLC  Partnership
Business Type:(Select ONE only)
If other than a Sole Proprietor, provide the Corporation, LLC or Partnership Name(s) below:
BUSINESS OWNERSHIP
Please list all persons with ownership greater than or equal to 10 percent.
Social Security
Name
Address
Percent
Number*
Ownership
1.
2.
3.
4.
5.
CORPORATIONS OR LLCs ONLY
Please provide the following information for each Officer, Director, Chief Executive or other
person who is able to directly or indirectly control the operation of the barbershop.
Officer’s Name
Title
Social Security
Address
Number*
1.
2.
3.
4.
5.
6.
7.
8.
* The disclosure of your Social Security number is mandatory on all professional and occupational license
applications, is solicited by the authority granted by 42 U.S.C. §§ 653 and 654, and will be used by the Department of
Business and Professional Regulation pursuant to §§ 409.2577, 409.2598, 455.203(9), and 559.79(3), Florida
Statutes, for the efficient screening of applicants and licensees by a Title IV-D child support agency to assure
compliance with child support obligations. It is also required by § 559.79(1), Florida Statutes, for determining eligibility
for licensure and mandated by the authority granted by 42 U.S.C. § 405(c)(2)(C)(i), to be used by the Department of
Business and Professional Regulation to identify licensees for tax administration purposes.
DBPR BAR 5 Barbershop Licensure
Incorporated by Rule: 61-35.006
June, 2015
5 of 8
Section III – Barbershop Information
BARBERSHOP REQUIREMENTS
Does the barbershop meet all of the safety and sanitary requirements established in
Rule 61G3-19.011, Florida Administrative Code, described in “GENERAL
 YES
BARBERSHOP SAFETY AND SANITATION REQUIREMENTS”, with requirements to
 NO
continue in full force and effect for the life of the barbershop?
Has the owner of the proposed barbershop ever held a barbershop license in Florida
 YES
that has been revoked, suspended, fined, placed on probation, or otherwise been acted
 NO
against?
If yes, please provide the following information
Previous Barbershop License Number
Date Barbershop Closed
Previous Barbershop Name
Previous Barbershop Address
Section IV– Affirmation By Written Declaration
AFFIRMATION BY WRITTEN DECLARATION
I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I
understand that my signature on this written declaration has the same legal effect as an oath or
affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts
stated in it are true. I understand that falsification of any material information on this application
may result in criminal penalty or administrative action, including a fine, suspension or revocation
of the license.
Signature
Date
Print Name
DBPR BAR 5 Barbershop Licensure
Incorporated by Rule: 61-35.006
June, 2015
Florida Department of Business & Professional Regulation Florida Legal Forms United States Legal Forms

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