Fillable Mobile Business Registration Form (Commonwealth of Massachusetts)

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Mobile Business Registration Form (Commonwealth of Massachusetts)

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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1
The Commonwealth of Massachusetts
Division of Professional Licensure
1000 Washington Street Suite 710
Boston, MA 02118-6100
Board of Registration of Cosmetology and Barbering
www.mass.gov/dpl/boards
617-727-9940
BOARD USE ONLY Please attach recent
Board:________________
License #:_____________ 2” X 2”
Type: ________________
Cash #:_______________ passport photograph here
Cash Date: ____________
Mobile Business Registration
The Board’s mobile cosmetology and barbering policy allows mobile services at locations chosen by the
client, such as a client’s home, office, etc., and services in a mobile vehicle equipped as a shop. Under this
policy, “all persons and businesses that offer Mobile Services shall register.” This means that each of the
following must be registered and approved before offering mobile services: (1) a licensee offering mobile
services, whether on location or in a vehicle (an individual); (2) a business with more than one licensee
providing mobile services (a mobile business); and (3) a vehicle equipped as a shop (a mobile unit). Each
licensee, business, and unit must register using a different form. An owner of a business or unit does not
need to be a licensee, but all individuals who provide mobile services must be licensed to provide those
services. This is a registration form ONLY for a mobile business.
To be complete, this application must include: (1) a passport photograph of the applicant; (2) a copy of a
driver’s license or state identification card for each owner; (3) a copy of the professional license(s) for each
owner (if applicable); and (4) a signed Criminal Offender Record Information (CORI) form for each owner, a
copy of which is attached.
After the Board receives and approves your registration, you will receive an approval letter. You are
not authorized to provide mobile services until you receive that approval letter.
Registration Information
Business Owner: _______________ _______ ________
Last First Middle
Social Security or Federal Tax Identification Number: _____________________________________
Pursuant to G.L. c. 62C, s. 47A, the Division of Professional Licensure is required to obtain your social
security number and forward it to the Department of Revenue. The Department of Revenue will use your
social security number to ascertain whether you are in compliance with the tax laws of the Commonwealth.
License Number(s) (if applicable): _____________________________________________________
Business Name: ________
2
Type(s) of Service(s) Offered (Check All That Apply):
Cosmetology Manicuring Aesthetics Barbering
Business Telephone Number: _______________________________________________________________
Business Email Address: ____________________________________________________________
Business Website: ___________________________________________________________________
Permanent Street Address in Massachusetts Where Records Will Be Maintained (Not a P.O. Box):
______________________________________________
Street Address
_____________________________________________________________________________________________
City State Zip
Business Type:
Individually Owned
Partnership or LLP
Names of Partners: _________________________________________________________________
If the business is owned by a partnership, please have all partners sign below.
Corporation – Name of Corporation: __________________________________________________
If the business is a corporation, an individual with signing authority must sign below.
LLC – Name of LLC:_______________________________________________________________
If the business is a limited liability company, an individual with signing authority must sign below.
Employer Identification Number: ______________________________________
A mobile business owner must notify the Board of Registration of Cosmetology and Barbering at least thirty
days before any change in the mobile business’s ownership.
3
Background Questions
1. Do you hold or have you held a professional license in any jurisdiction? Yes: No:
If your license is with the Board of Cosmetology and Barbering, please list your license number:
__________________________________________________________________________________________
For other licenses, please contact the jurisdiction’s licensing authority and arrange for that authority to send a
certificate of standing directly to the Board indicating the status of your license, information on any pending
actions, and any disciplinary information.
2. Has any disciplinary action been taken against you by a licensing board in any jurisdiction?
Yes: No:
If yes, please state details. (Use a separate sheet if necessary.):
__________________________________________________________________________________________
3. Are you the subject of pending disciplinary action by a licensing board in any jurisdiction?
Yes: No:
If yes, please state details. (Use a separate sheet if necessary.):
__________________________________________________________________________________________
4. Have you voluntarily surrendered a professional license to a licensing board in any jurisdiction?
Yes: No:
If yes, please state details. (Use a separate sheet if necessary.):
__________________________________________________________________________________________
5. Have you ever applied for and been denied a professional license in any jurisdiction?
Yes: No:
If yes, please state details. (Use a separate sheet if necessary.):
__________________________________________________________________________________________
6. Have you been convicted of a felony or misdemeanor in any jurisdiction?
Yes: No:
If yes, please state details. (Use a separate sheet if necessary.)
