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<br />~11:.l L &L~l:. ~:.....~;:,i J I~H" .~I;. j~1 i ..I.AI ~....". ,)1:.1 ..l:':II~Il..( '",1.1 p.. '1~IUI~ll.l..: J V'..l~L' ~p,:""...c.;l:L",.~Un. 10'I.L are no' ~.ega..,.y <br />required to provide this data. However, if you fail to do, the Department of Commeree may <br />~e unahte to.,. grant you a lieense. Data on licensees is a pUblic record under state laws <br />(M.S. 13.41) and will be accessible to anyone upon request. personal application data on <br />indiv1'duals who have not as yet been licensed is private information and may only be shared <br />with other govemmental agencies in the furtherance of mandated programs. (oCS-DP6) <br /> <br />I <br /> <br />COSMETOLOGY UNIT <br />METRO SQU AR.11: ELDG. <br />ST. PAUL, MN 55101 <br /> <br />READ INSTRUCTIONS BEFORE FILLING OUT APPLICATION <br /> <br />FOR OFFtCE USE ONLY <br />Date issued <br />Date Provo sent <br />Date Lie. sent <br /> <br />FEE: $65.00 <br /> <br />Salon Clerk 296-9403 FACILITIES LICENSE APPLICATION FORM PI-EASE PRINT <br /> <br />TYPE OF LICENSE APPLIED FOR, CHECK ONE: .I:1.Manicurist nCosmetology nBooth <br />CHECK ONE: ANEW SHOP .lJ..CHANGE LOCATIO~ .Q,.CHANGE OWNERSHIP <br />TYPE OF SHOP, CHECK ONE: D,.Residence ll~on-Residenee .Q.Nursing Hom.e 11.Beauty-Barber <br />Combination <br /> <br />SHOP !n.:A.!..'13 <br /> <br />Phone No. <br /> <br />Address <br /> <br />City <br /> <br />Zip Code <br /> <br />County <br /> <br />Owner's Name <br /> <br />Owner's Hom.e or Corporation Address <br /> <br />Ie of the licensed mallQier who will be <br />d expiration date. <br />e <br /> <br />,~_... <br /> <br />License Number <br /> <br />employed by the salon including license mllftber <br /> <br />~irat'1on Date <br /> <br />Business Hours. Days of week and hours of' day during which salon will be open, <br /> <br />Number of employees <br /> <br />Number of work stations <br /> <br />Date to be opened for business <br /> <br />Professional Liability Insurance Company <br />Policy No. <br />Workers' Compensation Insurance Company Name <br />Policy No. <br /> <br />FILL IN IF CHANGE OF LOCATION OR OWNERSHIP ONLY. <br /> <br />Former name of 3hop <br />Former Location <br />Former Owner <br /> <br />Y. t s Signature <br />S1llrribed and sworn to before me this <br />County of <br /> <br />day of <br /> <br />, 19_ <br /> <br />(Notarial Seal) <br />MY Commission expires <br /> <br />~~arf ~UDL~C ~~a~e 01 M1nneso~A <br />