Application Packet for a Child
Care Center License or Letter of
Compliance
Maryland State Department of Education
Division of Early Childhood Development
Office of Child Care
Resource Guide
2016
TABLE OF CONTENTS
Introduction ……………………………………………………….. … 2
• What is a Child Care Center?
• Government Regulations
• Use of Names
Steps to Take to Obtain a Center License or Letter of Compliance……4
Resources..…………………………………………………………….. 7
Where to find forms and other resource information…………………..7
Instructions for Completing the Application Form..………………….. 8
Appendix A – Regional Licensing Offices……………………………11
Appendix B – Application Packet Checklist…………………………..12
Appendix C – Independent Agencies Authorized to Evaluate
Foreign Credentials………………………………...…..13
Samples of Forms Needed to Apply for a Child Care Center License or a Letter of Compliance
(Actual forms may be found at
www.marylandpublicschools.org/MSDE/divisions/child_care/licensing_branch/forms
)
OCC 1200 - Application ……………………………………….14
OCC 1201 - Worker’s Compensation Insurance ………………18
OCC 1203 - Personnel List …………………………………….19
OCC 1204 - Medical Reports …………………………………..21
OCC 1205 - Individual Personnel Information ………………...22
OCC 1206 - Staffing Pattern …………………………………...23
OCC 1213 - Variance Request………………………………….25
OCC 1218 - Menu Plan ………………………………………...27
OCC 1260 - Release of Information ……………………………28
OCC 1268 - Environmental Health Survey …………………….29
OCC 1270 - Notice of Intent …………………………..……….30
1
Introduction
WHAT IS A “CHILD CARE CENTER"?
Under Maryland law, a child care center is a facility operated by an individual, agency, or
organization
that offers child care services for part or all of the day, or on a 24-hour basis on a
regular schedule, at least twice a week. Most child care centers are regulated by the Maryland
State Department of Education's Office of Child Care (OCC) under
COMAR 13A.16 ("Child
Care Centers")
.
Some child care programs operated by tax
-exempt religious organizations are eligible to be
regulated by OCC under
COMAR 13A.17
("Letters of Compliance"). A letter of compliance is
a form of licensure that exempts the facility from having to meet certain staff qualification and
program
requirements. To be eligible for a Letter of Compliance (LOC) the program must be
operated by
a tax-exempt religious organization in school buildings exclusively for children
who are enrolled in those schools, by whatever name known.
However, facilities licensed
under a
LOC must meet all of the same health and safety requirements as those licensed as a
Child Care Center
; and all child care facilities must meet applicable licensure requirements
before they may begin operating.
While child care facilities v
ary greatly in size, each one must remain within the maximum
child capacity established for it by the OCC
Licensing Branch. This means that no more than a
specified number of children may be present in a given facility at one time. There are different
type
s of child care programs and services, and a child care facility may be authorized to
provide more than one type:
• Some centers primarily provide care for infants and toddlers. Others serve only
preschool or school-age children. Most child care facilities provide care for a range of
ages. However, letter of compliance facilities may not provide care to children younger
than 2 years old.
• In many centers, children are usually grouped with others of the same age. Other
centers often use mixed-age groups (for example, infants or toddlers grouped with pre-
schoolers, or pre-schoolers grouped with school-age children). For child supervision
and safety purposes, child care regulations specify a maximum size for each group that
is based on the ages of the children in the group. The same basis is used to establish a
minimum staff-child ratio for each group.
• School-age child care facilities offer programs before and/or after school hours and
during school holidays and vacations.
GOVERNMENT REGULATIONS
The Maryland State Department of Education's Office of Child Care (OCC), is responsible
for all child care licensing and regulation in Maryland. OCC's goal is to make sure that
safe child care is available to all Maryland families. OCC maintains
13 Regional
Licensing Offic
es around Maryland, each of which is responsible for all child care
licensing activities in its geographical area.
A list of Regional Office may be found at
Appendix A.
2
In Maryland, child care centers are regulated under the Code of Maryland Regulations
COMAR 13A.1
6 or COMAR 13A.17. These regulations require a person to obtain a
“license” or a “Letter of Compliance
" (which is a form of license) before the person may
operate a child car
e program. Being licensed means that your program meets certain child
health and safety requirements. It also makes you eligible for tax deductions, certain food
subsidies, and liability insurance. These benefits make your child care
center attractive to
p
arents and more profitable as a business. COMAR 13A.16 and 13A.17 may be found at
www.marylandpublicschools.org/MSDE/divisions/child_care/regulat
THE USE OF NAMES
CO
MAR 13A.09.01 prohibits an individual, partnership, group, association, cooperative,
or corporation from using the words “preschool,” “school,” “institute,” or “academy” or
words of like meaning, in such a manner as to connote the offering of a high school, junior
high or middle school, elementary school, kindergarten, nursery school program, or any
combination thereof, unless the entity holds a Certificate of Approval from the State Board
of Education.
3
STEPS TO TAKE TO OBTAIN A CHILD CARE CENTER LICENSE OR LOC
1.
Contact Your OCC Regional Licensing Office
Call the
Regional Licensing Office responsible for your area to let them know that you are
interested in applying for a child care facility license or letter of compliance. That Regional
Office will be responsible for processing your application, inspecting your facility to make sure
it meets regulatory
requirements, issuing your license or letter of compliance, providing you
with technical assistance, and answering any questions you may have about regulatory issues.
The Regional Office will be your main point of contact for all matters related to your license or
letter of compliance throughout the time that your facility is located in the ar
ea. A list of
Regional Office may be found at
Appendix A.
