LB-36 0320
INSTRUCTIONS FOR FILING – BEAUTY SHOP (RELOCATION)
Access this form via website at: cca.hawaii.gov/pvl
APPLICATION
Complete the online fillable application form or print legibly in dark ink. Answer all applicable questions
and sign and date the application. Applicants are subject to requirements in effect at time of filing.
Failure to provide all the requested information will delay the processing of your application.
SOCIAL SECURITY
NUMBER
If you are applying as an individual/sole proprietor, your Social Security Number is used to verify your
identity for licensing purposes and for compliance with the below laws. For a licensed to be issued, you
must provide your Social Security Number, or your application will be deemed deficient and will not be
processed further. The following laws require that you furnish your Social Security Number to our
agency:
FEDERAL LAWS:
42 U.S.C.A. §666(a)(13) requires that Social Security Number of any applicant for a professional license or
occupational license be recorded on the application for license; and if you are a licensed health care
practitioner, 45 C.F.R., Part 61, Subpart B, §61.7 requires the Social Security Number as part of the
mandatory reporting we must do to the Healthcare Integrity and Protection Data Bank (HIPDB), of any
final adverse licensing action against a licensed health care practitioner.
HAWAII REVISED STATUTES (“HRS”):
§576D-13(j), HRS requires the Social Security Number of any applicant for a professional license or
occupational license be recorded on the application for license; and §436B-10(4), HRS which states that
an applicant for license shall provide the applicant’s Social Security Number if the licensing authority is
authorized by federal law to require the disclose (and by the federal cites shown above, we are
authorized to require the Social Security Number).
REQUIREMENTS FOR
RELOCATION
The following must be submitted to relocate your beauty shop license:
1. Completed application form signed by the Shop Owner (or officer, director, partner, or member
of the entity, as applicable) and of each licensee qualifying the shop to provide a particular
service;
2. Relocation fee (see section on RELOCATION FEE below);
3. Completed Shop Floor Plan Form (LB-01) (see section on SHOP FLOOR PLAN FORM, page 2);
FEES
ATTACH the relocation fee of $38.00 made payable to: COMMERCE AND CONSUMER AFFAIRS. Checks
must be made in U.S. dollars and be from a U.S. financial institution. The shop license is subject to
renewal on or before December 31 of odd-numbered years.
Relocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $38
NOTE: One of the numerous legal requirements that you must meet in order for your new license to be
issued is the payment of fees as set forth in this application. You may be sent a license certificate before
the payment you sent us for your required fees is honored by your bank. If your payment is dishonored,
you will have failed to pay the required licensing fee and your license will not be valid, and you may not
do business under that license. A $25.00 service change shall be assessed for payments that are
dishonored for any reason.
SHOP FLOOR PLAN
FORM
The Shop Floor Plan Form (LB-01) and its instructions are attached to the end of this application. On the
form, a box is provided for you to draw or sketch the floor plan of your shop. You may also attach a
separate document that details your shop, provided the Shop Floor Plan Form is signed and dated.
RELEASE OF
INFORMATION
If an agency or individual is assisting you with this licensure process, we will not be able to release any
information to them unless you provide us with authorization. If you wish to do so, please complete,
sign, and date the portion on Release of Information to Third Party.
(CONTINUED ON PAGE 2)
ADDRESS OF THE
BOARD
Mail all required items to: Deliver to office location at:
Board of Barbering and Cosmetology OR 335 Merchant Street, Room 301
DCCA, PVL, Licensing Branch Honolulu, HI 96813
P.O. Box 3469
Honolulu, HI 96801 Phone: (808) 586-3000
BOARD REVIEW
All beauty shop license applications are subject to review by the Board; thus, please schedule the
submittal of your application to allow for additional time that may be required for review and approval by
the Board.
DENIAL OF LICENSE
If for any reason you are denied the license you are applying form, you may be entitled to a hearing as
provided by Hawaii Revised Statutes chapter 91 and Hawaii Administrative chapter 16-201. Your written
request for a hearing must be directed to the agency that denied your application, and must be made
within sixty (60) calendar days of notification that your application for a license has been denied.
LAWS AND RULES
To obtain a copy of the Board of Barbering and Cosmetology’s laws and rules, submit a written request to
the address on Page 2 of these instructions, or you may download them from the Board’s website at:
cca.hawaii.gov/pvl. Click on “Barbering and Cosmetology”; then click on “Statute/Rule Chapter”.
• Barber law: Hawaii Revised Statutes chapter 438
• Barber rules: Hawaii Administrative Rules chapter 16-73
•
Cosmetology law: Hawaii Revised Statutes chapter 439
• Cosmetology rules: Hawaii Administrative Rules chapter 16-78
•
Professional and Vocational Licensing Act: Hawaii Revised Statutes chapter 436B
ABANDONMENT OF
APPLICATION
Pursuant to HRS section 436B-9, your application shall be considered abandoned and shall be destroyed
if you fail to provide evidence of continued efforts to complete the licensing process for two consecutive
years. The failure to provide evidence of continued efforts includes but is not limited to: (1) failure to
submit any required information and documents requested by the licensing authority within two
consecutive years from the last date the documents and information were requested; or (2) failure to
complete an examination requirement within two consecutive years from the date your application was
approved; or (3) failure to provide the licensing authority with any written communication during two
consecutive years indicating that you are attempting to complete the licensing process. If an application
is deemed to be abandoned, the applicant shall be required to reapply for licensure and comply with the
licensing requirements in effect at the time of the reapplication.
-2-
This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.
APPLICATION FOR LICENSE –
BEAUTY SHOP (RELOCATION)
Read “Requirements & Instructions” before completing this form.
