pennsylvania OFFICE OF CHILD DEVELOPMENT AND EARLY LEARNING

Application Purpose: DOpen new child care facility DChange of facility/legal entity information D Renew existing certificate that expires on:

1. LEGAL ENTITY INFORMATION:

1A. Name and Physical Address of Legal Entity 1B. Mailing Address of Legal Entity

NAME: ADDRESS LINE 1:

ADDRESS LINE 1: ADDRESS LINE 2:

ADDRESS LINE 2: ADDRESS LINE 3:

ADDRESS LINE 3: CITY:

CITY: STATE: IZTP CODE: STATE: IZIP CODE: COUNTY: COUNTY:

TELEPHONE:

CELL PHONE#:

EMAIL ADDRESS:

I FAX#: 12. TAX IDENTIFIER:

I Child care centers and group child care homes enter: FEIN: Family child care homes enter: SSN: or FEIN:

Tax type, tax number, and IRS documentation must be provided in order to participate in subsidized child care program or resource and referral, or both.

4. TYPE OF OWNERSHIP/CONTROL:

3. TYPE OF OPERATION

D Profit D Non-profit

D Individual D General Partnership D Association D Corporation D City Government D County Government

D Limited Partnership D School District D State Government

D Limited Liability Partnership D Limited Liability Company D Other Government 00ther

Ownership information below is mandatory when Type of Ownership/Control selected is "Individual" or "General Partnership."

List all the individual name(s):

FIRST NAME:

FIRST NAME:

FIRST NAME:

FIRST NAME:

I FIRST NAME:

MIDDLE NAME: LAST NAME: SUFFIX: DOB (MM/DD/YYYY):

MIDDLE NAME: LAST NAME: SUFFIX: DOB (MM/DD/YYYY):

MIDDLE NAME: LAST NAME: SUFFIX: DOB (MM/DD/YYYY):

MIDDLE NAME: LAST NAME: SUFFIX: DOB (MM/DD/YYYY):

MIDDLE NAME: LAST NAME: SUFFIX: DOB (MM/DD/YYYY):

Office of Child Development and Early Learning

APPLICATION FOR CERTIFICATE OF COMPLIANCE

D Family Child Care Home D Group Child Care Home Dcenter

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5. PRIOR LICENSE STATUS.

Has the Location(s) (item 11), or Legal Entity (item 1), or the person responsible (Operator) (item 12), or the person D Yes D No

signing the application ever been denied a Certificate or license, had a Certificate of Compliance or License revoked.

or had a Certificate of Compliance or License non-renewed in Pennsylvania or any other state? IfYES, explain:

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6. HAS THE LEGAL ENTITY, OWNER, OR OPERATOR:

Ever been convicted of a felony or convicted of a crime 1nvolving child abuse, child neglect, moral turpitude, or D Yes D No physical violence; Named a perpetrator in an indicated or founded report of child abuse in accordance wit h the Child Protective Service Law (23 Pa.C.S.Ch.63)? If YES, explain:

7. IS THE LEGAL ENTITY, OWNER, OR OPERATOR CURRENTLY CHARGED WITH A FELONY OR MISDEMEANOR?

If YES, explain: 0 Yes 0No

8 . DO ANY OF THE FOLLOWING STATEMENTS APPLY TO YOU OR ANY OTHER PERSON WHO WILL BE PRESENT IN YOUR FACILITY WHEN CHILDREN ARE IN CARE?

NOTE: DI RECTORS, OWNERS, AND OPERATORS SHOULD ANSWER THIS QUESTION BASED ON THE STAFF HEALTH ASSESSMENT FORMS THEY HAVE ON FILE. THEY SHOULD NOT QUESTION OR SURVEY STAFF DIRECTLY OR CONDUCT ANY ACTIVITY WHICH MAY BE A VIOLATION OF ADA OR HIPPA LAWS.