2.
Take the Child Care Center Orientation Session
If
you are interested in applying for a Child Care Center license, you or your representative
must
take the “on-line” interactive orientation session that is available on the “Orientation”
page of the
MSDE, OCC, Licensing Branch website. Applicants for a Letter of
Compliance
are not required to take this orientation but are strongly encouraged to do so. This
orientation session provides potential applicants with detailed information about the
application process and the requirements that will need
to be met. It is also intended to
familiarize applicants with
State and local regulations pertinent to child care. The “on-line”
O
rientation session is located at: http://earlychildhood.marylandpublicschools.org/child-care-
providers/licensing/orientations
3.
Submit a Complete Application
At least 60 days before the proposed opening date, you must submit an application packet for a
child care facility license or letter of compliance. This packet consists of (b
ut is not necessarily
limited to) the following items, all of which are discussed in detail during the orientation
session:
1. Notice of intent to operate a child care facility
2. OCC application form for a child care facility license or letter of compliance
3. Site plans
4. Floor plans with architectural details.
5. Written plan of operation
6. Documentation of compliance with local zoning, building, health, and fire codes
7. Documentation of workers compensation insurance coverage
8. Fire evacuation plan
9. Menu plan for the first 4 weeks of operation
10. Written child discipline procedures
In addition, the following items must be submitted to the Regional Licensing Office
for review before the application process can be considered complete:
11. List of all facility personnel, along with staff qualification documents (if applicable)
4
12. Staffing pattern
13. Results of a criminal background check application for the applicant (if the
applicant is an individual who will interact with the children in care), the director,
and each paid employee who will have access to children in care
14. Permission to examine records of abuse and neglect of children and adults for
information about the director, residents at the facility (if any), and company
officers who may interact with children in care (if the applicant is a company,
agency, or organization).
Also, facility staff must submit a completed medical evaluation before being
allowed to begin work.
4.
Make Sure the Facility is Safe and Properly Equipped
The facility must be in good repair and
meet all applicable building, sanitary facility, lighting,
and food storage/preparation/service requirements set forth in
COMAR 13A.16 or COMAR
13A.17
, as applicable. In addition, all areas of the facility to be used for child care must be safe
and properly equipped. The following are just a few examples of facil
ity safety and equipment
requirements:
15. All potentially hazardous items such as cleansers, medicines, tools, and sharp
implements are stored so that they are inaccessible to children
16. All child care areas are lead-safe
17. Electrical wall sockets are properly capped as required by the applicable fire code
18. A properly stocked first-aid kit is present
19. There are adequate, appropriate, and safe indoor and outdoor activity materials and
equipment for the children's use
20. If children under 2 years old will be in care, there are enough cribs to accommodate
the children, and each crib meets U.S. Consumer Product Safety Commission
standards.
5.
Pass OCC, Fire Safety, and Other Required Inspections
The facility will need to be inspected by the local fire authority to
make sure that it meets all
applicable fire codes. Inspections by the Health Department and/or other local government
agencies may also be required. There are no fees for any inspections conducted by the OCC
Regional Licensing Office. However, there may be
fees for inspections by fire, health, and/or
other local authoritie
s. A “Use and Occupancy Permit” from the local government agency
is required is use the property as a child care center.
Once everything is in place for your business, a Regional Office l
icensing specialist will
schedule an application inspection of your facility. This inspection is designed to determine if
the facility and the child care program you will offer meet all applicable child care licensing
regulations. It is also intended as an
opportunity to address any questions you may have about
operating a child care program.
After all application requirements have been met and all
necessary inspections have been passed, the OCC Regional Licensing Office will issue your
child care facility
license or letter of compliance.
5
A child care facility is initially authorized to operate for a period of two years. At the end of
that period, the license or letter of compliance may be converted to continuing (i.e.,
non-
expiring) status
that continues in effect until the license or letter of compliance is surrendered,
suspended, or revoked.
However, a non-expiring license may be placed on conditional (i.e.,
probationary) status if the center operator does not comply with certain State requirements.
Con
tinued failure to comply may result in suspension or revocation.
All license c
hild care centers receive an unannounced “drop in” visit annually to determine if
child health and safety requirements are being met.
6. Variance Requests
T
he Office of Child Care (OCC) may grant a variance to a regulation:
• If the safeguards to a child’s health, safety, or well-being are not diminished;
• When the provider/operator presents clear and convincing evidence that a regulation is
met by an alternative which complies with the intent of the regulation for which the
variance is sought; and
• For a limited period of time as specified by the Office, or for as long as the
license/LOC remains in effect and the provider/operator continues to comply with the
terms of the variance.
The Office of Child Care (OCC) will consider a request for a variance after reviewing the
following:
• Other variances approved for the facility;
• All supporting documentation and information submitted to the Office;
• The regulatory issue and the portion of the regulation which is not currently being met;
• Compensating Factors – A statement of clear and convincing evidence that alternatives
are present to meet the intent of the regulation until compliance is accomplished (e.g. –
Mary Smith exceeds the age requirement, has 5 years of preschool experience and has
completed the 64 hour course); and the
• Proposed Solution – A statement of how compliance will be achieved (e.g. – Mary
Smith has enrolled in the Bridge Course which will be completed in December).
21. Sign and date the form and send to the OCC Regional Office.
6
RESOURCES
As soon as you receive the license or letter of compliance, the facility may begin operating.
The following are some community resources you may find helpful with regard to developin
g
your program:
22. Maryland Child Care Resource Network -- A statewide network of agencies that
provide resource and referral services to parents to help them find child care. These
agencies also provide staff training and support services to child care facilities.
