USVI Public Records

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DHS-CO-202A GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HUMAN SERVICES BUREAU OF LICENSING APPLICATION FOR A VIRGIN ISLANDS LICENSE TO OPERATE A DAY CARE CENTER I. Name of Facility: __________________________________________________________ 1 Mailing Address: __________________________________________________________ Physical Address: __________________________________________________________ __________________________________________________________ FOR USE BY DHS ONLY Application Date____________ Date Approved_____________ Date Denied _______________ Telephone: __________________________________________________________ Check Type of Facility: Church Proprietorship Public Agency Commercial Partnership Corporation II. A. (Proprietorship or Partnership ONLY) Name(s) of Proprietors or Partners: 1. Name:_________________________________________________________ Telephone:_____________________ Last First M.I Home Mailing _____________________ Address:_________________________________________________________ Work Residence:_______________________________________________________ 2. Name:__________________________________________________________ Telephone:____________________ Last First M.I Home Mailing ____________________ Address:_________________________________________________________ Work Residence:_______________________________________________________ B. (Church, Commercial, Corporation, or Public Agency ONLY) Name of Church, Corporation or Public Agency: _________________________________________________________________________________________________ Address:_______________________________________________________ Telephone:______________________ Designated Representative:________________________________________ Title___________________________ Home Address:__________________________________________________ Telephone:______________________ 2 Include Articles of Incorporation Tax Exempt Certificates By Laws Names & Address of Board Members III. (For Proprietor, Partner, or President of Corporation/Agency) 1.______________________________________ 2._______________________________________ Date of Birth Date of Birth _______________________________________ ________________________________________ Place of Birth Place of Birth _______________________________________ ________________________________________ Citizenship Citizenship ________________________________________ ________________________________________ (If Naturalized give certificate #) (If Naturalized give certificate #) ________________________________________ ________________________________________ (Visa Number if applicable) (Visa Number if applicable) ________________________________________ ________________________________________ Social Security Number Social Security Number 3. Have any of the above ever been convicted of a Crime? YES NO _____________________________________________________________ Name If yes, give date, place & nature of offense_______________________________________________________________ __________________________________________________________________________________________________ 4. Educational Background_______________________________________________________________________________ Years Completed Name of School(s)___________________________________________________________________________________ Address____________________________________________________________________________________________ IV. 1.Type of Operation Full Day Half Day Other _________________ After-School Night-Care (Specify) 2. Open From_____AM/PM to ______AM/PM Days per Week: M T W T F S S (Circle each day open) Vacation Periods in Year______________________________________________________________________________ 3 3. Proposed Capacity: Total Number of Children (Include own pre-school children)_____________________________________ Minimum Age________________________ Maximum Age__________________________ Number of staff-full-time_______________ Part Time______________________________ Fees – Monthly Fee (Indicate any variations in established fee, for example, for more than one (1) child in same family.) ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Registration Fee (if any) $_______________ Insurance Fee (if any) $___________________ V. Attachments – Attach a Copy Of all forms, brochures, etc. to be used daily activity schedule for center floor plan of Center with all room measurements, specifying function(s) of each room. Show toilet facilities, including number of basins and commodes. Show isolation area for sickness. Give area of enclosed outdoor play space. written purpose and scope of service. (Proprietorship or Partnership ONLY) – statement of ownership, including who is responsible for policy making, administration, and operation. VI. 1. Describe proposed provision for medical or health inspections. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 2. Describe plans to work cooperatively with parents to promote the growth and development of each child. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 3. Describe proposed registration policy for children. _____________________________________________________________________________________________ 4 _____________________________________________________________________________________________ _____________________________________________________________________________________________ Please list as references the names, mailing addresses and telephone numbers of three (3) unrelated persons who are personally acquainted with you. (Churches, Corporations, or Public Agencies list three (3) references for each Officer of the Corporation or Governing body.) _________________________________ ____________________________________ ________________________ Name Mailing Address Telephone _________________________________ ____________________________________ ________________________ Name Mailing Address Telephone _________________________________ ____________________________________ ________________________ Name Mailing Address Telephone VIII. MEDICAL INFORMATION Name of Physician___________________________________________________________________________________ Address of Physician_________________________________________________________________________________ 5 TWO (2) PASSPORT SIZE PHOTOS FINGERPRINTS 1 R THUMB 2 R INDEX 3 R MIDDLE 4 L RING 5 R LITTLE 6 L THUMB 7 L INDEX 8 L MIDDLE 9 L RING 10 L LITTLE LEFT FOUR FINGERS TAKEN SIMULTANEOUSLY L. THUMB R. THUMB RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLY 6 1. I authorize the Department of Human Services of the Virgin Islands Government to make a reasonable evaluation to determine compliance with day care standards for issuance of a license, including the right to secure reference statements, as to my ability to meet requirements and prescribed rules and regulations. 2. I am aware that to operate a Day care Center in the Virgin Islands without a license violates Virgin Islands law and is a misdemeanor subject to penalty of the court. 3. I also state that the information given above and such other information given in the course of the licensing study, is to the best of my knowledge true and correct. ________________________________________________________________________________________________________ __________________________________________________ _________________ Signature of Applicant Date __________________________________________________ _________________ Signature of Applicant Date __________________________________________________ _________________ Signature of Licensing Specialist Date