Fillable Initial Application for a School License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Initial Application for a School License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Cosmetology and Hairstyling
124 Halsey Street, 6th Floor, P.O. Box 45003
Newark, New Jersey 07101
(973) 504-6400
Initial Application for a School License
Pursuant to the provisions of Title 45:5B of the Revised Statutes of the State of New Jersey, the undersigned hereby applies for
an initial license to conduct a School of Cosmetology and Hairstyling.
All information (one original and two copies) must be submitted in three-ring loose-leaf notebooks and tabulated into
appropriate sections. Section #1 • Ownership, Section #2 • Administration, etc.
Section #1 • Ownership - New Jersey Administrative Code (N.J.A.C. 13:28-6.2)
a. Name of school: __________________________________________________________________________________________
Address:
School telephone number: ( ) ____________________________________ (include area code)
b. Ownership information: (Check one) Individual Partnership Corporation
Name of principal owner ____________________________ Address
Name of principal owner ____________________________ Address
Name of principal owner ____________________________ Address
Section #2 • Administration
a. List the name(s) and title(s) of the person(s) responsible for directing/operating the school. When classes are in session,
please state the percentage of time the director/administrator will be in attendance.
%oftime
Director/Administrator Title inattendance
Name: ________________________________________ _______________________________________ ___________
Name: ________________________________________ _______________________________________ ___________
Name: ________________________________________ _______________________________________ ___________
(Please print)
(Please print)
(Please print)
b. Attach personal data forms or resumes for each individual.
c. Provide the name and address of one person who can certify the administrators’ business experience. Attach a letter of
reference.
Name: ____________________________________________Ofcial position: _______________________________________
Address:
Telephone number: Day ( ) ______________________________ Evening ( ) _____________________________
(include area code) (include area code)
d. Name of person (director or supervising teacher) who will be responsible for administering school policy and discipline.
Name: ____________________________________________Title/Position: __________________________________________
Section #3 • Supervising Teacher (N.J.A.C. 13:28-6.18)
a. Proposed schools must employ a supervising teacher with at least two years’ experience as a licensed teacher, who will be
responsible for the educational coordination of the proposed school. Please provide the name of the supervising teacher
and his/her current license number (s). Please state the percentage of time the supervising teacher will be in attendance
when classes are in session.
%oftime
Name LicenseNumber(s) inattendance
__________________________________________ _______________________________________ ___________
_______________________________________
_______________________________________
b. Submit a copy of an employment contract between the school and the supervising teacher (one-year minimum).
c. Provide a current resume of the supervising teacher.
d. Furnish one character reference for the supervising teacher. Attachaletterofreference.
Name: ____________________________________________Ofcial position: _______________________________________
Address:
Telephone number: Day ( ) ______________________________ Evening ( ) _____________________________
(include area code) (include area code)
Section #4 • Questions concerning Criminal History and Record of Licensure
1. Have any of the principal owners or the supervising teacher ever changed their name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
2. Have any of the principal owners or the supervising teacher ever been summoned; arrested; taken into custody; indicted; tried;
charged with; admitted into pre-trial intervention (P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor
or disorderly persons offense, in New Jersey, any other state, the District of Columbia or in any other jurisdiction? (Parking or
speeding violations need not be disclosed, but motor vehicle violations such as driving while impaired or intoxicated must be.)
Yes No
3. Have any of the principal owners or the supervising teacher ever been convicted of any crime or offense under any circumstances?
This includes, but is not limited to, a plea of guilty, non vult, nolo contendere, no contest, or a nding of guilt by a judge
or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation. (Attach additional sheets of paper to this application.)
Yes No
4. Have any of the principal owners or the supervising teacher previously applied for a cosmetologist/hairstylist, barbering,
manicuring or skin-care specialty license in New Jersey, any other state, the District of Columbia or in any other
jurisdiction?
__________________________________________________________________________________
If “Yes,”when and where?
NoYes
5. Do any of the principal owners or the supervising teacher currently hold, or have they ever held, a professional or occupational
license or certicate of any kind in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license was issued under a
different name, please provide that name. Please print.
