Fillable Family Systems Licensing Application (Minnesota Department of Revenue)

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Family Systems Licensing Application (Minnesota Department of Revenue)

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2/24/2014 1
Family Systems Licensing Application
Minnesota Statutes, Chapter 245A (Human Services Licensing Act)
FAMILY Child Care (FCC)
Minnesota Department of Human Services
Licensing Division
Office of Inspector General
Date of Application: _________________________________________________________
Please type or neatly print using black or blue ink. If you do not currently have a license from DHS, you must
complete all items on the license application.
1. License Type:
Individual - the site where services are provided is your primary residence.
Individual - the applicant is the primary provider of care and the site where services are provided is not your
primary residence.
Individual – the applicant is the primary provider of care and the site where the services are provided is
located in a commercial space. (Required documentation for Family Child Care provided in a Commercial Space must include a
narrative description of the program, a copy of the compliance with local zoning regulations, AND a copy of the completed Fire Code
Inspection designating what type of inspection was completed (Group E. or Group I-4), and of compliance with all Fire Marshal inspection
orders.) This information must be provided at initial application only.
Check One: New Application Renewal Update Change of Premise
2. License History: Are you currently or have you ever been licensed? YES (complete below) NO
Type of License (check all that apply)
Family Child Care Child Foster Care Adult Foster Care Family Adult Day Services Other___________
License Number
County/ Agency/ State
Effective Dates of License
2.1 Have you ever had a DHS license denied or revoked? Yes No
If yes, list the date of denial or revocation and license type or the license number(s)
DATE OF LICENSE DENIAL
LICENSE TYPE FOR DENIED LICENSE
DATE OF LICENSE REVOCATION
LICENSE TYPE & NUMBER FOR REVOKED LICENSE
** For additional denials or revocations, please attach additional pages
3. License holder information
3.1 License holder name(s)/Controlling Individual(s)/Authorized Agent(s)
The license holder is the business entity that is responsible for the license. An “individual” license holder is generally
a sole owner or sole proprietorship where the business is owned and run by one individual and in which there is no
legal distinction between the owner and the business. This means you have not formed a corporation (e.g., business,
for profit, nonprofit, limited liability corporation) and have not organized as a partnership, association, other
organization and are not a government entity. You may have registered with the Minnesota Secretary of State’s office
2/24/2014 2
to use an assumed name, and you may have employees, but you are still a sole owner/sole proprietor. Two or more
individuals may be co-applicants or co-license holders if they are not a corporation, partnership, voluntary association,
or other organization or government entity. All individual license holders and applicants are also the controlling
individuals as defined under section 245A.02, subdivision 5a, and authorized agents as required by section 245A.04,
subdivision 1 (b). Attach additional pages if needed.
Full Legal Name of Applicant/Controlling Individual/Authorized Agent
Street Address (and PO Box if required for mail delivery)
Email Address
City
County
State
Zip Code
Full Legal Name of Applicant/Controlling Individual/Authorized Agent
Street Address (and PO Box if required for mail delivery)
Email Address
City
County
State
Zip Code
3.2 Tax identification information (This information is not public):
You are required to provide your tax identification information, including your Federal Employer ID Number (FEIN),
if you have one.
You must provide your Minnesota Tax Identification Number, if you have one. The Minnesota Department of
Revenue requires a business to have a Minnesota Tax ID if it collects sales tax on retail sales in Minnesota; has
employees and collects withholding taxes; or is a corporation doing business in Minnesota and files a tax return with
the Department of Revenue.
For information on registering for a Minnesota Tax ID, go to the Minnesota Department of Revenue website. You
must also provide your FEIN, if you have one. This is a nine-digit number you obtained from the Internal Revenue
Service (IRS) because you have employees or operate your business as a corporation or partnership.