23. The Maryland Economic Development Assistance Authority and Fund --
Administered by the Maryland Department of Business and Economic
Development, this program provides special purpose loans to construct, expand, or
improve child care facilities.
T
he Child and Adult Care Food Program (CACFP)
The
Child and Adult Care Food Program is funded by the U.S. Department of Agriculture
and
administered in Maryland by MSDE's School and Community Nutrition Programs
Branch.
The program provides child care food subsidies for low-income families. Child care
centers that
participate in the program are eligible to receive reimbursement for program food
costs.
Where to find forms and other resource information.
Samples of the application and other forms needed to apply for a Family Child Care
Registration may be found in this packet on pages
14 - 30.
All forms are located on our website at
http://www.marylandpublicschools.org/MSDE/divisions/child_care/licensing_branch/forms
For other resource information, you may click on “Resource Documents” in the right margin.
The
“Planning Your Facility Resource Guide” and the “Hiring Staff Resource Guide”
will
be useful at this point.
7
Instructions for Completing the Notice of Intent and Application for a Child
Care Center License or a Letter of Compliance
Notice of Intent
The Notice of Intent to Operate a New Child Care Facility and the Application for the License or
Letter of Compliance may be submitted at the same time. However, if you are building a new
facility, it would be prudent to submit the Notice of Intent to receive consultation and
recommendations from the Office of Child Care and to begin the process. It would be cost
effective to make changes to the plans prior to construction or changes taking place.
The Notice of Intent is accompanied by a site plan and a floor plan of the facility drawn to scale.
The site plan must indicate the location of the playground, parking areas, roads and adjacent
buildings in relation to the facility. The following items must be indicated on the floor plans:
• Architectural details such as columns, built-ins, etc.;
• The relation of the space to ground level;
• Room numbers, if available;
• Ages of children who will occupy rooms, if known;
• Corridors or walkways;
• Walls or partitions;
• Doors and door swings;
• Windows:
• Stairways;
• Restrooms with fixtures;
• Food preparation area with equipment;
• Storage areas; and
• Office areas
The plan must indicate if any changes are being made to the facility, i.e., addition of toilets,
sinks, drinking fountains, walls, etc. If the room is a large open space, then the plan must
indicate how the space will be used if more than one group of children will be accommodated.
The remaining information requested on the Notice of Intent – name, address, and contact person
for the facility, proposed building information, proposed scope of service information, and
proposed food service information is the same as the information requested on the Application.
If you identify a property and want to be certain that it would be acceptable to use as a child care
center, you may submit a Notice of Intent and request the Regional Licensing Office to look at
the property and provide advice. They will be pleased to assist you!
8
Application for License or Letter of Compliance
Following are the sections to be completed on the application.
Organizational Structure
• Check the type of license for which you are applying: “License or “Letter of
Compliance”
• Check everything that applies to your organizational structure
Facility
• Enter the Name, Address, Telephone Number and Email address for the facility.
Operator – is the Person, Organization, Corporation or Representative responsible for the total
operation of the facility and responsible for compliance with all regulations.
• Enter name of responsible person or entity
• Enter Tax ID – Employee Identification Number (EIN) or Social Security Number (SSN)
as applicable.
• Enter address of operator. If same as facility, enter “Same”
• Enter name of Representative who will serve as agent for the operator
• Enter mailing address where you desire to receive all mail.
Scope of Service
• Specify the days, hours and months you plan to operate
• Check all of the types of care you desire to provide
Proposed Capacity – Capacity is established by the OCC Regional Office based on available
space, staff, equipment, and sanitary facilities. Indoor Space is measured at 35 square feet per
child excluding columns, vestibules, corridors, food preparation areas, kitchens, bathrooms,
adult work areas, permanently equipped isolation areas or sleeping rooms, storage units, storage
space, and furniture except for movable furniture and equipment. Outdoor space is measured at
75 square feet per child for ½ of the approved capacity, or for each child if he center has an
approved capacity of 20 or fewer children. In urban areas, outdoor space may be limited. Speak
with your Licensing Specialist about alternatives.
The capacity at opening may be 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. The local Fire Department and
local government Use & Occupancy issuing agencies will determine the maximum capacity
allowed in the facility.
• Enter your total planned capacity
• Enter your proposed capacity at opening
9
Proposed Building - Enter all requested information regarding the proposed building you plan
to use for the child care center.
Proposed Food Service – Enter the requested information regarding the type of food service you
plan to provide, and if an existing kitchen exists, describe existing equipment and fixtures.
SIGN AND DATE THE APPLICATION
Addendum to Application
• Enter “Yes” or “No” if the applicant is an individual. If, “Yes”, it is optional to enter the
race/ethnicity of the individual.
• Enter the full legal names and ages of all persons 18 years old or older who live on the
same premises as the child care facility. Nicknames are not acceptable.
• Enter “Yes” or “No” if the applicant an entity with corporate or partnership members. If
“Yes”, list their full legal names, titles, addresses, and whether or not they will have
frequent contact with the children in care. Nicknames are not acceptable.
•
This information is very important because individuals living on the premises or will have
frequent contact with children in care will need to complete OCC Form 1260 giving OCC signed
and notarized permission to examine their records of child and adult abuse and neglect.
SIGN AND DATE THE ADDENDUM
10
Appendix A
Regional Offices of Child Care
All regulatory activity is conducted through 13 regional offices throughout
Maryland. Please contact the regional office that licenses and registers child care
facilities in the county where you desire to provide child care.
