A. B. C.
D. E. F.
FOR DEPARTMENT USE ONLY
10. REQUESTED AGE
CAPACITY: RANGE:
INFANT _________ _________
TODDLER OPTION _________ _________
PRESCHOOL _________ _________
SCHOOL-AGE _________ _________
MILDLY ILL _________ _________
TOTAL CAPACITY _________
_________
DISTRICT:
COUNTY: FACILITY NUMBER:
DATE: ACTION TYPE:
REVIEWED BY: FACILITY TYPE:
B. PARTNERSHIP
F. OTHER PUBLIC AGENCY
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR A CHILD CARE CENTER LICENSE
(See Instructions on Back)
REPLY TO:
1. APPLICANT(S) NAME(S) (please print)
3. APPLICANT ADDRESS CITY
CITY
CITY
8. PERSON IN CHARGE OF FACILITY
12. DAYS AND HOURS OF OPERATION:
(IF A COMBINATION CENTER IS CHECKED, ENTER
DAYS AND HOURS FOR EACH COMPONENT.)
■ A. INFANT CARE CENTER
■ CHECK HERE FOR TODDLER OPTION
■ B. CHILD CARE CENTER (PRE-SCHOOL)
■ CHECK HERE FOR TODDLER OPTION
■ C. SCHOOL-AGE CENTER
■ D. CHILD CARE CENTER FOR MILDLY ILL CHILDREN
■ E. COMBINATION
(CHECK APPROPRIATE BOXES FOR COMBINATION
CENTER)
■ F. OTHER (SPECIFY)
9. TYPE OF FACILITY 11. IF PROVIDING CARE TO NON-AMBULATORY
CHILDREN, CHECK HERE:
NUMBER OF NON-AMBULATORY ___________
TITLE
STATE
ZIP CODE
STATE ZIP CODE
COUNTY
ZIP CODE
AREA CODE/TELEPHONE
( )
AREA CODE/TELEPHONE
( )
EMAIL (NOT REQUIRED)
ALTERNATIVE PUBLIC TELEPHONE
( )
4.
APPLICATION
FILED BY:
6. FACILITY ADDRESS
5. FACILITY/AGENCY NAME
13A. IF RENTING OR LEASING, NAME, ADDRESS AND PHONE NUMBER OF PROPERTY OWNER,:
15. IS MAJOR CONSTRUCTION REQUIRED?
DATE CONSTRUCTION TO BEGIN: _____________________________________________
DATE TO BE COMPLETED: ___________________________________________________
14. WAS FACILITY PREVIOUSLY LICENSED?
17. NAME AND FACILITY NUMBER OF OTHER COMMUNITY CARE, CHILD CARE, RESIDENTIAL CARE FACILITIES FOR THE ELDERLY, OR HEALTH FACILITIES LICENSED TO OR OWNED BY APPLICANT(S) WITHIN THE
LAST FIVE YEARS;
IF YES, FACILITY NAME AND NUMBER: LICENSING AGENCY NAME:
LIC 200A (6/08)
PAGE 1 OF 2
16. SOURCE OF WATER FOR HUMAN CONSUMPTION
■ PUBLIC ■ PRIVATE
■ YES ■ NO
■ YES ■ NO
13. PROPERTY OWNERSHIP:
■ OWN ■ RENT ■ OTHER (SPECIFY) __________________________________________________________________________________
7. MAILING ADDRESS
2. REQUESTED ACTION
(CHECK ONE):
■ A. INITIAL APPLICATION ■ E. CHANGE OF OWNERSHIP
■ B. CHANGE OF CAPACITY ■ F. CHANGE WITHIN CORPORATION
■ C. CHANGE OF LOCATION ■ G. OTHER (E.G., TODDLER OPTION,
■ D. CHANGE OF FACILITY TYPE COMBINATION CENTER, ETC.)
A. INDIVIDUAL
E. COUNTY
C. NON PROFIT CORP.
G. LIMITED LIABILITY COMPANY
D. PROFIT CORP
SIGNED _____________________________________________________ TITLE________________________________________ COUNTY WHERE SIGNED ______________________________ DATE_________________
SIGNED _____________________________________________________ TITLE________________________________________ COUNTY WHERE SIGNED ______________________________ DATE_________________
18.
APPLICANT(S)/LICENSEE(S) RESPONSIBILITIES:
A. IN ADDITION TO COMPLYING WITH THE HEALTH AND SAFETY CODE AND REGULATIONS APPLICABLE TO LICENSING AND FIRE SAFETY, I/WE UNDERSTAND THAT THERE MAY BE OTHER
STATE, FEDERAL AND/OR LOCAL LAWS WHICH ARE NOT ENFORCED BY THIS AGENCY BUT THAT MAY NEED TO BE MET, SUCH AS ZONING, BUILDING, SANITATION AND LABOR
REQUIREMENTS.
B. I/WE HAVE READ AND UNDERSTAND THE STATUTES AND REGULATIONS THAT PERTAIN TO MY/OUR LICENSING CATEGORY PRIOR TO THE ISSUANCE OF MY/OUR LICENSE.
C. I/WE SHALL ENSURE THAT ALL PERSONS SUBJECT TO FINGERPRINT REQUIREMENTS SHALL HAVE A DEPARTMENT OF JUSTICE CLEARANCE OR A CRIMINAL RECORD EXEMPTION
PRIOR TO EMPLOYMENT, RESIDENCE OR INITIAL PRESENCE IN THE FACILITY AS REQUIRED.
D. I/WE SHALL ENSURE THAT ALL PERSONS SUBJECT TO FINGERPRINT REQUIREMENTS SHALL ALSO SUBMIT A CHILD ABUSE INDEX CHECK FORM TO THE DEPARTMENT OF JUSTICE.
E. I/WE SHALL NOTIFY THE LICENSING AGENCY IMMEDIATELY IF A PERSON SUBJECT TO FINGERPRINTING REQUIREMENT, IS CONVICTED OF A CRIME AFTER EMPLOYMENT.
F. I/WE SHALL OBTAIN APPROVAL FROM THE LICENSING AGENCY PRIOR TO MAKING ANY CHANGE(S) THAT AFFECT THE TERMS OF THE LICENSE.
19. I/WE UNDERSTAND THAT I/WE HAVE THE RIGHT TO APPEAL ANY DECISION REGARDING THE DISPOSITION OF THIS APPLICATION.
20. I/WE DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS APPLICATION AND ON THE ACCOMPANYING ATTACHMENTS ARE CORRECT TO THE BEST OF MY/OUR
KNOWLEDGE.
■
