USVI Public Records

Document text

DHS-CO-202D GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Licensing & Regulatory Services APPLICATION FOR A VIRGIN ISLANDS LICENSE TO OPERATE A CHILDREN’S CAMP / AFTER SCHOOL PROGRAM I. Name of Facility: _____________________________________________ FOR USE BY DHS ONLY Application Date___________ Date Approved____________ Date Denied ______________ Street Address: _____________________________________________ Mailing Address: _____________________________________________ _____________________________________________ 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: __________________________________________ ____________ Last First M.I Res. Phone Mailing Address: _______________________________ ____________ Bus. Phone Residence: ____________________________________ 2. Name: __________________________________________ ____________ Last First M.I Res. Phone Mailing Address: _______________________________ ____________ Bus. Phone Residence: _____________________________________ 1 III (Church, Commercial, Corporation, or Public Agency ONLY) Name of Church, Corporation or Public Agency: __________________________________________________________________ Mailing Address:__________________________________ ______________ Bus. Phone Designated Representative:___________________________ ______________ Title Residence:________________________________________ ______________ Res. Phone Include Articles of Incorporation Tax Exempt Certificates By Laws Names & Address of Board Members (For Proprietor, Partner, or President of Corporation/Agency) _________________________ _________________________ Date of Birth Date of Birth _________________________ _________________________ Place Of Birth Place Of Birth _________________________ _________________________ Visa Number (If applicable) Visa Number (If applicable) _________________________ _________________________ (If naturalized give Certificate #) (If naturalized give Certificate #) _________________________ _________________________ 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 and nature of offense_________________________________ _____________________________________________________________________ 2 IV. 1.Type of Operation Full Day Half Day Over Night Other (Specify) _____________ Open From_____AM to ______PM Days per Week: M T W T F S S (Circle each day open) 2. Proposed Capacity: Total Number of Children (Include children of operation and staff) _______________ Minimum Age_________________ Maximum Age_________________ Number of staff-full-time_______________ Part Time________________ 3. 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. 1. Attachments – Attach a Copy Of all forms, brochures, etc. to be used Schedule of activities (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. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 3 2. Describe proposed registration policy for children. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ VII. 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 the Officer of the Corporation / Director of the Facility.) NAMES MAILING ADDRESSES ___________________________ ________________________ ___________________________ ________________________ ___________________________ ________________________ VIII. 1. I authorize the Department of Human Services of the Virgin Islands Government to make a reasonable evaluation to determine compliance with Virgin Islands Rules & regulations for Children’s Camps / After School Programs. 2. I am aware that to operate a Children’s Camp / After School Program in the Virgin Islands without a license from the Department of Human Services 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 Licensing Specialist Date 4