Region # County Telephone #
Region 1 Anne Arundel 410-573-9522
Region 2 Baltimore City 410-554-8300
Region 3 Baltimore 410-583-6200
Region 4 Prince George’s 301-333-6900
Region 5 Montgomery 240-314-1400
Region 6 Howard 410-750-8779
Region 7 Washington
Garrett
Allegany 301-791-4585
Region 8 Caroline
Dorchester
Kent
Queen Anne’s
Talbot 410-819-5801
Region 9 Somerset
Wicomico
Worcester 410-713-3430
Region 10 Calvert
Charles
St. Mary’s 301-475-3770
Region 11 Harford
Cecil 410-569-2879
Region 12 Frederick 301-696-9766
Region 13 Carroll 410-549-6489
Licensing staff will be pleased to assist you!
Paula Johnson, Chief of the Licensing Branch may be reached via:
Email: paul[email protected] or Phone: 410-569-8071
11
MARYLAND STATE DEPARTMENT OF EDUCATION OFFICE OF CHILD CARE
APPLICATION FOR CENTER LICENSE OR LETTER OF COMPLIANCE CHECKLIST
The applicant must submit the following information to the Office of Child Care (OCC) before the application can be
considered complete. (Check appropriate column for each listed item.)
Not needed for LOC Submitted N/A
A. Notice of Intent (OCC 1270)
B. Application for Child Care Center License or LOC (OCC 1200)
C. Articles of Incorporation
D. IRS Letter of Determination stating Tax-Exempt Status
E. MSDE Exemption Letter
F. Proof of Montessori Validation
G. Site Plans
H. Floor Plans (with architectural detail)
I. Evidence of Compliance with Local Building and Zoning Codes (U&O Permit)
J. Environmental Health Survey (OCC 1268)
K. Private Sewage & Water inspection Results
L. Boiler Inspection Report
M. Fire Inspection Report
N. Fire Evacuation Plan(s)
O. Lead Safe Environment (Certificate for Pre 1978 Residential Rental Property)
P. Workers Compensation Insurance Information (OCC 1201)
Q. Personnel List (OCC 1203) (with all related supporting documentation)
R. Medical Reports (OCC 1204) (for all staff)
S. Individual Personnel Information (OCC 1205) (with all requested documentation)
1. Director
2. Teacher(s)
3. Assistant Teacher(s)
4. Aide(s)
T. Staffing Pattern (OCC 1206)
U. Emergency Adult Agreement/On-Call Statement (for centers with children ages 2 and above)
V. Release of Information (OCC 1260) for:
1. The Director
2. Each Employee
3. Each individual 18 years old or older living on the same premises as the center
4. Each Substitute
5. The applicant, if the applicant is an individual who will have frequent contact with
the children in care
6. Trustee, managers, or board members who may have frequent contact with the
children in care, if the applicant is a corporation, agency, association, or organization
W. Plan of Operation (Schedule of Activities)
X. Discipline Policy
Y. Menu Plan for 4 weeks (OCC 1218)
Z. Operations Care Plan(s) (Sick Care, Adolescent, Drop-in Centers)
NOTE: The applicant, if an individual who will have frequent contact with children in care, each employee,
including paid substitutes and each individual 14 years old or older living on the premises as the child care
center, must get Criminal Background Checks. Be sure to use the child care facility and the OCC authorization
codes.
12
Appendix C
NATIONAL ASSOCIATION OF CREDENTIAL EVALUATION SERVICES, INC.
An Association of Independent Evaluation Services
If necessary, you may use any of these resources to evaluate educational credentials of individuals who
attended schools outside of the United States.
Center for Applied Research Evaluation & Education
P. O. Box 18358 Anaheim, CA 92817
Phone: 714-237-9272 www.iescaree.com
FACS, Inc.
Foreign Academic Credentials Service, Inc.
P.O. Box 400 Glen Carbon, IL 62034
Phone: 618-656-5292 www.facsusa.com
Educational Credential Evaluators, Inc.
P.O. Box 514070 Milwaukee, WI 53203-3470 Phone: 414-
289-3400 www.ece.org
Foundation for International Service, Inc.
14926 35th Avenue West Suite 210 Lynnwood, WA 98097
Phone: 425-248-2255 www.fis-web.com
Education Evaluators International, Inc.
11 S. Angell Street #348 Providence, RI 02906 Phone:
401-521-5340 www.educei.com
International Consultants of Delaware, Inc.
P. O. Box 8629 Philadelphia, PA 19101-8629 or 3600
Market Street, Suite 450
Phone: 215-222-8454 ext. 603 www.icdel.com
Education International, Inc.
29 Denton Road Wellesley, MA 02482
Phone: 781-235-7425 www.educationinternational.org
International Education Research Foundation, Inc. P.O.
Box 3665 Culver City, CA 90231-3665 Phone: 310-258-
9451 www.ierf.org
Educational Perspectives
P.O. Box 618056 Chicago, IL 60661-8056
Phone: 312-421-9300 www.edperspective.org
Josef Silny & Associates, Inc. International Education
Consultants
7101 SW 102 Avenue Miami, FL 33173
Phone: 305-273-1616 www.jsilny.com
Educational Records Evaluation Service, Inc.
601 University Avenue Suite 127 Sacramento, CA 95825
Phone: 916-921-0790 www.eres.com
Evaluation Service, Inc
333W. North Ave. #284 Chicago, IL 60610-1293 Phone:
847-477-8569 www.evaluationservice.net
Span Tran Educational Services, Inc.
7211 Regency Square Blvd.
Suite 205 Houston, TX 77036-3197
Phone: 713-266-8805
www.spantran-edu.org
World Education Services, Inc.
