Form CCL.201 "Application for a Licensed Day Care Home or Licensed Group Day Care Home" - Kansas

What Is Form CCL.201?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on May 1, 2019;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Available in Spanish;
  • 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.201 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL.201 "Application for a Licensed Day Care Home or Licensed Group Day Care Home" - Kansas

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Kansas Department of Health and Environment
CCL. 201
Bureau of Family Health
Rev. 5/2019
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone (785) 296-1270 Fax (785) 559-4244
Website: www.kdheks.gov/kidsnet
APPLICATION FOR A
LICENSED DAY CARE HOME OR LICENSED GROUP DAY CARE HOME
Good beginnings last a lifetime. The service you offer to children and youth is important to the community and will have a lasting
impact on the children and youth in your program. Kansas child care laws and regulations are designed to reduce the predictable risk
of harm to children and youth. By completing and submitting this application you are: 1) requesting a license to operate a child care
facility; and 2) affirming that you have read and agree to comply with all laws and regulations for a licensed day care home or licensed
group day care home.
=====================================================================================================
SECTION I: INTENT OF THE APPLICANT/OWNER. COMPLETE ONE OF THE THREE BOXES BELOW.
RENEWAL APPLICATION (with no changes)
______ This application is notification to renew our existing license for another year.
NEW APPLICATION / MOVE / PROGRAM CHANGE / OWNERSHIP CHANGE
* An Orientation Date is required to process a New, Move, Program Change or Change of Ownership application
If you have not attended an orientation session, STOP and contact the local child care licensing surveyor for your county
at
http://www.kdheks.gov/bcclr/download/county_contacts.pdf
before continuing with your application.
*Orientation Date (MM/DD/YYYY)
______/______/______
(Date you attended an orientation session with your local child care licensing surveyor)
Type of Application
Select one Program Type
What is your Anticipated Date to Open
______ New application (New Facility)
______ Licensed Day Care Home
______ Moving to a new location
_____________________ (MM/DD/YYYY)
______ Group Day Care Home
______ Changing Program Type
______ Changing Ownership
NOTIFICATION OF CLOSURE (DO NOT SEND UNTIL YOU ARE CLOSED)
______ This is a notification that I/we no longer provide child care services.
Close the child care facility license effective: _____________________ (MM/DD/YYYY). Please complete Sections II and VI.
=====================================================================================================
SECTION II: FACILITY INFORMATION. COMPLETE ALL INFORMATION REQUESTED. PLEASE PRINT.
License #
Official Name of the Facility to be stated (or as stated) on the license
Name of Facility Contact Person
Physical Address of the Facility: Street Address
City
Zip Code
County
Email Address
Phone Number
Fax Number
(Used for official KDHE Notification)
(
)
(
)
Kansas Department of Health and Environment
CCL. 201
Bureau of Family Health
Rev. 5/2019
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone (785) 296-1270 Fax (785) 559-4244
Website: www.kdheks.gov/kidsnet
APPLICATION FOR A
LICENSED DAY CARE HOME OR LICENSED GROUP DAY CARE HOME
Good beginnings last a lifetime. The service you offer to children and youth is important to the community and will have a lasting
impact on the children and youth in your program. Kansas child care laws and regulations are designed to reduce the predictable risk
of harm to children and youth. By completing and submitting this application you are: 1) requesting a license to operate a child care
facility; and 2) affirming that you have read and agree to comply with all laws and regulations for a licensed day care home or licensed
group day care home.
=====================================================================================================
SECTION I: INTENT OF THE APPLICANT/OWNER. COMPLETE ONE OF THE THREE BOXES BELOW.
RENEWAL APPLICATION (with no changes)
______ This application is notification to renew our existing license for another year.
NEW APPLICATION / MOVE / PROGRAM CHANGE / OWNERSHIP CHANGE
* An Orientation Date is required to process a New, Move, Program Change or Change of Ownership application
If you have not attended an orientation session, STOP and contact the local child care licensing surveyor for your county
at
http://www.kdheks.gov/bcclr/download/county_contacts.pdf
before continuing with your application.