_____________________ _____________________ ______________________ ___________________ _____________
Name of principal owner Date issued/expiredType of license or certicate Number State or jurisdiction that issued
the license or certicate
_____________________ _____________________ ______________________ ___________________ _____________
Name of principal owner Date issued/expiredType of license or certicate Number State or jurisdiction that issued
the license or certicate
_____________________ _____________________ ______________________ ___________________ _____________
Name of principal owner Date issued/expiredType of license or certicate Number State or jurisdiction that issued
the license or certicate
_____________________ _____________________ ______________________ ___________________ _____________
Name of supervising teacher Type of license or certicate Number State or jurisdiction that issued Date issued/expired
the license or certicate
Yes No
6. Have any of the principal owners or the supervising teacher ever held a temporary license or limited permit in New Jersey,
any other state, the District of Columbia or in any other jurisdiction?
If “Yes,” list the date of issuance and expiration and the jurisdiction where the temporary license or limited permit was granted.
_____________________ Expiration date _____________________ Jurisdiction______________________
Date of issuance
7. Have any of the principal owners or the supervising teacher ever been cited for disciplinary reasons or denied a professional
or occupational license or certicate of any kind in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
8. Have any of the principal owners or the supervising teacher ever had a professional or occupational license or certicate
of any type suspended, revoked or surrendered in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
9. Has any action (including the assessment of nes or other penalties) ever been taken against the professional or occupational
practice of any of the principal owners or the supervising teacher by any agency or certication board in New Jersey, any
other state, the District of Columbia or in any other jurisdiction? Yes No
10. Have any of the principal owners or the supervising teacher ever been named as a defendant in any litigation related to the
practice of cosmetology/hairstyling, beauty culture, barbering, manicuring or skin care specialty or other professional or
occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
11. Are any of the principal owners or the supervising teacher aware of any investigation pending against a professional or
occupational license or certicate issued to any of them by a professional or occupational board in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes No
12. Are there any criminal charges now pending against any of the principal owners or the supervising teacher in New Jersey,
any other state, the District of Columbia or in any other jurisdiction? Yes No
13. Have any of the principal owners or the supervising teacher ever been sanctioned by or is any action pending before any
employer, association, society, or other professional or occupational group related to the practice of cosmetology/hairstyling,
beauty culture, barbering, manicuring or skin-care specialty or other professional or occupational practice in New Jersey,
any other state, the District of Columbia or in any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 7 through 13, is “Yes,” provide a complete explanation of the
circumstances leading to the action, and any supporting documentation, on separate sheets of paper.
_______________________________________________
Last name First name Middle initial
Section #5 • Citizenship / Immigration Status
Every principal owner and the supervising teacher must indicate whether he/she is a U.S. citizen.
Principal owner’s name (please print) ________________________________________________
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
Principal owner’s name (please print) ________________________________________________
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
Supervising teacher’s name (please print) _____________________________________________
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
Section #6 • Social Security number
Everyprincipalownerandthesupervisingteachermustprovidehis/herSocialSecuritynumbertotheBoard.Failuretodo
sowillresultindenial/nonrenewaloflicensureorcertication.
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child
Support Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7,60.8 and 60.9, the Board or
Committee is required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also
obligated to provide your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records; and
b. the Probation Division or any other agency responsible for child support enforcement, upon request.
Principal owner’s name (please print) ________________________________________________
Principal owner’s Social Security number: __________ - __________ - __________ .
Principal owner’s name (please print) ________________________________________________
Principal owner’s Social Security number: __________ - __________ - __________ .
Principal owner’s name (please print) ________________________________________________
Principal owner’s Social Security number: __________ - __________ - __________ .
Supervising teacher’s name (please print) _____________________________________________
Supervising teacher’s Social Security number: ___________ - ____________ - ___________ .
Section #7 • Employment of Licensed Teachers (N.J.A.C. 13:28-6.24)
Please provide the name(s) and current license(s) of all teachers.
Name LicenseNo.
__________________________________________ _______________________________________
__________________________________________ _______________________________________
__________________________________________ _______________________________________
__________________________________________ _______________________________________
Section #8 • Building Information
a. Please check one: Owned Leased
If “Leased,” provide the expiration date of the lease. Date: _________________________________________________
b. The size of the oor space for the entire school is ____________________ square feet.
(Refer to Regulations Booklet, N.J.A.C. 13:28-6.7).
c. Does the school have a separate entrance? Yes No
d. Is there a school sign displayed at the entrance? Yes No
e. Is there a “Service by Students Only” sign posted at the entrance to the clinic? Yes No
(Refer to Regulations Booklet, N.J.A.C. 13:28-6.27).
f. Provide a copy of the lease agreement.
