Form OCC1200 "Child Care Center Application for License" - Maryland

What Is Form OCC1200?

This is a legal form that was released by the Maryland State Department of Education - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2015;
  • The latest edition provided by the Maryland State Department of Education;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form OCC1200 by clicking the link below or browse more documents and templates provided by the Maryland State Department of Education.

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Download Form OCC1200 "Child Care Center Application for License" - Maryland

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MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
CHILD CARE FACILITY
APPLICATION FOR LICENSE/LETTER OF COMPLIANCE
This form may be used to apply for a Child Care Center License or a Letter of Compliance.
Please type or print.
Submit to the Regional Office of Child Care (OCC) that regulates child care in the county where the facility will be located.
License
Letter of Compliance
The operator is applying for a (check only one):
Which of the following designations describes the status of the Operator? (check ALL that apply)
Private Non-Profit
An organization incorporated under Maryland tax law as a non-profit corporation.*
Submit letter of tax-exempt status. Tax-exempt #: __________________________
Submit copy of Articles of Incorporation.
Proprietary
An individual or partnership.*
An unincorporated private for-profit organization.
A private for-profit corporation.*
If incorporated, submit copy of Articles of Incorporation.
Public
An agency entirely funded by federal, state, county, municipal funds, or any
combination of public funds. If incorporated, submit copy of Articles of Incorporation.
Religious Organization
The Operator named above is a tax-exempt religious organization. Submit copy of IRS
Letter of Determination stating tax-exempt status.
Exempt School
There is also on the premises a school operated by a tax-exempt religious
organization that is exempt from approval under Article 2-206(e)(4), Annotated
Code of Maryland for levels/grades __________. Submit MSDE Letter of Exemption.
Approved School
The Operator named above also conducts a non-public school approved by the
Maryland State Department of Education for levels/grades ____________________.
Submit MSDE Certificate of Approval.
Montessori School
The Operator named above also conducts a nonpublic school certified by a Montessori
Validating organization. Submit Certificate of Validation
* Complete attached list of corporate or partnership members on Page 4.
Name of Facility:
Telephone #:
Address:
e-mail Address:
City/County:
State:
Zip Code:
Name of Person, Organization, Corporation, or Representative to be named as the operator responsible for the total operation of the facility and responsible for
compliance with all regulations:
Name:
Tax ID /EIN / or SSN #: (as applicable)
Address of Operator:
Telephone #:
(If different from facility’s)
e-mail:
Name of Representative who will serve as agent for operator:
Telephone #:
e-mail:
Mailing Address:
(If different from facility’s)
PROPOSED OPENING DATE ________________________________________________________________________
Page 1 of 4
OCC 1200 - Revised 3/15 - All previous editions obsolete.
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
CHILD CARE FACILITY
APPLICATION FOR LICENSE/LETTER OF COMPLIANCE
This form may be used to apply for a Child Care Center License or a Letter of Compliance.
Please type or print.
Submit to the Regional Office of Child Care (OCC) that regulates child care in the county where the facility will be located.
License
Letter of Compliance
The operator is applying for a (check only one):
Which of the following designations describes the status of the Operator? (check ALL that apply)
Private Non-Profit
An organization incorporated under Maryland tax law as a non-profit corporation.*
Submit letter of tax-exempt status. Tax-exempt #: __________________________
Submit copy of Articles of Incorporation.
Proprietary
An individual or partnership.*
An unincorporated private for-profit organization.
A private for-profit corporation.*
If incorporated, submit copy of Articles of Incorporation.
Public
An agency entirely funded by federal, state, county, municipal funds, or any
combination of public funds. If incorporated, submit copy of Articles of Incorporation.
Religious Organization
The Operator named above is a tax-exempt religious organization. Submit copy of IRS
Letter of Determination stating tax-exempt status.
Exempt School
There is also on the premises a school operated by a tax-exempt religious
organization that is exempt from approval under Article 2-206(e)(4), Annotated
Code of Maryland for levels/grades __________. Submit MSDE Letter of Exemption.
Approved School
The Operator named above also conducts a non-public school approved by the
Maryland State Department of Education for levels/grades ____________________.
Submit MSDE Certificate of Approval.
Montessori School
The Operator named above also conducts a nonpublic school certified by a Montessori
Validating organization. Submit Certificate of Validation
* Complete attached list of corporate or partnership members on Page 4.
Name of Facility:
Telephone #:
Address:
e-mail Address:
City/County:
State:
Zip Code:
Name of Person, Organization, Corporation, or Representative to be named as the operator responsible for the total operation of the facility and responsible for
compliance with all regulations:
Name:
Tax ID /EIN / or SSN #: (as applicable)
Address of Operator:
Telephone #:
(If different from facility’s)
e-mail:
Name of Representative who will serve as agent for operator:
Telephone #:
e-mail:
Mailing Address:
(If different from facility’s)
PROPOSED OPENING DATE ________________________________________________________________________
Page 1 of 4
OCC 1200 - Revised 3/15 - All previous editions obsolete.
I request that this application be evaluated in order that the facility named above may be licensed to provide services as follows:
Specify Days of Operation
Specify Hours of Operation
Specify Months of Operation
Type of Care:
(Check ALL that apply)
INFANT (6 weeks through 17 months old)
SPECIAL CARE FACILITY (Acutely Ill Children)
TODDLER (18 through 23 months old)
NURSERY SCHOOL (Religious Exempt)
PRESCHOOL (2 through 5 years old)
NURSERY SCHOOL INSTRUCTIONAL PROGRAM
SCHOOL-AGE (Grades K - Middle School)
ADOLESCENT (Middle/Junior High School)
DROP-IN (exclusively)
PROPOSED CAPACITY
Capacity is established by the OCC regional office based on available space, staff, equipment, and sanitary facilities. The capacity at
opening may be set lower than what the building can accommodate, but the capacity may be increased as staff and equipment are
added. It is important to have the building approved by the local jurisdiction for the maximum number of children.
Total planned capacity: ________________________________
Proposed capacity at opening: _________________________
PROPOSED BUILDING
1.
Will the facility be housed in an existing building?
YES
NO
If YES, describe the building’s previous and/or current use: ________________________________________________________
Date of construction (if existing building): _____________________________________________________________________
2.
Is the building now or will it become a multi-use building?
YES
NO
If YES, describe all other uses: ______________________________________________________________________________
________________________________________________________________________________________________________
3.
Type of construction:
Brick/Masonry
Reinforced Concrete
Structural Steel
Wood Frame
4. Type of Heating System:
Electric
Boiler (inspection report required)
Natural Gas
Heat pump
Oil
Other (specify) ___________________________
5.
Type of Heating Source:
Forced Air
Radiators
Other (specify)________________________________________________________
6. Type of water supply:
Public
Private
7. Type of sewage disposal:
Public
Private
8.
If existing building, will any alterations or additions be made to the building’s structure?
YES
NO
If YES, describe: __________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Page 2 of 4
OCC 1200 - Revised 3/15 - All previous editions obsolete.
PROPOSED BUILDING: (Continued)
9. List all permits that will be obtained from local jurisdiction (building, alteration, plumbing, etc.): __________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
10. Is there a swimming pool on the premises?
YES
NO
If YES, describe: __________________________________________________________________________________________
________________________________________________________________________________________________________
Has this pool been inspected by the local jurisdiction?
YES
NO
Is the pool to be used by children in care at the facility?
YES
NO
PROPOSED FOOD SERVICE
1. Type of Food Service:
Carried Lunch
Catered
Lunch prepared at Facility
Snacks prepared at Facility
Other, explain: ________________________________________________________
2. If a kitchen currently exists, describe existing equipment and fixtures: ________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
I hereby verify that all information provided on this application and in all accompanying documentation is true and
accurate to the best of my knowledge and belief. I understand that reporting false information may be grounds for denial
or revocation of a license or letter of compliance.
______________________________________
_____________________________
_______________
Signature of Operator or Representative
Title
Date
Page 3 of 4
OCC 1200 - Revised 3/15 - All previous editions obsolete.
COMAR 13A.16.02 and 13A.17.02 require that a signed and notarized Release of Information (OCC 1260), giving permission to examine records of child and adult abuse and
neglect, be submitted for: the applicant/Operator (if the applicant/Operator is an individual), each adult living on the same premises as the child care facility, and trustees, managers, or
board members of corporations, agencies, associations, or other organizational entities who have frequent contact with children in care.
Is the applicant an individual?  YES  NO
OPTIONAL: If YES, what is the race/ethnicity of the applicant (check all that apply)?
 American Indian or Alaskan Native  Asian  Black or African American  Native Hawaiian or Pacific Islander  White  Other ___________________
 Hispanic  Latino
 Non-Hispanic  Non-Latino
Please list all persons, 18 years old or older, who live on the same premises as the child care facility:
FULL NAME
AGE
FULL NAME
AGE
Is the applicant an entity having corporate or partnership members?  YES  NO
If YES, please list the corporate or partnership members below:
FULL NAME OF
FREQUENT CONTACT
CORPORATE OR
TITLE
ADDRESS
WITH CHILDREN
PARTNERSHIP MEMBER
IN CARE?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
________________________________________________________________________________________
__________________________________________________
Signature and Title of Operator or Representative
Date
OCC 1200 - Revised 3/15 - All previous editions obsolete.
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