*Orientation Date (MM/DD/YYYY)
______/______/______
(Date you attended an orientation session with your local child care licensing surveyor)
Type of Application
Select one Program Type
What is your Anticipated Date to Open
______ New application (New Facility)
______ Licensed Day Care Home
______ Moving to a new location
_____________________ (MM/DD/YYYY)
______ Group Day Care Home
______ Changing Program Type
______ Changing Ownership
NOTIFICATION OF CLOSURE (DO NOT SEND UNTIL YOU ARE CLOSED)
______ This is a notification that I/we no longer provide child care services.
Close the child care facility license effective: _____________________ (MM/DD/YYYY). Please complete Sections II and VI.
=====================================================================================================
SECTION II: FACILITY INFORMATION. COMPLETE ALL INFORMATION REQUESTED. PLEASE PRINT.
License #
Official Name of the Facility to be stated (or as stated) on the license
Name of Facility Contact Person
Physical Address of the Facility: Street Address
City
Zip Code
County
Email Address
Phone Number
Fax Number
(Used for official KDHE Notification)
(
)
(
)
SECTION II: FACILITY INFORMATION. (Continued)
Show Facility Physical Address and Telephone Number on the Public Website?  Yes  No
Is the physical address a non-residential or commercial location?  Yes  No
Year Facility Built
If yes, additional information is required. See instructions.
Mailing Address of the Facility: Street Address
City
Zip Code
Public Water  Yes  No
Public Sewer  Yes  No
Fire Safety: I/We have read, completed, and signed the Kansas State Fire Marshal’s Office Fire/Life Safety Agreement (FLSA). It will
remain posted by the license at all times (see instructions).
(LEAVE DATE BLANK IF NO INSPECTION WAS CONDUCTED)
The facility was inspected for fire safety by a state/local fire official on _________________________________ (MM/DD/YYYY)
======================================================================================================
SECTION III: LEGAL OWNER/OPERATOR INFORMATION. COMPLETE ALL INFORMATION REQUESTED. PLEASE PRINT.
st
Name of 1
Legal Owner/Operator
Physical Address of the Owner/Operator: Street Address
City
State
Zip Code
County
Email Address
Phone Number
Fax Number
(Used for official KDHE Notification)
(
)
(
)
Mailing Address of the Owner/Operator (if different): Street Address
City
State
Zip Code
nd
Name of 2
Legal Owner/Operator
Physical Address of the Owner/Operator: Street Address
City
State
Zip Code
Phone Number
Fax Number
Email Address
County
(Used for official KDHE Notification)
(
)
(
)
Mailing Address of the Owner/Operator (if different): Street Address
City
State
Zip Code
Type of Ownership. The Legal Owner/Operator is a (check ONE of the following):
Individual or individuals that is/are not incorporated
(*Question below is required to be answered)
 Yes  No
*Is each individual applicant a high school graduate or the equivalent (GED)
Corporation, LLC, LLP
Federal Employer ID No. (FEIN) ______________________
Business Entity ID No. (BEIN) _________________
Government entity/agency or school district
Federal Employer ID No. (FEIN) ______________________
Business Entity ID No. (BEIN) _________________
==================================================================================================
SECTION IV: FACILITY OPERATION INFORMATION. COMPLETE ALL INFORMATION REQUESTED. PLEASE PRINT.
Indicate the months of the year, hours and days of the week you will be providing services to children and youth (check only
one option for each schedule you complete):
_____ All Year (Jan through Dec)
_____ Summer Only (May through Aug)
_____ School Year Only (Sept through May)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
_____ All Year (Jan through Dec)
_____ Summer Only (May through Aug)
_____ School Year Only (Sept through May)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Do you have a Provider Agreement with Department for Children and Families (DCF)?  Yes  No
If you would like more information about becoming a DCF Provider, please call 1-888-369-4777.
SECTION V: ADDITIONAL INFORMATION FOR NEW APPLICANTS ONLY. COMPLETE ALL INFORMATION. PLEASE PRINT.
I/we had a child care license/certificate in the past.  Yes  No If yes, complete the following:
Name on the previous license or certificate ___________________________________________________________________
License/Certificate Number ____________________________ Year(s) of operation __________________________________
Address on the previous license or certificate _________________________________________________________________
=====================================================================================================
SECTION VI: AGREEMENTS AND AUTHORIZED SIGNATURE. READ EACH STATEMENT AND SIGN THE APPLICATION.
I/We the undersigned, am [are the person(s)] named as the Applicant or the person(s) authorized to represent the owner listed above.