Section #9 • Floor Plan (N.J.A.C. 13:28-6.7)
Enclose a sketch, drawn to scale, showing classroom space, lavatories, locker rooms, ofce space and any other areas to be
included in the school. Dimensions and total square footage of each room/area/space must be visible on the oor plan as well
as the total square footage of the entire school. In addition, each room must be identied regarding its use (for example,
classroom, clinic, lunch room, etc.).
Sanitaryfacilities: Please indicate the number and locations of toilets, wash basins and drinking fountains.
Toilets: __________ Locations:
Wash basins: __________ Locations:
Dr inking fountains: __________ Locations:
Section #10 • Minimum Equipment (N.J.A.C. 13:28-6.20)
Equipment Quantity Equipment Quantity
Six shampoo bowls with at least one bowl per
classroom
A high-frequency instrument and attachments
Three metal pressing combs and three at irons Robes for patrons
Six manicure tables A barber chair
Three Marcel ovens and Marcel irons A latherizer
Six hair dryers One hone
One container for enzymatic cleaning solution for
each manicuring table that allows implements and
tools to be totally immersed.
One strop
One ultraviolet sterilizer Electric clippers (for barbering)
A clean, closed receptacle for storage of sanitized
implements and tools at each work station.
One locker for each pupil with provisions for security
Foot soaking equipment. One lavatory for men
Six canvas or styrofoam blocks One lavatory for women
One practice manikin per student
One teachers’ lavatory for schools having three or
more teachers
One reclining facial chair
Student tool kits - Cosmetology/Hairstyling
(N.J.A.C. 13:28-6.20(c)) Provide a list of all of the
tools (combs, clips, etc.) the student will receive.
A utility table with disposable sanitary covering
Student tool kits - Manicuring
(N.J.A.C. 13:28-6.20(f)) Provide a list of all of the
tools the student will receive.
A make-up stool
Student tool kits - Skin care specialty
(N.J.A.C. 13:28-6.20(g)) Provide a list of all of the
tools the student will receive.
Professional clinical uniform or lab-type jacket per
student
Student tool kits - Barbering
(N.J.A.C. 13:28-6.20(e)) Provide list of all of the tools
the students will receive.
Professional clinical uniform or lab-type jacket per
student
Student tool kits - Beauty Culture
(N.J.A.C. 13:28-6.20(d)) Provide list of all of the tools
the students will receive.
A facial steamer
Working stations, chairs, mirrors, shelves, facilities,
blackboards and charts.
(N.J.A.C. 13:28-6.20(g)) Provide a list of workplace
equipment.
A suction machine and attachments Separate closed cabinets for supplies
A galvanic machine and attachments One closed container for soiled linens per classroom.
A magnifying lamp
One closed container for all waste materials per
classroom.
An electric brushing machine and attachments
Sufcient supply of properly labeled lotion containers
with tops or covers.
A waxing machine
Separate classrooms.
(N.J.A.C. 13:28-6.20(k)) Provide a list of all separate
classrooms.
A spray machine and attachments
Furnishings and supplies to properly teach students.
(N.J.A.C. 13:28-6.20(l))
A Wood’s lamp A bulletin board
Total square footage:Section #11 • Enrollment Agreement / Student Contract (N.J.A.C. 13:28-6.2(b))
a. An enrollment agreement must be used to clearly state the length of the course, the cost of the course, the method of
payment and the refund policy.
b. The refund policy must conform to acceptable standards.
c. A sample of the enrollment agreement must be submitted with this application.
Section #12 • Courses (N.J.A.C. 13:28-6.2 and 6.28 to 6.34)
a. Attach an outline of each course showing the hours of instruction, both theory and practical, for each unit.
b. For each course, attach a daily lesson plan for three separate instructional units. Each plan should include an hour-by-hour
breakdown.
c. List all of the textbooks that will be used.
Textbook
Textbook
Textbook
Textbook
Textbook
Section #13 • Course Outline for Students (N.J.A.C. 13:28-6.28 to 6.34)
A course outline must be furnished to each student upon enrollment in the course. Providing the student with a school bulletin
or catalog that contains an outline of the course will satisfy this requirement.
