{"id":2196,"date":"2025-04-24T13:49:52","date_gmt":"2025-04-24T17:49:52","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/norfolk\/?page_id=2196"},"modified":"2025-04-24T14:03:55","modified_gmt":"2025-04-24T18:03:55","slug":"personal-services-permit-application","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/norfolk\/personal-services-permit-application\/","title":{"rendered":"Personal Services Permit Application"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_8'  action='\/norfolk\/wp-json\/wp\/v2\/pages\/2196' data-formid='8' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Instructions<\/h3><div class='gsection_description' id='gfield_description_8_1'>For new, <b>unpermitted personal personal service facilities,<\/b> the plan review process is required before permitting. Please submit this application, floor plans, and other supporting documents, along with a <b>$40 plan review fee.<\/b> Submit plan review packet by email, fax, mail, or in-person. Payments: Submit check or money order by mail or in-person. Make payable to Norfolk Department of Public Health. Call the Environmental Health Office at 757-683-2712 to pay by credit card.\n\nFor Annual permit  renewal of <b>currently permitted personal service establishments,<\/b> please complete and submit this application via email, fax, mail, or in-person. <b>Note: there is no annual permit fee for personal services establishments,<\/b> except for those offering permanent make-up services, which requires submission of a separate tattoo application and fee payment.\n\n<b>Note:<\/b> We are unable to process incomplete applications.\n\nAdditionally, licensures required by other agencies or board, such as Department of Professional and Occupational Regulation - DPOR, or the Board of Nursing (massage therapists), must be obtained by the applicant prior to the health department permitting.<\/div><\/div><div id=\"field_8_4\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Application Type<\/h3><\/div><fieldset id=\"field_8_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Select One Category:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_5'><div class='gchoice gchoice_8_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='New'  id='choice_8_5_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_5_1' id='label_8_5_1' class='gform-field-label gform-field-label--type-inline'>New<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_5_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.2' type='checkbox'  value='Permit Renewal'  id='choice_8_5_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_5_2' id='label_8_5_2' class='gform-field-label gform-field-label--type-inline'>Permit Renewal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_5_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.3' type='checkbox'  value='Name Change'  id='choice_8_5_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_5_3' id='label_8_5_3' class='gform-field-label gform-field-label--type-inline'>Name Change<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_5_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.4' type='checkbox'  value='Change-of-Owner'  id='choice_8_5_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_5_4' id='label_8_5_4' class='gform-field-label gform-field-label--type-inline'>Change-of-Owner<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Type of Facility\/Services Provided<\/h3><\/div><fieldset id=\"field_8_7\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Categories<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_7'><div class='gchoice gchoice_8_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Cosmetology'  id='choice_8_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_1' id='label_8_7_1' class='gform-field-label gform-field-label--type-inline'>Cosmetology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='Barbering'  id='choice_8_7_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_2' id='label_8_7_2' class='gform-field-label gform-field-label--type-inline'>Barbering<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='Nail Care'  id='choice_8_7_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_3' id='label_8_7_3' class='gform-field-label gform-field-label--type-inline'>Nail Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_7_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.4' type='checkbox'  value='Wax Care'  id='choice_8_7_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_4' id='label_8_7_4' class='gform-field-label gform-field-label--type-inline'>Wax Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_7_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.5' type='checkbox'  value='Esthetics (Skin Care)'  id='choice_8_7_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_5' id='label_8_7_5' class='gform-field-label gform-field-label--type-inline'>Esthetics (Skin Care)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_7_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.6' type='checkbox'  value='Tanning'  id='choice_8_7_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_6' id='label_8_7_6' class='gform-field-label gform-field-label--type-inline'>Tanning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_7_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.7' type='checkbox'  value='Health Parlor (Massage\/Massage Therapy)'  id='choice_8_7_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_7' id='label_8_7_7' class='gform-field-label gform-field-label--type-inline'>Health Parlor (Massage\/Massage Therapy)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_7_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.8' type='checkbox'  value='Permanent Make Up (requires a Tattoo Parlor Application)'  id='choice_8_7_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_8' id='label_8_7_8' class='gform-field-label gform-field-label--type-inline'>Permanent Make Up (requires a Tattoo Parlor Application)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_7_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.9' type='checkbox'  value='Electrology'  id='choice_8_7_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_9' id='label_8_7_9' class='gform-field-label gform-field-label--type-inline'>Electrology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_7_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.11' type='checkbox'  value='Other (Please Specify)'  id='choice_8_7_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_11' id='label_8_7_11' class='gform-field-label gform-field-label--type-inline'>Other (Please Specify)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_8\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Establishment Information<\/h3><\/div><div id=\"field_8_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_9'>Establishment Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_8_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_10\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_8_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_8_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_8_10_1' value=''    aria-required='false'    \/>\n                                        <label