8A. Diagnosed or receiving therapy or medication for mental illness? 0 Yes 0No IfYES, explain:

NOTE: DIRECTORS, OWNERS, AND OPERATORS SHOULD ANSWER T HIS QUESTION BASED ON THE STAFF HEALTH ASSESSMENT FORMS THEY HAVE FILE. THEY SHOULD NOT QUESTION OR SURVEY STAFF DIRECTLY OR CONDUCT ANY ACTIVITY WHICH MAY BE A VIOLATION OF ADA OR HIPPA LAWS.

SB. Evidence of drug or alcohol related addiction during the past 12 months? 0 Yes 0 No IfYES, explain:

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http:Pa.C.S.Ch.63

9. DO YOU NOW OR HAVE YOU PREVIOUSLY HAD A PROVIDER AGREEMENT WITH A CCIS? 0 Yes 0 No

10. HOUSEHOLD:

10A. Is your facility located in a residence? 0Yes 0No

108. If you answered "Yes" to question 10A, list all individuals, including yourself if applicable, who are living in the residence and are at least 18 years of age. (Include only those who Live in the residence at least 30 days in a calendar year.)

FI RST NAME MIDDLE NAME LAST NAME SUFFIX DATE OF BIRTH (MM/ DD/ YYYY) -

11. LOCATION INFORMATION:

11A. Name and Physical Address of Location 11B. Mailing Address of Location

NAME: IADDRESS UNE' ADDRESS LINE 1: ADDRESS LINE 2 :

ADDRESS LINE 2: ADDRESS LINE 3:

ADDRESS LINE3: CllY:

CITY: STATE: IZIPCODE: STATE: IZIP CO DE: COUNTY: -

COUNTY:

MUN!CIPALilY: (CITY/TWP./BORO.)

TELEPHONE #: Ext.#:

CELL PHONE#:

EMAIL ADDRESS:

FAX#:

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' 12. FACILITY WATER SUPPLIER (FAMILY CHILD CARE HOME APPLICANTS, SKIP, ALL OTHERS MUST ANSWER)

Is the facility a customer of a water supplier (i.e. does the facility receive a bill for water service)? 0 Yes 0No If YES, submit a copy of the most recent billing notice or a letter from t he water supplier to verify that they provide water to the location address.

13. RESPONSIBLE PERSON/LEGAL ENTITY DESIGNEE - - -

FIRSTN.AME LAST NAME

TITLE DATE OF BIRTH (MM/DD/YYYY)

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DECLARATION (Any false information or statement knowingly given in this application is punishable under Section 4904 of the Pennsylvania Crimes Code) I understand that the Certificate of Compliance will be issued to me on the condition that I will operate the above-named facility in accordance with the laws of the Commonwealth of Pennsylvania and with the rules and regulations of the Department of Human Services; Title VI and TITLE VIH of the Civil Rights Act of 1964; the Age Discrimination Act of 1975; the Rehabilitation Act of 1973; the Pennsylvania Human Relations Act of 1955; and the Americans with Diabilities Act of 1990.

Specifically, the above named facility will not permit discrimination on the basis of color, race, religious creed, disability, ancestry, national origin, age, or sex In any aspect of service delivery and employment.

I hereby declare that the information given in this application is true to the best of my knowledge.

PRINT OR TYPE - NAME

(Where the Legal Entity is a corporatlon, the lndM dual must be a corporate officer.)

TITLE

ADDRESS

SIGNATURE OF THE LEGAL ENTITY/REPRESENTATIVE

DATE (MM/DD/YYYY)

CD 633 10/17

INSTRUCTIONS FOR COMPLETION OF AN

APPLICATION FOR A CERTIFICATE OF COMPLIANCE

APPLICATION PURPOSE:

New application or renew existing facility: A facility applying to renew their existing Certificate of Compliance. The name and address of the facility and the name of the legal entity should be the same as it is on the P.xistinq CPrtificate of CompUance.

