Form CCL.032 "Request for Licensing Amendment" - Kansas

What Is Form CCL.032?

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

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • 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 CCL.032 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

ADVERTISEMENT
ADVERTISEMENT

Download Form CCL.032 "Request for Licensing Amendment" - Kansas

962 times
Rate (4.3 / 5) 58 votes
CCL. 032
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson Street, Suite 200
Topeka, KS 66612-1274
Phone: 785-296-1270 Fax: 785-559-4244
Website: www.kdheks.gov/kidsnet
REQUEST FOR LICENSING AMENDMENT
Instructions: Please complete the form and return it to your local child care surveyor. If this change is requested at a time
other than renewal, a $35 state fee is required for school age programs (make check payable to KDHE or complete credit card
information below). A local fee may also be required. Incomplete requests and requests sent to KDHE without review by the
local child care surveyor will be returned to the facility.
Name of Facility (exactly as stated on the license)
License #
Street Address of Facility
City
Zip Code
County
I am requesting that the current license be amended to:
Change the name of the facility to
_
No change in ownership has occurred.
Change the name of the owner. The name of the owner was changed to:
_
because (i.e. marriage, divorce):
. If the ownership has changed to another entity, do
not use this form. Contact the local child care facility surveyor.
Change the license capacity as follows: A total capacity from _________ (current) to _________ (requested).
Required: List the units to be added, removed, or modified on the license below (attach additional page if necessary). Provide
all required information listed on page 2 of this form. ALLOW A MINIMUM OF 90 DAYS FOR PROCESSING.
Circle One
Room/Unit Name
# of Children
Ages
(match to floor plan)
_EX:
Blue Room________
___10___
____12 months to 2 ½ years_
_________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
Requested effective date (may not be prior to receipt by KDHE). ________________________________ (MM/DD/YYYY)
Signature of Authorized Person
Date Signed
Phone #
Email Address
(
MM/DD/YYYY)
(
)
Credit Card Information - DISCOVER CARD ONLY
Discover Card Account #______________________________________ Expiration Date_________________________
(Please print clearly)
Amount of the license or registration fee $________________________
Signature as it is written on the Card __________________________________________________________________
By my signature, I acknowledge my understanding that a 2.5%
Convenience fee will be included in the final total of this transaction.
CCL. 032
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson Street, Suite 200
Topeka, KS 66612-1274
Phone: 785-296-1270 Fax: 785-559-4244
Website: www.kdheks.gov/kidsnet
REQUEST FOR LICENSING AMENDMENT
Instructions: Please complete the form and return it to your local child care surveyor. If this change is requested at a time
other than renewal, a $35 state fee is required for school age programs (make check payable to KDHE or complete credit card
information below). A local fee may also be required. Incomplete requests and requests sent to KDHE without review by the
local child care surveyor will be returned to the facility.
Name of Facility (exactly as stated on the license)
License #
Street Address of Facility
City
Zip Code
County
I am requesting that the current license be amended to:
Change the name of the facility to
_
No change in ownership has occurred.
Change the name of the owner. The name of the owner was changed to:
_
because (i.e. marriage, divorce):
. If the ownership has changed to another entity, do
not use this form. Contact the local child care facility surveyor.
Change the license capacity as follows: A total capacity from _________ (current) to _________ (requested).
Required: List the units to be added, removed, or modified on the license below (attach additional page if necessary). Provide
all required information listed on page 2 of this form. ALLOW A MINIMUM OF 90 DAYS FOR PROCESSING.
Circle One
Room/Unit Name
# of Children
Ages
(match to floor plan)
_EX:
Blue Room________
___10___
____12 months to 2 ½ years_
_________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
_________________________
________
_____________________________________________________
Add
Remove
Mod
Requested effective date (may not be prior to receipt by KDHE). ________________________________ (MM/DD/YYYY)
Signature of Authorized Person
Date Signed
Phone #
Email Address
(
MM/DD/YYYY)
(
)
Credit Card Information - DISCOVER CARD ONLY
Discover Card Account #______________________________________ Expiration Date_________________________