Bowling Green Station
P.O. Box 5087 New York, NY 10274-5087
Phone: 212-966-6311 www.wes.org
Foreign Educational Document Service
P.O. Box 4091 Stockton, CA 95024
Phone: 209-948-6589 www.documentservice.org
World Education Services, Inc.
P.O. Box 745 Old Chelsea Station New York, NY 10113-
0764
Phone: 1- 800-937-3895
Fax: 212-966-6395
1-800-937-3897 Washington, DC
13
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
CHILD CARE FACILITY
APPLICATION FOR LICENSE/LETTER OF COMPLIANCE
FACILITY
Name of Facility:
Telephone #:
Address:
e-mail Address:
City/County: State: Zip Code:
OPERATOR
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:
(If different from facility’s)
Telephone #:
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 ________________________________________________________________________
OCC 1200 - Revised 3/15 - All previous editions obsolete. Page 1 of 4
INSTRUCTIONS
• 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.
ORGANIZATIONAL STRUCTURE
The operator is applying for a (check only one):
License Letter of Compliance
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.
14
SCOPE OF SERVICE
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)
TODDLER (18 through 23 months old)
PRESCHOOL (2 through 5 years old)
SCHOOL-AGE (Grades K - Middle School)
ADOLESCENT (Middle/Junior High School)
DROP-IN (exclusively)
SPECIAL CARE FACILITY (Acutely Ill Children)
NURSERY SCHOOL (Religious Exempt)
NURSERY SCHOOL INSTRUCTIONAL PROGRAM
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: __________________________________________________________________________________________
________________________________________________________________________________________________________
OCC 1200 - Revised 3/15 - All previous editions obsolete. Page 2 of 4
15
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
OCC 1200 - Revised 3/15 - All previous editions obsolete.
Page 3 of 4
16
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
CORPORATE OR
PARTNERSHIP MEMBER
TITLE
ADDRESS
FREQUENT CONTACT
WITH CHILDREN
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.
Page 4 of 4
17
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
Worker’s Compensation Insurance Information
Provide the following information in compliance with the Labor and Employment Article, §9-201 et seq.,
Annotated Code of Maryland.
Do you employ one or more persons full or part time? Yes No
If the answer is NO, sign and date the form, and return it with your application.
If the answer is YES, check (A) or (B) below and complete the information needed. Then sign and
date the form and return it with your application.
IF YOU ANSWERED YES, YOU MUST:
A) Attach a copy of your Worker’s Compensation Insurance Policy statement page.
It must show the effective and expiration dates.
Or
B) Complete the information below about your Worker’s Compensation Commission policy or
binder number.
1) Policy or Binder Number:___________________________________________
2) Insurance Company: _______________________________________________
________________________________________________________________
3) Effective Date: ____________________________________________________
4) Expiration Date: ___________________________________________________
Signature: _______________________________________________________________________
Title: ___________________________________________________________________________
Date: ___________________________________________________________________________
County: _________________________________________________________________________
Name of Center: __________________________________________________________________
If you have questions about Workman’s Compensation, contact your insurance carrier or Workman’s
Compensation Commission.
OCC 1201- Revised 3/15 - All previous editions are obsolete.
18
MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
CHILD CARE FACILITY PERSONNEL LIST/STAFF CHANGE FORM
Complete and return page 1 of this form to the Regional Office of Child Care (OCC) with the Application for a Child Care Center License/Letter of Compliance (OCC 1200) or with
the Request for Continuing License/Letter of Compliance (OPCC 672). Please list all facility personnel, whether paid or unpaid, and include volunteers who work at the facility on a
routine basis. (*see position titles below)
If you are reporting a staff change, complete and return pages 1 and page 2 to the Regional Office of Child Care, within 5 working days.
Name of Facility: ____________________________________________________________________________________Telephone #: _________________________________
Address: ________________________________________________________________________________E-Mail Address: _________________________________________
PLEASE PRINT OR TYPE
NOTE: Completion of items in shaded columns is optional for partially exempt facilities and Letter of Compliance facilities.
Name of Staff Member
Position
*
Hire Date
W
/Operator
Age of
Group
Orienta
tion
Date
Date
Criminal Background Check
Received
Notarized
Release of
Information
Date of
Medical
Report
Date of
Emergency
Prep
Date of
Medication
Admin
Date
First Aid
Expires
Date
CPR
Expires
Date
Approved
by OCC
for
Position
Continued Training
Hours
MD
OCC
√
FBI
OC
C
√
Date
Submitted
OCC
√
Core of
Know-
ledge
Elective
* Position Title: Operator, Director, Teacher, Assistant Teacher, Aide, Food Service Worker, Clerical Worker, Driver, Custodian, Substitute and/or Volunteer.
_________________________________________
Signature of Operator or Director Date
Please return this completed form to the Regional Office of Child Care at: _______________________________________________________________________________________________________________________
19
ADDITIONAL STAFF MEMBER CHANGE INFORMATION
Complete this section if change information is being reported, i.e. new staff, deleting and existing staff member, staff position change, etc. Page 1 must be submitted with page 2.
Name of
Staff Member
Type of Change
Transferring from another facility in Maryland?