IDENTIFICATION: 1. LEGAL ENTITY NAME, PHYSICAL ADDRESS, MAILING ADDRESS, EMAIL ADDRESS, TELEPHONE NUMBER, CELL PHONE NUMBER:

Indicate name, physical address, mailing address, email address, telephone, and cell phone number of Legal entity. A post office box may not be entered in the physical address information.

2. TAX IDENTIFIER: Indicate the FEIN of the person, partnership, association, organization, corporation or governmental body responsible for the operation of the facility. Family child care homes enter SSN or FEIN. IRS documentation is a copy of your social security card if using your SSN, and a label or letter from the IRS if using a FEIN. This information is required in order to participate in the child care work (subsidy) program or the resource and referral program.

3. TYPE OF OPERATION: Profit: Operating with the expectation of providing a financial benefit to someone or something other than the facility itself. The focus is upon the ultimate aim of the enterprise, not the financial results of any particular period of operation. The focus is also upon the particular premises involved and not the legal entity which operates the facility. A non-profit legal entity may be considered as operating a facility for profit if the particular premises involved provides a financial benefit t o the parent legal entity. Any legal entity not possessing a certificate of tax exempt status from the Internal Revenue Service will be considered operating for profit unless it provides satisfactory proof otherwise.

Non-Profit: Operating other than for profit. Copy of tax exempt certificate should be submitted with the initial application.

4. TYPE OF OWNERSHIP/CONTROL: LLC, LLP, OR CORP: Proof of who the partners or incorporators are must be submitted with the application. If the corporation is publicly held, then a list of the board members should be submitted with a statement regarding each member's involvement in the following: working wittl children, oversight/ supervisor of staff, managerial decisions regarding staff and/or establishment and enforcement of policies and procedures.

Individual or General Partnership: Complete First Name, Middle Name, Last Name, Suffix, and Date of Birth in this section regarding each individual or partner that is included in the ownership.

5. Please answer YES or NO. If the answer is "Yes", please provide an explanation.

6. Please answer YES or NO. Ifthe answer is "Yes", please provide an explanation.

7. Please answer YES or NO. If the answer is "Yes", please provide an explanation.

BA. Please answer YES or NO. If the answer is "Yes", please provide an explanation. Directors, owners, and operators should answer t hese questions based on the staff health assessment forms they have on file. They should not question or survey staff directly or conduct any activity which may be a violation of ADA or HIPPA laws.

BB. Please answer YES or NO. Ifthe answer is "Yes", please provide an explanation. Directors, owners, and operators should answer these questions based on the staff health assessment forms they have on file. They should not question or survey staff directly or conduct any activity which may be a violation of ADA or HIPPA laws.

9. Please answer YES or NO.

10A. Is your facility located in a residence? A residence is defined as the physical structure in which one lives. Check "YES" or " NO" to indicate whether the

facility you identified in 1A Is located in a residence.

108. List all individuals by name and birth date who are 18 years of age or older who reside in your residence at least 30 days in a calendar year including

yourself, if applicable.

11. LOCATION NAME, PHYSICAL ADDRESS, MAILING ADDRESS, EMAIL ADDRESS, TELEPHONE NUMBER, CELL PHONE NUMBER: Indicate name, physical address, mailing address, email address, telephone, and cell phone number of the physical location where the child care services are provided. If the application is for a renewal of an existing certificate, the name and address of the location should be the same as on the previous application. A post office box may not be entered in the physical address information.

12. FACILITY WATER SUPPLIER - Family Child Care Home Applicants SKIP, all others must answer: Is the facility a customer of a water supplier (i.e. does the facility receive a water bill for water service)?

I f YES, submit a copy of the most recent billing notice or a letter from the water !;Upplicr to verify that they provide water to the Location address.

If NO, contact the Department of Environmental Protection (DEP) at www.dep.pa.gov to determine If the facility meets the definition of a public water system.

For those that do qualify as a public water system, submit a copy of the signed Brief Description Form and Brief Description Form Approval letter (or DEPlssued Operation Permit). For facilities that do not qualify as a public water system because less than 25 individuals are served, submit a notarized copy of the Public Water Supply Determination Survey (Affidavit).

