Form Lic 200a - Application For A Child Care Center License
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1
2STATE 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:
FOR DEPARTMENT USE ONLY
DISTRICT:
COUNTY:
FACILITY NUMBER:
DATE:
ACTION TYPE:
2.
REQUESTED ACTION (CHECK ONE):
REVIEWED BY:
FACILITY TYPE:
I
I
A. INITIAL APPLICATION
E. CHANGE OF OWNERSHIP
I
I
1.
APPLICANT(S) NAME(S)
(please print)
B. CHANGE OF CAPACITY
F. CHANGE WITHIN CORPORATION
I
I
C. CHANGE OF LOCATION
G. OTHER (E.G., TODDLER OPTION,
I
D. CHANGE OF FACILITY TYPE
COMBINATION CENTER, ETC.)
STATE
ZIP CODE
AREA CODE/TELEPHONE
3.
APPLICANT ADDRESS
CITY
(
)
4.
APPLICATION
A.
INDIVIDUAL
B.
PARTNERSHIP
C.
NON PROFIT CORP.
D.
PROFIT CORP
FILED BY:
E.
COUNTY
F.
OTHER PUBLIC AGENCY
G.
LIMITED LIABILITY COMPANY
5.
FACILITY/AGENCY NAME
EMAIL (NOT REQUIRED)
AREA CODE/TELEPHONE
(
)
6.
FACILITY ADDRESS
CITY
COUNTY
ZIP CODE
ALTERNATIVE PUBLIC TELEPHONE
(
)
7.
MAILING ADDRESS
STATE
ZIP CODE
CITY
8.
PERSON IN CHARGE OF FACILITY
TITLE
9.
TYPE OF FACILITY
10.
REQUESTED
AGE
11. DAYS AND HOURS OF OPERATION:
CAPACITY:
RANGE:
(IF A COMBINATION CENTER IS CHECKED,
ENTER DAYS AND HOURS FOR EACH
I
I
INFANT
_________
_________
COMPONENT.)
A.
INFANT CARE CENTER
D.
CHILD CARE CENTER FOR MILDLY ILL CHILDREN
TODDLER OPTION
_________
_________
I
I
CHECK HERE FOR TODDLER OPTION
PRESCHOOL
_________
_________
E.
COMBINATION
I
SCHOOL-AGE
_________
_________
(CHECK APPROPRIATE BOXES FOR COMBINATION
B.
CHILD CARE CENTER (PRE-SCHOOL)
CENTER)
MILDLY ILL
_________
_________
I
I
CHECK HERE FOR TODDLER OPTION
F.
OTHER (SPECIFY)
I
TOTAL CAPACITY
_________
C.
SCHOOL-AGE CENTER
_________
12.
PROPERTY OWNERSHIP:
I
I
I
OWN
RENT
OTHER (SPECIFY) ________________________________________________________________________________________________________________________________
12A.
IF RENTING OR LEASING, NAME, ADDRESS AND PHONE NUMBER OF PROPERTY OWNER,:
IF YES, FACILITY NAME AND NUMBER:
LICENSING AGENCY NAME:
13.
WAS FACILITY PREVIOUSLY LICENSED?
I
I
YES
NO
14.
IS MAJOR CONSTRUCTION REQUIRED?
15.
SOURCE OF WATER FOR HUMAN CONSUMPTION
DATE CONSTRUCTION TO BEGIN: _____________________________________________
I
I
I
I
YES
NO
PUBLIC
PRIVATE
DATE TO BE COMPLETED: ___________________________________________________
16.
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;
A.
B.
C.
D.
E.
F.
17.
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 / W E 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 / W E 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 / W E 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 / W E 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 / W E SHALL NOTIFY THE LICENSING AGENCY IMMEDIATELY IF A PERSON SUBJECT TO FINGERPRINTING REQUIREMENT, IS CONVICTED OF A CRIME AFTER EMPLOYMENT.
F.
I / W E SHALL OBTAIN APPROVAL FROM THE LICENSING AGENCY PRIOR TO MAKING ANY CHANGE(S) THAT AFFECT THE TERMS OF THE LICENSE.
18.
I / W E UNDERSTAND THAT I / W E HAVE THE RIGHT TO APPEAL ANY DECISION REGARDING THE DISPOSITION OF THIS APPLICATION.
19.
I / W E 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.
SIGNED _____________________________________________________
TITLE ________________________________________
COUNTY WHERE SIGNED ______________________________
DATE_________________
SIGNED _____________________________________________________
TITLE ________________________________________
COUNTY WHERE SIGNED ______________________________
DATE_________________
LIC 200A (2/17)
PAGE 1 OF 2
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