Request For Temporary And Voluntary Cease Of Operation printable pdf download

REQUEST FOR TEMPORARY AND VOLUNTARY CEASE OF OPERATION

I, _________________________________________________, hereby voluntarily state and declare:

(Licensee Name)

I am the Licensee of _________________________________________________________________,

(Facility Name and Address)

which is licensed as __________________________(License Type) _____________(License Number)

I am requesting Department approval to place my license on Temporary and Voluntary Cease of Operation for the following

reason: _____________________________________________________________________________________

_____________________________________________________________________________________

If approved, I understand and agree to the following conditions during this Cease of Operation:

Temporary and Voluntary Cease of Operation: A Licensee may request to voluntarily cease operation of the child care

program for a period of up to one year. The Licensee must:

Have attained an operating license;

Intend to re-open the child care program at the same location;

Not serve any children during the period of ceased operation;

Not be the subject of an investigation of alleged non-compliance with regulations, or outstanding non-compliance;

and

Pay license fees during the period.

If the Licensee is the subject of any negative or disciplinary action, the period of Ceased Operation does not count toward the

period of Negative or Disciplinary action.

No routine Fire Safety, Sanitation, or Department inspections will be conducted during the period of Ceased Operation.

The period of Ceased Operation may be extended beyond the one-year limit if the Licensee shows a reasonable cause.

Reinstatement: A Licensee may request reinstatement after a period of Ceased Operation by submitting an application at least

30 days before the scheduled re-opening date. The Department will review the application and decide if additional information,

an on-site inspection, or a Fire Safety Inspection is needed to determine compliance with regulations.

Please sign and return this Temporary and Voluntary Cease of Operation Agreement to your Child Care Inspection Specialist.

_________________________________________

____________________________________

Signature of Licensee

Date

Department Approval/Disapproval

Approved

Disapproved (circle one)

_________________________________________

_____________________________________

Signature of Child Care Licensing Supervisor

Date

Effective: 05-20-13

Revised: 04-17-15

Request For Temporary And Voluntary Cease Of Operation