Add
Delete
Other change
(please explain, i.e. hours, position, age of group)
No
Yes
Name and County of previous facility
Date left
PLEASE NOTE: Notification of New Staff – An operator shall:
(1) Within 5 working days of adding a new employee or staff member, provide to the Office:
(a) Written notification of the individual’s addition to the center staff;
(b) Information about the individual’s work assignment; and
(c) A signed and notarized permission to examine records of abuse and neglect of children and adults for information about the
individual; and
(2) Within 15 working days of adding the new employee or staff member, provide to the office:
(a) If applicable, documentation that the individual meets the requirements of this chapter for the assignment, unless documentation
already is on file in the office, and
(b) If the individual is paid by the center operator, proof of compliance with the laws and regulations pertaining to criminal background
checks.
20
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
MEDICAL REPORT FOR CHILD CARE
Name of Person being evaluated: ____________________________________ Date of Birth: ___________
Name of Child Care Applicant/Provider/Facility: _________________________________________________
Address of Facility: ________________________________________________________________________
Dear Health Practitioner:
The person to be evaluated either provides (or plans to provide) child care services or lives in a home where
family child care is (or will be) given.
1) RESTRICTED OR REQUIRE SPECIAL CONDITIONS from contact with children in care due to having any of the
following:
a) Communicable disease: ___________________________________________________________
b) Chronic medical condition or physical impairment: _____________________________________
c) Vision/Hearing/Speech Disorder: ___________________________________________________
d) Nervous or Emotional Disorder: ____________________________________________________
e) Drug or Alcohol Abuse: __________________________________________________________
f) Immunization status: _____________________________________________________________
2) Tuberculosis Screening: (if needed or required by the Local Health Officer.)
Type of test: ________________ Results: ________________ Date: _________________
Answer question 3 if the person being evaluated provides (or plans to provide) child care services:
Persons who provide child care services must be able to participate fully in a program for active young children.
This includes lifting infants and young children, getting up and down from the floor, lively outdoor activities,
and moving furniture. It may also include transporting children in a motor vehicle.
3) Describe medical limitation(s) or medication(s) the person is taking, that may impair the person’s ability to perform care-
related activities, such as the ones noted above.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________________ __________________ _______________________
Signature of Physician, CNP, RPA Date Phone Number
OCC 1204 - Revised 6/08 - All previous editions obsolete and replaces OCC 1258.
STAMP, PRINT, OR TYPE: Name and Address of Physician, Certified Nurse Practitioner, Registered Physician’s
Assistant.
21
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
INDIVIDUAL PERSONNEL INFORMATION
This form is to be completed by potential or new staff not previously evaluated or staff requesting re-evaluation. SEND THE
COMPLETED FORM AND ALL SUPPORTING DOCUMENTATION TO THE OFFICE OF CHILD CARE REGIONAL
OFFICE. THE EVALUATION WILL BE BASED SOLELY ON DOCUMENTATION SUBMITTED TO OCC.
NAME: ____________________________________________________________________________________________________________________
Last First Middle Maiden
HOME ADDRESS: __________________________________________________________________________________________________________
Street P.O. Box or Apt. # City County State Zip Code
HOME PHONE: (_______)__________________________________ WORK PHONE: (_______)_________________________________________
BIRTHDATE: (attach copy of Birth Certificate or Driver’s License) SOCIAL SECURITY #: ________________________________
Have you been evaluated to work in a child care center in the State of Maryland?
No Yes (attach copy of evaluation)
Center name/location: ________________________________
EDUCATION:
1. Did you complete high school? No Yes (attach copy of diploma, equivalency certificate or transcript)
2. Did you complete any of the following?
No Yes (check all that apply) (attach copies of certificates/transcripts)
45 hour course: Infant/Toddler School age School age Director
90 hour course: Infant/Toddler Preschool School age
Other: Child Development Associate Credential Military Certificate
3. Did you attend college? No Yes, number of credits earned _________ (attach copy of transcript)
4. Did you earn a degree? No Yes, Year ____________ Name of School ___________________________________________________
Major _______________________________________ Degree earned ______________ (attach copy of degree/transcript)
5. Do you have a teaching certificate or approval from the MD State Dept. of Education or another state? No Yes (attach copy of
certificate or approval letter)
6. Do you have Montessori Credentials? No Yes, Credential Level(s) _________________________________(attached copy of credential(s))
EXPERIENCE:
Provide information about your supervised experience working with groups of children in licensed child care centers, public/private schools, as a
registered provider or other approved settings. Attach documentation from each employer, which states the number of hours worked, the ages of
the children worked with, the position and the length of time worked. Attach additional pages if necessary.
Dates Worked
From To
Mo Yr Mo Yr
Name of Facility
(start with present employer)
Address and Phone #
Supervisor
Position
Ages of
Children
# of Hours
Worked
Per Week
I confirm that the above information is true and correct to the best of my knowledge.
____________________________________________________ ___________________
Signature Date
OCC 1205 - Revised 6/08 - All previous editions are obsolete.
I am applying for: (check all that apply)
___ Aide ___ Assistant Teacher (school age)
___Teacher: ___ Infant/Toddler ___ Preschool ___ School age
___ Director: ___ Infant/Toddler ___ Preschool ___ School age
22
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
STAFFING PATTERN FOR CHILD CARE CENTERS
AND
LETTER OF COMPLIANCE FACILITIES
Name of Facility: _________________________________________________________ Facility #: ___________________________
Hours of Operation:__________________________ Total Hours Per Week: ____________ Days of Operation: _______________
Effective Date: _________________________________________________ Director: _____________________________________
DIRECTOR’S WORK SCHEDULE:
SUN:
MON:
TUES:
WED:
THURS:
FRI:
SAT:
Number of hours each day the Director is regularly scheduled with a group to directly supervise children:
SUN:
MON:
TUES:
WED:
THURS:
FRI:
SAT:
See directions on back for instructions on how to fill in the staffing pattern.