13. RESPONSIBLE PERSON/LEGAL ENTITY DESIGNEE:

Indicate the full name, date of birth, and title of the person who is responsible for the daily operation of the facility.

DECLARATION: The declaration must be signed by the legal entity. If the legal entity is a partnership, association, or organization, the person authorized to sign such documents must sign. Where the legal entity is a corporation, the signature must be of a corporate officer. Type or print the name and title of the person signing.

CD 633 10/17

http:www.dep.pa.gov

IMPI: NAME: ADDRESS LINE 1: ADDRESS LINE 1_2: ADDRESS LINE 2: ADDRESS LINE 3: CITY: CITY_2: STATE I ZIP CODE: TELEPHONE: CELL PHONE: EMAIL ADDRESS: FAX: NAME_2: ADDRESS LINE 1_3: ADDRESS LINE 1_4: ADDRESS LINE 2_2: ADDRESS LINE 2_3: ADDRESS LINE 3_2: ADDRESS LINE 3_3: CITY_3: CITY_4: MUNICIPALITY CITY TWPBORO: CELL PHONE_2: EMAIL ADDRESS_2: FAX_2: Ext: State: FEIN: SSN: Prior License Status: County: Telephone #: Date: Medication: Addiction: Address Line3: Address Line 4: State 1: State Zip Code2: County2: FEIN3: U1: U2: U3: U4: U5: U6: U7: U8: U9: U10: U11: U12: U13: U14: U15: U17: U18: U19: U20: U21: U22: U23: U24: U25: U26: Legal Entity, Ownet, Operator: Felony and Misdemeanor: T5: T6: T7: T8: T9: T10: T11: T12: T13: T14: T15: T16: T17: T18: T19: T20: T21: T22: T23: T24: T26: T27: T28: T29: T30: T31: T32: T33: T34: T35: State 3: State 4: STATE I ZIP CODE_5: STATE I ZIP CODE_6: COUNTY 3: County 4: LAST NAME 13: FlRSTNAME 13: TITLE 13: DATE OF BIRTH MMDDYYYY_13: PRINT OR TYPE NAME D: TITLE_2 D: ADDRESS D: DATE MMODYYYY D: Signature 23: 7: 22: 24: 26: 28: 30: 32: 34: 36: 1: 4: 9: 5: 6: 2: 3: 10: 11: 12: 13: 14: 15: 16: 17: 18: 19: 20: 21: IMPI_2: 0Family Child Care Home 0Group Child Care Home Ocenter: 1 LEGAL ENTITY INFORMATION: 1B Mailing Address of Legal Entity: 1A Name and Physical Address of Legal Entity: ADDRESS LINE 1_5: ADDRESS LINE 1_6: ADDRESS LINE 2_4: ADDRESS LINE 3_4: ADDRESS LINE 3_5: STATE I ZTPCODE: STATE I ZIP CODE_2: COUNTY: TELEPHONE_2: CELL PHONE_3: EMAIL ADDRESS_3: FAX_3: 2 TAX IDENTIFIER: 1_2: 2_2: undefined: Protective Service Law 23 PaCSCh63 IfYES explain: undefined_2: 10 HOUSEHOLD: SUFFIXRow1: DATE OF BIRTH MMDDYYYYRow1: SUFFIXRow2: DATE OF BIRTH MMDDYYYYRow2: DATE OF BIRTH MMDDYYYYRow3: 11B Mailing Address of Location: NAME_3: ADDRESS LINE 1_7: ADDRESS LINE 1_8: ADDRESS LINE 2_5: ADDRESS LlNE 2: ADDRESS LINE 3_6: ADDRESS LlNE 3: CITY_5: CITY_6: STATE I ZIP CODE_3: STATE I ZIP CODE_4: MUNCCJPALITY CITY TWPBORO: CELL PHONE_4: EMACL ADDRESS: FAX_4: PRINT OR TYPE NAME: TITLE: ADDRESS: