Form LIC 200A Application for a Child Care Center License - California

Form LIC200A is a California Department of Social Services form also known as the "Application For A Child Care Center License". The latest edition of the form was released in June 1, 2008 and is available for digital filing.

Download an up-to-date fillable Form LIC200A in PDF-format down below or look it up on the California Department of Social Services Forms website.

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STATE 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:
A. INITIAL APPLICATION
E. CHANGE OF OWNERSHIP
1.
APPLICANT(S) NAME(S)
(please print)
B. CHANGE OF CAPACITY
F. CHANGE WITHIN CORPORATION
C. CHANGE OF LOCATION
G. OTHER (E.G., TODDLER OPTION,
D. CHANGE OF FACILITY TYPE
COMBINATION CENTER, ETC.)
3.
APPLICANT ADDRESS
CITY
STATE
ZIP CODE
AREA CODE/TELEPHONE
(
)
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
EMAIL (NOT REQUIRED)
AREA CODE/TELEPHONE
5.
FACILITY/AGENCY NAME
(
)
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. IF PROVIDING CARE TO NON-AMBULATORY
CAPACITY:
RANGE:
CHILDREN, CHECK HERE:
INFANT
_________
_________
A.
INFANT CARE CENTER
D.
CHILD CARE CENTER FOR MILDLY ILL CHILDREN
TODDLER OPTION
_________
_________
NUMBER OF NON-AMBULATORY ___________
CHECK HERE FOR TODDLER OPTION
PRESCHOOL
_________
_________
E.
COMBINATION
SCHOOL-AGE
_________
_________
(CHECK APPROPRIATE BOXES FOR COMBINATION
B.
CHILD CARE CENTER (PRE-SCHOOL)
12. DAYS AND HOURS OF OPERATION:
CENTER)
(IF A COMBINATION CENTER IS CHECKED, ENTER
MILDLY ILL
_________
_________
DAYS AND HOURS FOR EACH COMPONENT.)
CHECK HERE FOR TODDLER OPTION
F.
OTHER (SPECIFY)
TOTAL CAPACITY
_________
C.
SCHOOL-AGE CENTER
_________
13.
PROPERTY OWNERSHIP:
OWN
RENT
OTHER (SPECIFY) __________________________________________________________________________________
13A.
IF RENTING OR LEASING, NAME, ADDRESS AND PHONE NUMBER OF PROPERTY OWNER,:
IF YES, FACILITY NAME AND NUMBER:
LICENSING AGENCY NAME:
14.
WAS FACILITY PREVIOUSLY LICENSED?
YES
NO
15.
IS MAJOR CONSTRUCTION REQUIRED?
16.
SOURCE OF WATER FOR HUMAN CONSUMPTION
DATE CONSTRUCTION TO BEGIN: _____________________________________________
YES
NO
PUBLIC
PRIVATE
DATE TO BE COMPLETED: ___________________________________________________
17.
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.
APPLICANT(S)/LICENSEE(S) RESPONSIBILITIES:
18.
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.
19.
I / W E UNDERSTAND THAT I / W E HAVE THE RIGHT TO APPEAL ANY DECISION REGARDING THE DISPOSITION OF THIS APPLICATION.
20.
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 (6/08)
PAGE 1 OF 2
STATE 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:
A. INITIAL APPLICATION
E. CHANGE OF OWNERSHIP
1.
APPLICANT(S) NAME(S)
(please print)
B. CHANGE OF CAPACITY
F. CHANGE WITHIN CORPORATION
C. CHANGE OF LOCATION
G. OTHER (E.G., TODDLER OPTION,
D. CHANGE OF FACILITY TYPE
COMBINATION CENTER, ETC.)
3.
APPLICANT ADDRESS
CITY
STATE
ZIP CODE
AREA CODE/TELEPHONE
(
)
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
EMAIL (NOT REQUIRED)
AREA CODE/TELEPHONE
5.
FACILITY/AGENCY NAME
(
)
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. IF PROVIDING CARE TO NON-AMBULATORY
CAPACITY:
RANGE:
CHILDREN, CHECK HERE:
INFANT
_________
_________
A.
INFANT CARE CENTER
D.
CHILD CARE CENTER FOR MILDLY ILL CHILDREN
TODDLER OPTION
_________
_________
NUMBER OF NON-AMBULATORY ___________
CHECK HERE FOR TODDLER OPTION
PRESCHOOL
_________
_________
E.
COMBINATION
SCHOOL-AGE
_________
_________
(CHECK APPROPRIATE BOXES FOR COMBINATION
B.
CHILD CARE CENTER (PRE-SCHOOL)
12. DAYS AND HOURS OF OPERATION:
CENTER)
(IF A COMBINATION CENTER IS CHECKED, ENTER
MILDLY ILL
_________
_________
DAYS AND HOURS FOR EACH COMPONENT.)
CHECK HERE FOR TODDLER OPTION
F.
OTHER (SPECIFY)
TOTAL CAPACITY
_________
C.
SCHOOL-AGE CENTER
_________
13.
PROPERTY OWNERSHIP:
OWN
RENT
OTHER (SPECIFY) __________________________________________________________________________________
13A.
IF RENTING OR LEASING, NAME, ADDRESS AND PHONE NUMBER OF PROPERTY OWNER,:
IF YES, FACILITY NAME AND NUMBER:
LICENSING AGENCY NAME:
14.
WAS FACILITY PREVIOUSLY LICENSED?
YES
NO
15.
IS MAJOR CONSTRUCTION REQUIRED?
16.
SOURCE OF WATER FOR HUMAN CONSUMPTION
DATE CONSTRUCTION TO BEGIN: _____________________________________________
YES
NO
PUBLIC
PRIVATE
DATE TO BE COMPLETED: ___________________________________________________
17.
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.
APPLICANT(S)/LICENSEE(S) RESPONSIBILITIES:
18.
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.
19.
I / W E UNDERSTAND THAT I / W E HAVE THE RIGHT TO APPEAL ANY DECISION REGARDING THE DISPOSITION OF THIS APPLICATION.
20.
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 (6/08)
PAGE 1 OF 2
INSTRUCTIONS FOR APPLICATION FOR A CHILD CARE CENTER LICENSE
Type or print clearly. Prepare application in duplicate. Return original.
1.
Applicant(s): Enter the name(s) of the person(s) or organization legally responsible for the facility. Enter full names.
Individuals enter first, middle and last name. If joint application, all applicants must sign this application. Individuals, each
partner, and chief executive officer or authorized representative of a firm, association, corporation, county, city, public
agency or governmental entity must complete Applicant Information (LIC 215). Corporations and other organizations also
complete Administrative Organization, (LIC 309).
2.
Requested Action: Check appropriate box.
3.
Applicant Address: Enter legal home address of individual(s) and headquarters address of corporations. Major partner
enters principal business address. Other partners enter principal business address on Applicant Information (LIC 215).
Enter area code with telephone number.
4.
Application Filed by: Check appropriate box.
5.
Facility/Agency Name: Enter the name used to designate the single facility under application. If an agency, fill in the name of
the agency which provides the services and hyphenate the single facility name, e.g., YMCA-Peppertree Day Care School.
6.
Facility Address: Enter the address of the physical location of the facility. If applicant has more than one facility, a separate
application must be completed for each facility. Enter area code with telephone number.
7.
Mailing Address: Enter the address where all mail from the department/licensing agency should be sent.
8.
Person in Charge of Facility: Enter the name and title of person who will directly supervise the facility. If not yet employed,
enter “Unknown.”
9.
Type of Facility: Check the appropriate box for type of facility as defined in California Code of Regulations, Title 22.
10. Requested Capacity and Age Range: Enter the total number of children and age range for whom care will be provided at
any time.
11. Check box and enter number of non-ambulatory children for which you are providing care.
12. Days & Hours of Operation: Enter days and hours of operation of facility.
13. Property Ownership: Check the appropriate box.
13A. Control of Property: If applicant(s) is leasing or renting, enter name, address and phone of owner of facility premises.
14. Was Facility Previously Licensed? Check YES or NO. If yes, enter facility name, number and name of agency which issued
license(s).
15. Is Facility to be Constructed or Require Major Building Change? Self-explanatory.
16. Source of Water for Human Consumption: Check PUBLIC or PRIVATE water source.
17. Other Facilities: Enter the facility name and number of any other community care or health facilities owned or operated by
applicant(s).
18. Statement of applicant(s)/licensee(s) responsibilities of compliance with all applicable laws and regulations.
19. Acknowledgement of right to appeal.
20. Signatures of all applicants or authorized person(s) (e.g., general partners of a partnership and executive officer or duly
authorized representative for all corporations, public agencies, etc.).
LIC 200A (6/08)
PAGE 2 OF 2

Download Form LIC 200A Application for a Child Care Center License - California

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