Individual applicants and license holders must also provide their Social Security Number (SSN). If the FEIN and the
SSN are both entered, the FEIN will be used for tax purposes and the SSN will be used for identification purposes
only. Tax identification information is not public, except that under section 270C.72, DHS is required to provide the
Minnesota Department of Revenue the tax identification number and the Social Security Number of each license
applicant. Under the Minnesota Government Data Practices Act, we must advise you that:
i. This information may be used to deny the issuance of a license, or to revoke a license, if you owe the
Minnesota Department of Revenue delinquent taxes, penalties, or interest.
ii. DHS will only provide the tax identification information to the Minnesota Department of Revenue.
However, under the Federal Exchange of Information Act, the Department of Revenue is allowed to
supply this information to the Internal Revenue Service.
2/24/2014 3
MN TAX ID (IF YOU HAVE ONE)
SSN(s) (FOR EACH INDIVIDUAL APPLICANT )
FEDERAL EMPLOYER ID NUMBER (FEIN)
(IF YOU HAVE ONE)
4. Program name and physical location
Please enter the name and physical location of your program. The “Program Name” may be different from the
license holder name.
Program Name
Street Address (and PO Box if required for mail delivery)
Email Address
Telephone Number
City
State
Zip Code
5. Dwelling Information
(check all that apply)
Single Family Home Duplex/Twin home Apartment/Condo Townhome Mobile Home Other
Owned Rented Basement Second Floor Above Second Floor
Attached Garage Wood Burning Stove/Fireplace
6. All Children and Adults/Living and/or Working in the Program
(attach additional pages if needed)
Name (Last, First, MI)
Relationship
Gender
Birth Date
Name (Last, First, MI)
Relationship
Gender
Birth Date
Name (Last, First, MI)
Relationship
Gender
Birth Date
Name (Last, First, MI)
Relationship
Gender
Birth Date
Name (Last, First, MI)
Relationship
Gender
Birth Date
Name (Last, First, MI)
Relationship
Gender
Birth Date
Name (Last, First, MI)
Relationship
Gender
Birth Date
Name (Last, First, MI)
Relationship
Gender
Birth Date
2/24/2014 4
7. References (Required at initial licensure only)
Name (Last, First, MI)
Street Address
Telephone Number
City
State
Zip Code
Name (Last, First, MI)
Street Address
Telephone Number
City
State
Zip Code
Name (Last, First, MI)
Street Address
Telephone Number
City
State
Zip Code
8. Class of License (check one)
Licensed Capacity
Total under Total infants
Maximum
Adult Total Capacity school age and toddlers # of infants
A-Family
1
10
6
3
2
B1-Family (Specialized Infant and Toddler)
1
5
3
3
3
B2-Family (Specialized Infant and Toddler)
1
6
4
4
2
C1- Group Family
1
10
8
3
2
C2- Group Family
1
12
10
2
1
C3- Group Family
2
14
10
4
3
D- Group (Specialized Infant and Toddler)
2
9
7
7
4
2/24/2014 5
9. Hours of Operation
Open from the month of: __________________________ through the month of ___________________________
Daily Hours :
Monday _____________________________ Friday _______________________________
Tuesday _____________________________ Saturday _____________________________
Wednesday __________________________ Sunday ______________________________
Thursday ____________________________
10. Workers compensation insurance verification
You must complete and submit the Certificate of Compliance Minnesota Workers’ Compensation Law MN LIC 04
form with your license application in order for your application to be complete. Under section 176.182 DHS is
prohibited from issuing a license until the applicant presents acceptable evidence of compliance with the worker’s
compensation insurance requirement of Minnesota Statutes, Chapter 176.
Minnesota workers’ compensation law requires all employers to purchase workers’ compensation insurance or
become self-insured. This is often referred to as ”mandatory coverage.” Employers are generally defined as those
who hire another to perform services. Employees are generally defined as people performing services for another,
for hire, including minors and workers who are not citizens. For information on worker’s compensation insurance
requirements go to the Minnesota Department of Labor and Industry website at:
http:www.dli.mn.gov/WorkComp.asp.