(Please print clearly)
Amount of the license or registration fee $________________________
Signature as it is written on the Card __________________________________________________________________
By my signature, I acknowledge my understanding that a 2.5%
Convenience fee will be included in the final total of this transaction.
REQUEST TO AMEND LICENSE CAPACITY OR CHANGES IN UNITS FOR CHILD CARE CENTERS, PRESCHOOLS,
HEAD START CENTERS, OR SCHOOL AGE PROGRAMS
Facilities must continue operation under the
A MINIMUM OF 90 DAYS IS REQUIRED TO PROCESS AN AMENDED LICENSE.
current license until an amended license is received.
Qualified Program Director. Submit a KDHE Program Director Approval letter if available. If not available, complete and
return a Program Director's Application. The Program Director must be qualified for the change in license capacity requested.
PHYSICAL PLANT: If increasing license capacity or adding/changing units, the following must be submitted:
1.
Floor plan.
a) Specify the linear dimensions for each unit or room to be used by children or youth, and mark the exits
from each unit or room to be used for children’s or youth’s activities.
b) Include a drawing showing how the units or rooms fit into the overall floor plan of the building (all levels).
c) Child Care Centers, Preschools and Head Start Programs must identify the age groups to be served in
each of the units. School Age Programs must identify the interest areas or use of rooms.
d) Indicate the location and total number of toilets, changing tables (if applicable), and hand sinks available to
the children or youth, the source of drinking water, and indicate how restrooms and drinking water are
accessed by the children or youth.
e) Mark all of the exits to the outside.
f)
Indicate on the floor plan which direction is north.
2.
Outdoor play area. (Outdoor play area is not required for preschools or school age programs unless the
programs include outdoor play as part of its program of activities. ) OUTDOOR PLAY AREAS MAY NOT BE
SHARED WITH ANOTHER FACILITY. Outdoor play space must be on the premises.
a)
Specify the location and linear dimensions of the fenced outdoor play area, and include the height of the
fence. (Fencing may not be required for School Age Programs unless hazards exist.)
b) Show the route children or youth will take from their units to enter the playground.
c) Indicate the location of drinking water and restrooms, and how they will be accessed by the children or youth.
d) Mark the location of any stationary play equipment (swings, climbers, slides, etc.), and indicate the distance
between each piece of equipment.
e) Specify the type of impact-absorbing material under and around the equipment, and the outdoor surface
material on the remaining playground.
3.
Fire safety acceptance from the State Fire Marshal. Fire approval is required for requests to increase license
capacity or change the age of children or youth to be served on the license or in a unit or room to be used. Contact
the State Fire Marshal’s Office at 785-296-3401 for requirements to amend the license. A license cannot be amended
until acceptance by the State Fire Marshal is received.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
MUST BE COMPLETED BY THE LOCAL CHILD CARE FACILITY SURVEYOR:
Child Care Facility Surveyor Recommendation:
_____
Approve: Meets compliance or does not cause facility to be noncompliant if change to license is made.
_
Disapprove: Does not meet compliance for the following reason: __________________________________________________
If the amendment request is to change license capacity or change units in center-based facilities, please complete the following:
On-site compliance check was conducted on
. Notice of Survey Findings is attached.
(MM/DD/YYYY)
Answer each of the following questions Yes, No or NA:
_____
Attached floor plan was verified during an on-site visit. Measurements are correct for the indoor and outdoor areas. The floor
plan accurately reflects the layout of the child care facility including location of bathrooms, number of toilets, hand sinks,
changing tables (if applicable), location of exits, and outdoor play area.
_____
If an increase in capacity, the indoor and outdoor play spaces contain adequate square footage and are in compliance with
regulations for the ages of children requested.
_____
If an increase in capacity, change(s) in the ages of children served (younger) or change(s) in location of the units (new space),
State Fire Marshal Acceptance is attached.
_____
The Program Director is qualified for the requested license capacity and age ranges of children served in the facility.
Signature of Surveyor
Date (MM/DD/YYYY)
County
Page of 2