Form Center

Please answer the following questions.

Hours of Operation (Hours/Day)

How many children are you trying to be licensed for?

What age groups?

Is this center located in a residence?

Yes
No

What year was the structure built?

If the structure is built prior to 1978, then a lead hazard investigation will be completed by the Health Department. Is a lead hazard investigation required?

Yes
No

Have you contacted the State licensing agent?

Yes
No

Please list his/her name.

Water Supply

Municipal
Well

Wastewater Disposal

Municipal
Septic System

Please answer the following questions in each category.

Main Food Service

How will meals be provided?

Prepared/cooked on-site
Catered from a permitted Food Service Establishment or approved Child Care Center
Other (parents, etc.)

If other, please explain.

Where will children eat meals?

(Family Style in classroom, dining area, etc.)

Will dishes, trays, silverware, etc. be used or disposable utensils?

Is the following provided in the kitchen?

Check all that apply.

Separate hand wash lavatory
At least a two-compartment sink with drain boards or adequate countertop space
Refrigeration equipment
Cooking equipment
Food preparation countertop
A separate and lockable closet or cabinet for hazardous chemicals

How will the kitchen be made inaccessible to the children?

Please check with the Fire Marshall for methods of inaccessibility.

Infant / Toddler Food Service

Will bottles be stored, prepared, warmed, served out of the kitchen?

Yes
No
N/A

Will bottles be stored, prepared, warmed, served in infant classrooms?

Yes
No
N/A

Does the infant room have countertop space for warming bottles?

Yes
No

What method will be used to warm bottles?

Is there a refrigerator for bottle storage?

Yes
No

Is there a separate hand wash lavatory used exclusively for bottle/food preparation hand washing?

Yes
No

Diapering

Will the child care center be caring for children with diapering needs?

Yes
No

Do the infant, toddler, and two-year-old rooms all have diapering stations?

Yes
No

If diapering stations are not in each room, please explain.

Can the caregiver view other children while changing diapers?

Yes
No

Where and how will soapy water and disinfectant be stored (at least 5 feet from the floor)?

Where will diaper creams, powders, etc. be stored out of reach of children (at least 5 feet from the floor)?

Is there a separate hand wash lavatory used exclusively for diaper changing hand washing?

Yes
No

Storage

Will each child have their own storage space?

Yes
No

Are coat hooks spaced at least 12 inches apart?

Yes
No

(Double hooks may not be used for two children.)

Where will medicines (both refrigerated and non-refrigerated) be stored and locked?

Locked storage rooms and cabinets shall include those which are unlocked with a combination, electronic or magnetic device, key or equivalent locking device.

How will non-aerosol sanitizing, disinfecting, and detergent solutions, hand sanitizers, and hand lotions be kept out of reach (at least 5 feet from the floor)?

How will personal belongings (purses, keys, employee items) be inaccessible to children?

Where will all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled be stored and locked?

Locked storage rooms and cabinets shall include those which are unlocked with a combination, electronic or magnetic device, key or equivalent locking device.

Beds, Cribs, Cots, Mats & Linens

Is the child care center an after-school program only, and bedding will not be provided?

Yes
No

Will cribs have the capability of being spaced 18 inches apart while in use?

Yes
No

(If not, crib dividers and partitions are acceptable.)

How and where will cots and/or mats be stored?

Where will crib, cot, and mat sheets be washed and stored?

Designated Sick Child Area

Where is the designated sick area with cot/mat/vomitus receptacle?

Cleanings / Sanitizing

Where will toys, in classrooms with children in diapers, be washed and sanitized?

If establishment will only enroll children ages 3 and up, just enter "N/A".

Where is the can wash facility (mop sink) for cleaning trash cans, dumping mop water, etc.?

Not required for establishments with a planned occupancy of less than 13 children. Enter "N/A".

Additional Hand Wash Lavatory Information

Does each toilet area have a conveniently located non-food service related hand wash lavatory?

Yes
No

Does the food service area in the infant and toddler room have a hand wash lavatory exclusively for food service hand washing?

Yes
No

What types of faucets are at all hand wash lavatories?

Please note that metering type are not allowed unless they can retain warm water for at least 20 seconds at the first pressing.

Hot Water Supply

Please relay the following to your plumber and engineer. The water temperature at the kitchen dish sink and the clothes washing machine will need to be a minimum of 120 degrees Fahrenheit. The Department has found that using two water heaters is the best option. Provide water heater(s) specifications. (Please note if you are using two water heaters and which one is for the kitchen/laundry and which one is for the classrooms.)

Water Heater Number 1 Information

Storage Tank Size / British Thermal Units (BTUs) / Kilowatts (kW)

Gallons Per Hour (GPH) Recovery

Type of Fixtures Served

Water Heater Number 2 Information

Storage Tank Size / British Thermal Units (BTUs) / Kilowatts (kW)

Gallons Per Hour (GPH) Recovery

Type of Fixtures Served

Lighting

Do all light fixtures have shatter-proof or shielded bulbs?

Yes
No

Will a minimum of 50 foot-candles of lighting be provided at all work surfaces (including food prep, utensil washing, diaper changing, children's work tables, desks, and easels etc.)?

Yes
No

Will a minimum of 10 foot-candles of lighting be provided at all other areas, including storage?

Yes
No

Finishes

Please describe the finishes/construction material in the following areas. All must be washable.

Diaper Changing Counters and Backsplashes

Food Service Counters and Back-Splash in Infant Room

Floors Around Food Service Counters in Infant and Toddler Rooms

Cabinetry

Kitchen Floor and Base

Kitchen Walls

Kitchen Ceiling

Note: Kitchen and toilet room ceilings may be acoustical ceiling tiles providing adequate ventilation is provided to keep down moisture.

Toilet Room Ceilings

Note: Kitchen and toilet room ceilings may be acoustical ceiling tiles providing adequate ventilation is provided to keep down moisture.

Outside Premises

Please describe the playground area (type of play equipment, type of fence, water activities, etc.).

Is there a can wash facility outside?

Yes
No

If yes, and if the water is greater than 110 degrees Fahrenheit, is there a fence around it and lock so it is not accessible to children?

Yes
No

Is the HVAC, mechanical equipment, etc. locked with a fence around it and not accessible to children?

Yes
No

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Child Care Center Plan Review Application

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Introduction & Checklist

Project Information & Contacts

Acknowledgement & Signature

Questionnaire

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