for='input_8_10_1' id='input_8_10_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_8_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_8_10_2' value=''     aria-required='false'   \/>\n                                        <label for='input_8_10_2' id='input_8_10_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_8_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_8_10_3' value='Norfolk'    aria-required='false'    \/>\n                                    <label for='input_8_10_3' id='input_8_10_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_8_10_4_container' >\n                                        <input type='text' name='input_10.4' id='input_8_10_4' value='Virginia'      aria-required='false'    \/>\n                                        <label for='input_8_10_4' id='input_8_10_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_8_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_8_10_5' value=''    aria-required='false'    \/>\n                                    <label for='input_8_10_5' id='input_8_10_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_8_10_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_8_11\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_11'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_8_11' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_12\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_12'>Fax Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_8_12' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_13\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_13'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_13' id='input_8_13' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_14\" class=\"gfield gfield--type-website gfield--input-type-website gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_14'>Website<\/label><div class='ginput_container ginput_container_website'>\n                    <input name='input_14' id='input_8_14' type='url' value='' class='large'    placeholder='https:\/\/'  aria-invalid=\"false\" \/>\n                <\/div><\/div><fieldset id=\"field_8_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Owner Information<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_16'><div class='gchoice gchoice_8_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Individual Owner'  id='choice_8_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_16_1' id='label_8_16_1' class='gform-field-label gform-field-label--type-inline'>Individual Owner<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Corporation'  id='choice_8_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_16_2' id='label_8_16_2' class='gform-field-label gform-field-label--type-inline'>Corporation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Partnership'  id='choice_8_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_16_3' id='label_8_16_3' class='gform-field-label gform-field-label--type-inline'>Partnership<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Other'  id='choice_8_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_16_4' id='label_8_16_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_17'>If Other, please specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_8_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_18'>Corporation\/LLC or Owner Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_8_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_19\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_8_19' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_8_19_1_container' >\n                                        <input type='text' name='input_19.1' id='input_8_19_1' value=''    aria-required='false'    \/>\n                                        <label for='input_8_19_1' id='input_8_19_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_8_19_2_container' >\n                                        <input type='text' name='input_19.2' id='input_8_19_2' value=''     aria-required='false'   \/>\n                                        <label for='input_8_19_2' id='input_8_19_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_8_19_3_container' >\n                                    <input type='text' name='input_19.3' id='input_8_19_3' value='Norfolk'    aria-required='false'    \/>\n                                    <label for='input_8_19_3' id='input_8_19_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_8_19_4_container' >\n                                        <input type='text' name='input_19.4' id='input_8_19_4' value='Virginia'      aria-required='false'    \/>\n                                        <label for='input_8_19_4' id='input_8_19_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_8_19_5_container' >\n                                    <input type='text' name='input_19.5' id='input_8_19_5' value=''    aria-required='false'    \/>\n                                    <label for='input_8_19_5' id='input_8_19_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_19.6' id='input_8_19_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_8_20\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_20'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_8_20' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_21\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_21'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_21' id='input_8_21' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_22\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Billing Information (if different from above)<\/h3><\/div><fieldset id=\"field_8_23\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_8_23' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_8_23_1_container' >\n                                        <input type='text' name='input_23.1' id='input_8_23_1' value=''    aria-required='false'    \/>\n                                        <label for='input_8_23_1' id='input_8_23_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_8_23_2_container' >\n                                        <input type='text' name='input_23.2' id='input_8_23_2' value=''     aria-required='false'   \/>\n                                        <label for='input_8_23_2' id='input_8_23_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_8_23_3_container' >\n                                    <input type='text' name='input_23.3' id='input_8_23_3' value='Norfolk'    aria-required='false'    \/>\n                                    <label for='input_8_23_3' id='input_8_23_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_8_23_4_container' >\n                                        <input type='text' name='input_23.4' id='input_8_23_4' value='Virginia'      aria-required='false'    \/>\n                                        <label for='input_8_23_4' id='input_8_23_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_8_23_5_container' >\n                                    <input type='text' name='input_23.5' id='input_8_23_5' value=''    aria-required='false'    \/>\n                                    <label for='input_8_23_5' id='input_8_23_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_23.6' id='input_8_23_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_8_24\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_24'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_8_24' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_25\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_25'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_25' id='input_8_25' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">On-site