__________________________________________________________________________________________
4
Attestation
I certify, under the pains and penalties of perjury, that the information I have provided pursuant to this application
for registration is truthful and accurate. I understand that the failure to provide accurate information may be
grounds for the Massachusetts Board of Registration of Cosmetology and Barbering to deny me the right to sit as
a candidate or to suspend or revoke a license or registration issued to me in accordance with Massachusetts Law.
I further attest that, pursuant to Massachusetts General Laws c. 62C, §49A, to the best of my knowledge and
belief, I and/or the business entity I represent have filed all state tax returns and paid all state taxes required by
law. I further agree that I am responsible for ensuring that the actions of the above referenced business will
adhere to all applicable Massachusetts laws and regulations pertaining to the practice of cosmetology or
barbering.
If your business is a partnership, all partners must sign, and in signing, agree that the named applicant may
represent all partners with regard to any Board business.
If your business is incorporated or otherwise organized, only a member, manager, or officer of the organization
who is authorized to sign on behalf of the business may sign below.
Signature of Applicant Date
Print Name Position (if applicable)
Signature of Applicant Date
Print Name Position (if applicable)
Signature of Applicant Date
Print Name Position (if applicable)
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
The Division of Professional Licensure by itself and on behalf of boards of registration pursuant to
M.G.L. c. 13, §9 [hereinafter, “Division of Professional Licensure”] is registered under the provisions of
M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified
prospective license applicants and current licensees.
As a license applicant or current licensee, I understand that a CORI check will be submitted for my
personal information to the Department of Criminal Justice Information Services (“DCJIS”). I hereby
acknowledge and provide permission to the Division of Professional Licensure to submit a CORI check
for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I
may withdraw this authorization at any time by providing the Division of Professional Licensure written
notice of my intent to withdraw consent to a CORI check.
FOR LICENSING PURPOSES ONLY:
The Division of Professional Licensure may conduct subsequent CORI checks within one year of the
date this Form was signed by me. If subsequent CORI checks are necessary, the Division of
Professional Licensure will provide me with written notice of the subsequent CORI checks.
By signing below, I provide my consent to a CORI check and acknowledge that the information provided
on Page 2 of this Acknowledgement Form is true and accurate.
_________________________________ _________________________________
Signature Date
Please provide the name of the board of registration and license type for which you are applying or currently hold:
_________________________________ _________________________________
Board of Registration License Type
NOTE: DPL CANNOT ACCEPT THIS TWO-PAGE CORI ACKNOWLEDGMENT FORM UNLESS IT IS
EITHER (1) SIGNED IN PERSON AT THE BOARD'S OFFICES IN THE PRESENCE OF A DPL
EMPLOYEE WHO HAS VERIFIED THE APPLICANT'S IDENTITY THROUGH ACCEPTABLE
IDENTIFICATION, OR (2) SIGNED IN THE PRESENCE OF A NOTARY PUBLIC WHO HAS LIKEWISE
VERIFIED IDENTITY AND THEN MAILED OR OTHERWISE DELIVERED TO THE BOARD'S OFFICES
AT THE ADDRESS SET FORTH ABOVE.
Page 1 of 2
SUBJECT INFORMATION: (An asterisk (*) denotes a required field)
________________________ _________________________ _______________________ ______
*Last Name *First Name Middle Name Suffix
___________________________________________________________________________________
*Maiden Name (or other name(s) by which you have been known)
___________________ ____________________________
*Date of Birth Place of Birth
*Last Six Digits of Your Social Security Number: ______ - _____________
Sex: ______ Height: ____ ft. ____ in. Eye Color: ___________
Driver’s License or ID Number: ___________________ State of Issue: ________________________
Current and Former Addresses:
______ ____________________________________ ______________________ _____ ________
Number Name City/Town State Zip
______ ____________________________________ ______________________ _____ ________
Number Name City/Town State Zip
SECTION A: VERIFICATION BY DPL EMPLOYEE: I hereby certify that I verified the identity of the
above-referenced subject by reviewing the following form(s) of government-issued identification:
1
Passport State-issued driver’s license Military identification State-issued identification card
VERIFIED BY:
Name of Verifying DPL Employee (Please Print)
Signature of Verifying DPL Employee (Please Print) Date
SECTION B: VERIFICATION BY NOTARY:
On this ______ day of _____________, 20____, before me, the undersigned notary public, personally
appeared _________________________________ (name of document signer), and proved to me
through satisfactory evidence of identification, which was the following:
1
Passport State-issued driver’s license Military identification State-issued identification card
to be the person whose name is signed on the preceding or attached document, and acknowledged to
me that (he) (she) signed it voluntarily for its stated purpose.
Notary Public: Notary Commission Expires On:
1
If a subject does not have an acceptable government-issued identification, his or her identity shall be verified by the other
forms of identification documentation as determined by DCJIS. 803 CMR 2.09 (2).
Page 2 of 2
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Mobile Business Registration Form (Commonwealth of Massachusetts)

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Completed 18 July 2020

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