Time
of Day
Room # / Group ID:
Total
# of
Children
# of
2 yr.
Olds
# of
Toddlers
18-24 mo.
# of
Infants
0-18 mo.
Age:
Capacity:
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
Day(s)
OCC 1206 - Revised 6/08 - All previous editions are obsolete. Page 1 of 2
Time
of Day
Room # / Group ID:
Total
# of
Children
# of
2 yr.
Olds
# of
Toddlers
18-24 mo.
# of
Infants
0-18 mo.
Age:
Capacity:
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
Day(s)
Signature of Operator, Agent or Director
:_________________________________
Date:_____________________
23
DIRECTIONS
1. Clearly identify each room/group, ages and list its capacity. Identify the days of the week covered by this pattern.
2. Use vertical lines to indicate hours of the day each staff member is directly supervising children in the room/group identified for each
block. Some staff members may appear in more than one block at different times of the day or on different days of the week.
3. Do not continue a line through times when a staff member is not directly supervising children, i.e., off duty or on a break. Add name
of person supervising children during this time.
4. Write full name of each staff member and position.
D = Director TI = Teacher with Infants/Toddlers TP= Teacher with Preschool Age TS = Teacher with School Age
ATS = Assistant Teacher with School Age A = Aide
5. List total number of children present in each group and number of two year olds, toddlers and infants included in each group for
specific hours of the day. The number of children present cannot exceed the room’s capacity.
SAMPLE
Time
of Day
Rm#/Group ID:
Total
# of
Children
# of
2 yr. Olds
# of
Toddlers
18-24 mo.
# of
Infants
0-18 mo.
Age: 2’s and 3’s
Capacity: 20
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + *
* * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
* * * *
+ + + +
0
0
0
0
2
1
6
1
6
2
6
3
10
3
15
3
20
6
20
6
10
4
6
1
0
0
0
0
Day(s) Monday, Wednesday, Friday
OCC 1206 - Revised 6/08 - All previous editions are obsolete. Page 2 of 2
Identify each room/group
Use vertical lines to indicate
hours worked
Write in staff using full
name and position
Donna Jones (TP)
Sherry Smith (A)
Beverly Johnson (A)
Joan Brown (TP)
Indicate the total
Indicate the number of
2 year olds present
Indicate the number
of toddlers present
Indicate the number
of infants present
24
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
VARIANCE REQUEST
COMAR 13A.15.03.06, COMAR 13A.16.03.08, COMAR 13A.17.03.08, and COMAR 13A.18.03.08 state that the Office may grant a
variance to a regulation:
1. If the safeguards to a child’s health, safety, or well being are not diminished.
2. When the provider/operator presents clear and convincing evidence that a regulation is met by an alternative which complies
with the intent of the regulation for which the variance is sought; and
3. For a limited period of time as specified by the Office, or for as long as the registration/license/letter remains in effect and the
provider/operator continues to comply with the terms of the variance.
The Office of Child Care (OCC) will consider a request for a variance after reviewing the following:
24. Other variances approved for the facility.
25. All supporting documentation and information submitted to the Office.
TO BE FILLED OUT BY THE FACILITY:
Facility Name: ____________________________________________________________________________
Facility Address: __________________________________________________________________________
Facility Phone Number: _____________________________________________________________________
I am requesting a variance to Chapter/Regulation Number: __________ Title: __________________________
Regulatory Issue: (if staffing variance is requested, name of staff person) _____________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Compensating Factors: _____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Proposed Solution: ________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________
Provider/Operator/Agent Signature
_______________________________________________
Date
Send completed form and all supporting documentation to your OCC Regional Office.
OCC 1213 (Revised 06/15) - All previous editions are obsolete Side 1 of 2
25
VARIANCE REQUEST INSTRUCTIONS
Type or Print Legibly:
1. Facility Name – The name of the family provider or center which is requesting the variance.
2. Facility Address – The complete address of the facility.
3. Facility Phone Number – The facility phone number, including area code.
4. I am requesting a variance to Chapter/Regulation Number – The number of the chapter and regulation
for which the variance is requested (for example, Chapter 03.04).
Title – The title of the regulation for which the variance is requested (e.g. – Child Records).
5. Regulatory Issue – (if staffing variance is requested, name of staff person) – The name of the staff
person; complete this only when the variance is for a staff person.
AND – The portion of the regulation which is not currently being met (e.g. – staff person, Mary Smith, has
not completed the 90 hour course).
6. Compensating Factors – A statement of clear and convincing evidence that alternatives are present to
meet the intent of the regulation until compliance is accomplished (e.g. – Mary Smith exceeds the age
requirement, has 5 years of preschool experience and has completed the 64 hour course).
7. Proposed Solution – A statement of how compliance will be achieved (e.g. – Mary Smith has enrolled in
the Bridge Course which will be completed in December).
8. Sign and date the form and send to the OCC Regional Office.
NOTE: Attach all pertinent documentation (i.e. – floor plans, staff information, proof of enrollment in a class,
written statement of intent to take class, etc.).
26
Maryland State Department of Education
Division of Early Childhood Development – Office of Child Care
MENU PLAN
Week of ___________________________ Year __________
1
Juice may not be served when milk is the only other component served at snack.
2
MSDE recommends children over age two receive low-fat (1%) or fat-free (skim) milk.
