R.R.I.S. Beauty Salon/ Barber Shop Questionnaire                 

Beauty Salon & Barber Shop Supplemental Application

Date:

Applicant:  Agent:  Describe the process and products used to perform the following services: Hair dying and shampoo tinting:  Eyebrow & eyelash coloring:  Stain removing:  Dry Shampoo:  Electrolysis:  Hair removal if other than electrolysis:  Hair straightening:  Describe all services or treatments not mentioned above: List any products that you re-package, re-bottle or re-label in your name: Are pre-disposition tests run before applying products?  Yes    No Are permanent records kept on each customer?  Yes    No Does the applicant sell/service hairpieces or wigs?  Yes    No Is fingernail design performed in your salon?  Yes    No If yes, describe processes:  Acryllic    Fiberglass    Silk Wrap    Gels      Other  Do you store any flammable liquids in the shop?  Yes    No If yes, describe the type, quantity and how it is used:  Do you allow smoking in this area?  Yes    No Names of Employees # of Years Check if # of Hours Check Items applicable: Other services Check if (inc. Owner) Experience Part-time if part-time Perms Dyes Nails Rendered licensed If operators are not licensed according to state regulations, explain:  Is any space, booth or chair rented to others?  Yes    No If Yes, give names of lessees:   Are certificates of insurance required of lessees?  Yes    No Do you employ students in your shop?  Yes    No Are they salaried?  Yes    No Do you operate a beauty/barber school?  Yes    No Do students pay tuition?  Yes    No Number of Instructors:     Estimated number of students graduated annually:  Do students serve customers from the general public?  Yes    No Are hold harmless waivers signed?  Yes    No What processes are performed by the students:  Are pre-disposition tests run before applying products?  Yes    No       _______________________________________________________ ____________________

Ritchie & Rose Insurance Services, Inc.
Bus  (530) 365-4705   Fax (866) 885-1428   DOI License No.  0F44143