11. Applicant acknowledgement of public funding reimbursement for licensed services
Under section 245A.04, subdivision 1, DHS license holders who elect to receive any public funding reimbursement,
including Medical Assistance or Child Care Assistance, for the licensed services, must acknowledge that they will
comply with funding requirements, that compliance with those requirements may be monitored by DHS Licensing,
and that they know the consequences for noncompliance with those requirements. As a DHS license applicant you
must verify whether you intend to receive any public funding by checking the applicable box for item 1 or 2 below. If
you check item 2, you are acknowledging the conditions stated in (a) to (c):
1. I do not elect to receive any public funding reimbursement for the licensed services.
2. I do elect to receive public funding reimbursement for the licensed services and I acknowledge the
following:
a. I must comply with the provider enrollment agreement or registration requirements for receipt of
public funding;
b. My compliance with the provider enrollment agreement or registration requirements for receipt of
public funding may be monitored by DHS Licensing as part of a licensing investigation or licensing
inspection; and
c. That noncompliance with the provider enrollment agreement or registration requirements for receipt of
public funding that is identified through a licensing investigation or licensing inspection, or
noncompliance with a licensing requirement that is a basis of enrollment for reimbursement for a
service, may result in:
(1) a correction order or a conditional license under section 245A.06, or sanctions under section 245A.07;
(2) nonpayment of claims submitted by the license holder for public program reimbursement;
(3) recovery of payments made for the service;
(4) disenrollment in the public payment program; or
(5) other administrative, civil, or criminal penalties as provided by law.
2/24/2014 6
12. Applicant Agreement, Acknowledgement and Verification Form
All Applicant(s)/Controlling Individual(s)/Authorized Agent (s)named above in Section 3, must review
and approve the license application before it is submitted to DHS, and must sign below only in the
presence of a notary public. For more than one applicant, each applicant must complete a separate
signatory page.
*Please note:
• Notarization is required at initial application for new applicants
• Notarization is required at the next relicensing date for existing license holders
• Notarization is only required ONE TIME, and is not needed for subsequent applications at
relicensing
By signing below, I agree that the information that I have provided on this application form is true,
accurate and complete. If the Commissioner of Human Services grants me a license, I agree to comply
with the requirements contained in Minnesota Statutes, chapter 245A and all applicable laws and rules,
at all times during the terms of the license. I acknowledge that the Commissioner’s representative has
the right to request any documentation required by Minnesota Rules or Laws and to inspect the
facility/service at any time during the hours that services are provided. Further, I acknowledge that the
documentation and inspection required by statutes and rules is necessary for the Commissioner to
determine whether I am complying with Minnesota Rules and Laws. Finally, I understand that the
Commissioner may fine, suspend, revoke or make conditional, or deny a license if an applicant or a
license holder fails to comply fully with the applicable laws or rules, or knowingly withholds relevant
information from or gives false or misleading information to the Commissioner in connection with an
application for a license or during an investigation.
In accordance with Minnesota Statutes, section 245A.04, subdivision 1, by signing your name you are
affirming that you are the individual applicant or the authorized agent for the nonindividual applicant,
responsible for dealing with the Commissioner of Human Services on all matters provided for in
Minnesota Statutes, Chapter 245A and on whom service of all notices and orders must be made.
I, ________________________________________________________ (print full legal name), being
sworn, state that I am the authorized agent for the license holder identified above. I understand that, by
signing below, I am responsible for dealing with the commissioner of human services on all matters
provided for in Minnesota Statutes, chapter 245A. I also understand that service of all notices and
orders affecting any license held by the License Holder identified above may be made on me, in
accordance with Minnesota Statutes 2012, section 245A.04, subdivision 1.
_____________________________________________
_
Signature of Authorized Agent
(WAIT- SIGN ONLY IN FRONT OF A NOTARY PUBLIC)
Subscribed and sworn to before me on
this ____ day of __________________ , 20____ ,
________________________________________
Notary Public
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Completed 10 February 2022

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