License Application Addendum
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5Minnesota Department of Human Services
April 2013
Office of Inspector General
Licensing Division
Child Care Center (DHS Rule 3) License Application
License Application Addendum
You must complete and attach this addendum page to the main license application form. Failure to do so will result in an
incomplete application.
1. Type of child care program
Check the applicable boxes for the type service(s) you will provide.
Full-day program
Half-day program
Half-day program with extended care
Drop-in program
Night care program
Sick care program
2. Hours of operation
Identify the days and hours of operation of your program. For half-day programs, list the hours as a.m. and/or p.m.
sessions as applicable.
Monday
From ___________________________
am
pm
To __________________________
am
pm
Tuesday
From ___________________________
am
pm
To __________________________
am
pm
Wednesday
From ___________________________
am
pm
To __________________________
am
pm
Thursday
From ___________________________
am
pm
To __________________________
am
pm
Friday
From ___________________________
am
pm
To __________________________
am
pm
Saturday
From ___________________________
am
pm
To __________________________
am
pm
Sunday
From ___________________________
am
pm
To __________________________
am
pm
3. Months of operation
From _____________________________
To _____________________________
4. Requested license capacity
Infant (six weeks through 15 months):
____________
Toddler (16 months through 32 months):
____________
Preschool (33 months through pre-kindergarten):
____________
School age (kindergarten through 12 years of age):
____________
0
TOTAL:
____________
5. Food service
Check all the applicable boxes indicating what meals or snacks the program will provide.
Breakfast
Morning snack
Lunch
Afternoon snack
Dinner/supper
Evening snack
Check all the applicable boxes indicating where meals or snacks will be prepared or taken.
Food prepared onsite
Food catered
Meals taken at separate location
Bag lunches
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