Please indicate how the course outline will be furnished to the student.
A sample of the course outline must be submitted with this application.
Section #14 • School Bulletin
A sample of the school bulletin must be submitted with this application. The following items should serve as a guide in the
development of the school bulletin.
Name of school A statement regarding the record of academic
progress kept by the school and furnished to the
student.
School address Policy relating to student conduct and conditions
of dismissal
Telephone, fax, e-mail numbers Tuition costs
Volume number and publication date Other charges
License requirements Statement of the tuition refund policy
Name of governing body Is the refund policy in compliance with State
regulations?
Names of administrators Course outline with hours
Names of faculty members Course descriptions (optional)
School calendar showing legal holidays and
beginning and ending dates of each term, etc.
Description of school facilities and equipment
Entrance requirements for each course School policy relative to granting credit for previ-
ous education
School policy on leave, absences, class cuts,
make-up work and interruptions for unsatisfac-
tory progress
Requirements for graduation
Policy on the standards of progress required for
the student
Grading system
Probational period
Re-entrance conditions
Student equipment list
Section #15 School Records (N.J.A.C. 13:28-6.12(c) and 6.15)
The following school records must be submitted. Place a check (
) mark next to the records the school will maintain.
Please enclose samples.
Records Maintained Records Maintained
Attendance (Sign-in sheets) N.J. Cosmetology & Hairstyling Laws and
Regulations
Student’s time sheet Tuition payments
Student’s progress (Must show units of instruction
completed with a periodic grade.)
N.J. State Board of Cosmetology & Hairstyling
examination results
Make-up class Graduate information
School rules and regulations Job placement
Item PageNo. Item PageNo.
Section #16 • Class Schedules (N.J.A.C. 13:28-6.11, 12 and 13)
List the hours classes are in session.
Mondayhours Tuesdayhours Wednesdayhours Thursdayhours Fridayhours Saturdayhours
Day
Evening
Make-upclasses
Section #17 • Policy of the School regarding Absences (N.J.A.C. 13:28-6.21(g), (i) and (n))
Briey describe the policy of the school dealing with absences and make-up work.
Section #18 • Credit for Prior Training (N.J.A.C. 13:28-6.21(l))
Will appropriate credit be given for previous training and experience? Yes No
How will this be accomplished?
Section #19 • Other School Policies
What other rules and regulations will serve as school policy and be enforced as such?
Section #20 • Certicate of Completion (N.J.A.C. 13:28-6.2(b))
Provide a sample of the certicate that will be issued to students upon successful completion of the course.
Section #21 • Board of Health Approval
Provide a copy of the Board of Health approval.
Section #22 • Advertising (N.J.A.C. 13:28-6.4)
Provide a sample of any proposed advertising. The applicant must indicate the sources that will be used, such as newspapers,
magazines, radio, etc.
Section #23 • Insurance
List the names of the liability and worker’s compensation insurance companies, policy numbers and the amount of coverage
currently in effect.
Insurancecompany Policynumber Amountofcoverage
List the name of the performance bond insurance company, the policy number and expiration date, and the amount of coverage
currently in effect. (Regulations Booklet, N.J.A.C. 13:28-6.35)
Insurancecompany Policynumber Expirationdate Amountofcoverage
A copy of the school bond must be submitted with this application.
Section #24 • Certied/Audited Financial Data (N.J.A.C. 13:28-6.2 (b))
Provide nancial information for the corporate or individual owners responsible for the operation of the school.
A complete certied-audited statement of nancial responsibility and nancial ability to conduct a school must be submitted.
a. Assets - a complete statement of real estate and personal property owned.
b. Liabilities - include all indebtedness, unpaid accounts, judgments, mortgages and all other liabilities.
c. Financialability - furnish proof of nancial ability and responsibility. Bank references must be submitted.
d. Submitacopyoftheproject’soperatingbudgetfortherstyear.
Certication / Signature of Applicant(s)
I/We hereby certify that the statements made herein are true to the best of my/our knowledge and belief, and are made for the
purpose of inducing the New Jersey State Board of Cosmetology and Hairstyling to issue a school license. If granted, I/we agree
to comply with the laws and rules and regulations of the Board.
Name: ___________________________________________________ Title: ______________________________________________
Name: ___________________________________________________ Title: ______________________________________________
Name: ___________________________________________________ Title: ______________________________________________
This application must be executed before an individual authorized by law to administer oaths.