Manager(s), District, or Regional Contacts<\/h3><\/div><div id=\"field_8_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_31'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_8_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_28'>Title<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_8_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_29\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_29'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_8_29' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_30\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_30'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_30' id='input_8_30' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_32'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_8_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_33'>Title<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_8_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_34\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_34'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_34' id='input_8_34' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_35\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_35'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_35' id='input_8_35' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_36'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_8_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_37'>Title<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_8_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_38\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_38'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_8_38' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_39\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_39'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_39' id='input_8_39' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Hours of Operation<\/h3><\/div><div id=\"field_8_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_41'>Monday Open:<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_8_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_42'>Monday Close:<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_8_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_44'>Tuesday Open:<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_8_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_43'>Tuesday Close:<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_8_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_46'>Wednesday Open:<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_8_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_45'>Wednesday Close:<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_8_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_56'>Thursday Open:<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_8_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_55'>Thursday Close:<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_8_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_54'>Friday Open:<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_8_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_53'>Friday Close:<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_8_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_52'>Saturday Open:<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_8_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_51'>Saturday Close:<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_8_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_57'>Sunday Open:<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_8_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_50'>Sunday Close:<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_8_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_58\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other Information<\/h3><\/div><div id=\"field_8_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_59'>DPOR Shop License #:<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_8_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_60'>DPOR Individual\/Professional License #:<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_8_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_61'>Massage Therapist (Board of Nursing) License #: (Please provide copy of appropriate license)<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_8_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_62\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Refuse Disposal:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_62'><div class='gchoice gchoice_8_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='City'  id='choice_8_62_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_62_1' id='label_8_62_1' class='gform-field-label gform-field-label--type-inline'>City<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='Private Waste Company (health department dumpster permit required)'  id='choice_8_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_62_2' id='label_8_62_2' class='gform-field-label gform-field-label--type-inline'>Private Waste Company (health department dumpster permit required)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_63\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Certification<\/h3><div class='gsection_description' id='gfield_description_8_63'>By signing below, I attest to the accuracy of the information provided. I agree that I will comply with City of Norfolk Code of Ordinances, Chapter 7 (Barbering and Beauty Culture) or Chapter 21 (Health Parlor Ordinance) as required by scope of service offered and will allow the regulatory authority access to the establishment.<\/div><\/div><div id=\"field_8_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_64'>Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_8_64' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_65'>Title<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_8_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_66\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_66'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_66' id='input_8_66' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_67\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_67'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_67' id='input_8_67' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_8_67_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_67_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_67' class='gform_hidden' value='https:\/\/www.vdh.virginia.gov\/content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_68\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Information provided in this application may be subject to disclosure under the Freedom of Information Act (FOIA).<\/h3><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_8' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_8' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_8' id='gform_theme_8' 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