I/We have read the laws and regulations governing the operation of this licensed facility and it is the intention of this applicant to
comply. I/We understand that I/we are responsible for meeting and maintaining compliance with all applicable child care licensing
laws and regulations at all times.
I/We understand that a new application may take up to 90 days for processing by the Kansas Department of Health and
Environment (KDHE), once KDHE receives a complete application. I/We understand that I/we are not authorized to provide services
to children and youth prior to receiving a Temporary Permit or License from KDHE.
In accordance with K.S.A. 44-1009, I/we shall not exclude any child from care for reason of race, religion, color, sex, physical
handicap, national origin, or ancestry.
I/We attest, under penalty of perjury, that to the best of my/(our) knowledge, that the information provided in this application is true and
correct.
Authorized Signature:
Date (MM/DD/YYYY)
Authorized Signature (if more than one applicant):
Date (MM/DD/YYYY)
FEE: IF PAYING THE LICENSE FEE BY DEBIT OR CREDIT CARD, PLEASE COMPLETE THE FOLLOWING INFORMATION:
Debit or Credit Card Information – VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS
Card Account #: ________________________________________________________ Expiration Date: ______________________
(Please print clearly)
Amount of the license fee (see instructions): __________________
Print your name as it appears on the front of the card: ______________________________________________________________
Signature as it is written on the Card: ___________________________________________________________________________
By signing your name, you authorize KDHE to charge your card for the amount listed above.
Kansas Department of Health and Environment contracts with local health departments or private contractors for local regulatory
services. Please contact your local child care licensing surveyor to determine if additional fees are required.
Some local ordinances may apply to your child care facility in addition to the state laws and regulations. Please contact your local
child care licensing surveyor to determine if there are local ordinances which may apply to the operation of a licensed day care home
or group day care home.
For information about requirements of the Americans with Disabilities Act (ADA), contact: Great Plains Disability and Business
Technical Assistance Center, University of Missouri at Columbia, 100 Corporate Lake Drive, Columbia, MO 65203,
Phone: 1-800-949-4232.
===================================================================================================
SECTION VII: MAILING INSTRUCTIONS. Return the completed and signed application along with the documents listed in
one of the three boxes below, as applicable. Follow the mailing instructions provided.
NEW APPLICATION / MOVE / PROGRAM CHANGE/ OWNERSHIP CHANGE
Return the following:
1.
Completed and signed application. * YOUR DATE OF ORIENTATION IS REQUIRED ON THE APPLICATION *
2.
Completed CCL 002 (revised 12/2018) Background and Registry Checks for Child Care Facilities form.
**Effective 12/1/2018** - Form CCL 002a LDCH-GDCH must be used to determine appropriate role for each affiliate.
License Fee: Debit or credit card, check, cashier’s check or money order for $85 for LDCH OR $87 for GDCH. If
3.
paying by check, cashier’s check or money order make payable to KDHE. If paying by debit or credit card,
complete credit card information. The license fee is not refundable.
SEND THE ABOVE TO: KDHE, Child Care Licensing Program, 1000 SW Jackson, Suite 200, Topeka, KS 66612-1274.
RENEWAL APPLICATION
Return the following:
1.
Completed and signed application.
2.
Completed CCL 002 (revised 12/2018) Background and Registry Checks for Child Care Facilities form.
**Effective 12/1/2018** - Form CCL 002a LDCH-GDCH must be used to determine appropriate role for each affiliate.
License Fee: Debit or credit card, check, cashier’s check or money order for $85 for LDCH OR $87 for GDCH. If
3.
paying by check, cashier’s check or money order make payable to KDHE. If paying by debit or credit card, complete
credit card information. The license fee is not refundable.
SEND THE ABOVE TO: KDHE, Child Care Licensing Program, 1000 SW Jackson, Suite 200, Topeka, KS 66612-1274.
NOTIFICATION OF CLOSURE
* DO NOT SEND UNTIL YOU ARE CLOSED – You are required to post your current license until you are officially closed. *
Return the following after you have closed:
1.
Completed (Sections I, II, and VI) and signed application.
2.
Your License.
SEND THE ABOVE TO: KDHE, Child Care Licensing Program, 1000 SW Jackson, Suite 200, Topeka, KS 66612-1274.
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