Please type or print LEGIBLY in black ink.
FOR OFFICE USE
License No.
BSH -
□ Approved (Initials/date):
Name of Entity (Name of Corporation, Partnership, LLC, LLP; OR LAST-First-Middle:
Checklist:
□
FLOOR PLAN
□
BAR-BEO - D
Complete Business Address:
Mailing Address (ONLY if different from residence location):
Social Security No. (Individual/Sole Owner):
Current Beauty Shop License No.:
BSH -
Business Phone No:
IF THERE HAVE BEEN ANY CHANGES IN THE OPERATIONS, OR OF OFFICERS, MANAGERS, OR MEMBERS OF THE SHOP,
COMPLETE THE SECTION BELOW. If there are no changes, write “No Changes”.
OFFICERS OF CORPORATION, PARTNERS,
MANAGERS, OR MEMBERS
NAME (First-MI-Last)
ADDRESS (Include Zip Code)
President, Partner, Manager, or Member
Current Residence Address
Current Business Address
Vice-President, Partner, Manager, or Member
Current Residence Address
Current Business Address
Secretary, Partner, Manager, or Member
Current Residence Address
Current Business Address
Treasurer, Partner, Manager, or Member
Current Residence Address
Current Business Address
Answer Question 1 and continue to Page 2.
1. Check the appropriate boxes that fully describe the services that will be performed at this shop
(Cosmetology includes Hairdressing, Esthetics, and Nail Technology):
□ Barbering □ Cosmetology □ Hairdressing □ Esthetics □ Nail Technology
(CONTINUED ON PAGE 2)
Beauty Reloc . . . . . . 139 . . . . . . . $38
Shop: Svc. Fee . . . BCF . . . . . . . $25
Print Name of Applicant: _____________________________________________________ Date: ___________________________
List NAMES and LICENSE NUMBERS of the barbers/beauty operators to qualify this shop to provide the services noted on Page 1.
Complete a Confirmation of Employment Form with EACH licensee listed below.
BARBER/BEAUTY OPERATOR
QUALIFYING SHOP FOR SERVICE
Name (First, Middle, Last)
License No.
License Category:
Name (First, Middle, Last)
License No.
License Category:
Name (First, Middle, Last)
License No.
License Category:
Name (First, Middle, Last)
License No.
License Category:
Confirmation of Licensees Qualifying Shop for Licensure (attach additional sheets if needed):
I hereby confirm that I will be employed at this shop and that I have a current and active license in good standing to
qualify this shop to perform the service as certified by the Shop Owner.
__________________________________ ____________
__________________________________ ____________
Signature of Licensee Date
Signature of Licensee Date
__________________________________ ____________
__________________________________ ____________
Signature of Licensee Date
Signature of Licensee Date
Affidavit of Applicant:
I hereby certify that the statements, answers and representations made in this application and in the documents
attached are true and correct. I also certify there will be a licensed barber/beauty operator qualified to perform the service(s) this
shop will provide as noted on Page 2 of the application form. I understand that any misrepresentation is grounds for refusal to
grant or subsequent revocation of license and is a misdemeanor (See, Section 436B-19, Section 438-14, Hawaii Revised Statutes)
and/or grounds for criminal prosecution (See, Section 710-1017, Hawaii Revised Statutes). I further certify that I have read and
agree to comply with all laws and rules pertaining to the Board of Barbering and Cosmetology, including but not limited to Hawaii
Administrative Rules chapters 16-73 and 16-78, and Hawaii Revised Statutes chapters 436B, 438, and 439.
_______________________________________________________
Signature of Applicant (Shop Owner)
________________________
Date
_______________________________________________________
Title
Release of Information to Third Party
To assist me in the licensing process, I hereby authorize the Department of Commerce and Consumer Affairs to release
any and all information regarding my application, including but not limited to, application status, to the following third party:
Print Name of Individual who is assisting you: ___________________________________________________________________
_______________________________________________________
Signature of Applicant
________________________
Date
This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit
your request.
-2-
SHOP FLOOR PLAN FORM – BEAUTY SHOP
This form can be obtained online at: cca.hawaii.gov/pvl
Instructions:
In the box below, DRAW OR SKETCH the floor plan of the shop including the entrance/exit as well as the surrounding area. LABEL appropriate
equipment, for example, sanitary facilities such as toilets, sinks, and/or wash basins with hot and cold running water, etc. If a sanitary facility is
located outside the shop in common areas of the building or venue, DRAW OR SKETCH the pathway connecting the sanitary facility and the shop.
In the case of a booth or chair rental, LABEL the booth or chair of your shop and its surrounding area within the existing shop. You may also attach
your floor plan using a separate page (write “see attached” in box), provided the floor plan is appropriately labeled.
SIGN and DATE this form and attach to your application.
AFFIDAVIT OF APPLICANT:
I hereby certify that the statements, answers, and representations contained in this form are true and correct. I further certify that the beauty
shop sketched above is adequately equipped for the practices in which it engages. I understand that any misrepresentation is grounds for refusal
to approve my beauty shop license application, or subsequent revocation of license, and is a misdemeanor (See, Hawaii Revised Statutes sections
439-19, 436B-19), and/or grounds for criminal prosecution (See, Hawaii Revised Statutes section 710-1017). I certify that I have read, understand,
and agree to comply with all laws and rules pertaining to the Board of Barbering and Cosmetology, including but not limited to HAR §16-73 and 16-
78, and the Hawaii Revised Statutes chapters 436B, 438, and 439.
______________________________________________________________
Signature of Applicant (Shop Owner)
_____________________
Date
______________________________________________________________
Title
LB-02 0320