State of ____________________________________County of ____________________________________
On this _______ day of _______________________, 20_____ , personally appeared before me the said
_________________________________________________________________ to me known to be
the individual(s) described herein and who executed the foregoing instrument, and he/she/they duly
acknowledged to me that he/she/they executed the same, and that the statements contained therein are true.
Signature of ofcer: _______________________________ Ofcial title: ____________________________
Expiration of commission: _________________________
If you have an ofcial seal,
please afx here.
Revised12/12
NewJerseyOfceoftheAttorneyGeneral
DivisionofConsumerAffairs
New Jersey State Board of Cosmetology and Hairstyling
School Bond
Know all these men by this document that we,
_________________________________________________________________________________________________
oftheCityof Countyof andStateof
asPrincipal,andtheSurety,________________________________________________________ , are held and rmly
bounduntotheState of New Jersey,fortheuseandbenetofanyperson,orpersons,interestedinthesubjectmatterof
thisbond,inthepenalsumof_____________ dollars, ($_____________), forthepaymentofwhichwellandtrulytobe
made,weherebybindourselves,ourheirs,executors,administratorsandassignsbythisdocument.
Dated this _______day of _______________________ , 20 _____
Whereas,thePrincipalhasappliedtotheNewJerseyStateBoardofCosmetologyandHairstylingforalicensetooperate
acosmetologyandhairstylingschoolintheStateofNewJerseyunderSection10ofN.J.S.A.45:5B.
Whereas,thisbondisrequiredforthedueandfaithfulperformancebythePrincipalincompliancewiththeprovisionsof
N.J.S.A.45:5B-1throughN.J.S.A.45:5B-38,inclusive.
Now, therefore, the condition of this bond is such that if the Principal shall duly and faithfully perform the terms and
conditionsofanyandallcontracts,oralorwritten,madewithstudentsattendingitsschool,andtheprovisionsofN.J.S.A.
45:5B-1throughN.J.S.A.45:5B-38,inclusive,thenthisobligationshallbevoid,otherwisetoremaininfullforceandeffect.
The term of this bond is from __________________________ to ______________________________ .
It is mutually understood and agreed between all parties hereto that if the Surety shall so elect, this bond may be
cancelledbygivingthirty(30)days’noticeinwritingtothesaidObligeeandthisbondshallbedeemedcancelledattheexpirationof
saidthirty(30)days,thesaidSuretyremainingliableforalloranyactoractscoveredbythisbond,whichmayhavebeen
committedbythePrincipaluptothedateofsuchcancellation,undertheterms,conditionsandprovisionsofthisbond.
Signed,sealedanddeliveredinthepresenceof
By__________________________________
Witness
__________________________________
Principal
Afxsealhere
New Jersey Ofce of the Attorney General
DivisionofConsumerAffairs
NewJerseyStateBoardofCosmetologyandHairstyling
124HalseyStreet,6thFloor,P.O.Box45003
Newark,NewJersey07101
(973)504-6455
Cosmetology School Bulletin Evaluation Criteria Work Sheet
1. Are the following items included in the bulletin?
Yes No Comments
Name of school
School address
Telephone, fax, e-mail numbers
Volume number and date of publication
License requirements
Name of governing body
Names of administration
Names of faculty
School calendar showing legal holidays and beginning and ending
dates of each term
Entrance requirements for each course
School policy on leave, absences, class cuts, make-up work and
interruptions for unsatisfactory progress
Policy on the standards of progress required for the student
Grading system
Probational period
Re-entrance conditions
A statement regarding the record of academic progress kept by the
school and furnished to the student
Policy relating to student conduct and conditions of dismissal
Tuition costs
Other charges
Statement of the tuition refund policy
Is the refund policy in compliance with State regulations?
Course outlines with hours
Course descriptions (optional)
Description of school facilities and equipment
School policy relative to granting credit for previous education
Requirements for graduation
Student equipment list
2a. Misleading statements
2b. Misleading illustrations
2c. Approval / Accrediting statements
Typographical, proofreading, grammatical errors3.
4. Other
Comments
School: __________________________________________________ Attention: _________________________________________
The enclosed school bulletin is is not in compliance.
Date: ____________________________________________________ By: _______________________________________________
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Initial Application for a School License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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