MEAL
REQUIREMENTS
PORTION SIZES
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
Age 1-2
Age 3-5
Age 6-12
BREAKFAST
Fluid Milk
½ cup ¾ cup
2
1 cup
2
Fruit OR vegetable
¼ cup ½ cup ½ cup
Bread OR bread
alternate OR cereal
½ slice
¼ cup
½ slice
1/3
cup
1 slice
¾ cup
SNACK-Choose 2
Fluid Milk
1
½ cup ½ cup
2
1 cup
2
Fruit OR vegetable
½ cup ½ cup ¾ cup
Bread OR bread
alternate OR cereal
½ slice
¼ cup
½ slice
1/3 cup
1 slice
¾ cup
Meat or meat alternate
½ oz ½ oz 1 oz
LUNCH or SUPPER
Fluid Milk
½ cup ¾ cup
2
1 cup
2
Meat/poultry/fish OR
1 oz 1 ½ oz 2 oz
Cheese OR
1 oz 1 ½ oz 2 oz
Large egg OR
½ ¾ One
Peanut butter OR
2 tbsp 3 tbsp 4 tbsp
Dried beans & peas OR
¼ cup 3/8 cup ½ cup
Yogurt
½ cup ¾ cup 1 cup
2 different fruits OR
2 different vegetables
OR 1 fruit and 1
vegetable
¼ cup ½ cup ¾ cup
Bread OR bread
alternate, OR pasta OR
rice
½ slice
¼ cup
½ slice
¼ cup
1 slice
½ cup
27
28
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
ENVIRONMENTAL HEALTH SURVEY
THIS SECTION TO BE COMPLETED BY THE APPLICANT
Name of Provider/Facility:
Address of Provider/Facility:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Phone Number:
County:
Number living in Family Child Care Home: (do not include provider’s own children under 6 years of age)
Requested Capacity: (maximum number of children at any time including provider’s own children under 6 years of age)
Water Supply:
PUBLIC
PRIVATE
Sewage Disposal:
PUBLIC
PRIVATE
THIS SECTION TO BE COMPLETED BY LOCAL HEALTH DEPARTMENT
In Compliance
Not in Compliance
Recommendation:
License/Register
License/Register with plan to correct
Do not License/Register
Emergency Suspension because of imminent risk to children
Comments: ____________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
_________________________________________ ____________ __________________________________ _________________
Health Department Inspector Signature Date Health Officer Representative Signature Date
Return completed form to: ________________________________________________________ by: ____________________________
OCC 1268 (Revised 7/05) All previous editions are obsolete.
Findings:
Water Supply:
Sewage Disposal:
29
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
NOTICE OF INTENT TO OPERATE A NEW CHILD CARE FACILITY
Complete all information and submit to the Office of Child Care (OCC) regional office before making application to the local jurisdiction for any
required construction or occupancy permits. IF NO PERMITS ARE REQUIRED, SUBMIT THIS FORM WITH THE APPLICATION
AT
LEAST 60 DAYS BEFORE THE FACILITY’S PROPOSED OPENING DATE.
This form must be accompanied by a site plan and a floor plan of the facility that are drawn to scale. The site plan must indicate the location of the
playground, parking areas, roads and adjacent buildings in relation to the facility. The following items must be indicated on the floor plans: architectural
details such as columns, built-ins, etc.; the relation of the space to ground level; room numbers, if available; ages of children who will occupy rooms, if
known; corridors or walkways; walls or partitions; doors and door swings; windows; stairways; restrooms with fixtures; food preparation area with
equipment; storage areas; office areas. The plan must indicate if any changes are being made to the facility – i.e., addition of toilets, sinks, drinking
fountains, walls, etc. If the room is a large open space, then the plan must indicate how the space will be used if more than one group of children will be
accommodated.
The purpose of submitting plans to the OCC prior to construction or changes being made is to allow the OCC time to review the plans and
to provide consultation and recommendations. It would be cost effective to make changes to the plans prior to construction/changes
taking place.
NAME OF FACILITY: _____________________________________________________________________________________
ADDRESS: ________________________________________________________________________________________________
Street
___________________________________________________________________________________________________________
City County Zip Code
NAME OF OPERATOR: ____________________________________________________________________________________
CONTACT PERSON: _______________________________________________________________________________________
Name Telephone Number
ADDRESS: ________________________________________________________________________________________________
City County State Zip Code
___________________________________________________________________________________________________________
RELATIONSHIP TO FACILITY: ________________________________ PROPOSED OPENING DATE: _____________
PROPOSED BUILDING
4. 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): _____________________________________________________________________
5. Is the building now or will it become a multi-use building? YES NO
If YES, describe all other uses: ______________________________________________________________________________
________________________________________________________________________________________________________
6. 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)________________________________________________________
OCC 1270 - Revised 6/08 - All previous editions are obsolete. Page 1 of 2
30
PROPOSED BUILDING: (Continued)
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: __________________________________________________________________________________________
________________________________________________________________________________________________________
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 SCOPE OF SERVICE
1. Describe type of facility: ___________________________________________________________________________________
________________________________________________________________________________________________________
2. Months of Operation: ______________________________________________________________________________________
________________________________________________________________________________________________________
3. Days of Operation: ________________________________________________________________________________________
________________________________________________________________________________________________________
4. Hours of Operation: _______________________________________________________________________________________
5. Ages to be served (be specific): ______________________________________________________________________________
6. Capacity: (Note: 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 at this time to have the building approved by the local jurisdiction for the maximum
number of children.)
Total planned capacity: ________________________________ Proposed capacity at opening: _________________________
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: ________________________________________________
___________________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________ ____________________________________
Applicant’s Signature Date
OCC 1270 - Revised 6/08 - All previous editions are obsolete. Page 2 of 2
31
32
33
