11-10-1986 Council Packet - Laserfiche WebLink

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Please type or use ink. complete all items. I. IDENTIFYING INFORMATION Name off ility busy Beaver Day -Care APPLICATION FOR GROUP CARE LICENSE AND RENEWAL OF LICENSE __ :-'Now program O Renewal application Change in location Street or B o City Inc. �� W. Wayzata Blvd., Orono Name of director In§eborg Cici Mailing Address, If different from above Name Open from month of: through month of: Year around Kind of service (Check (✓) appro All Half riate service) Day Day LJ ❑ Day Care/Nursery ❑ ❑ Head Start ❑ ❑ Nursery School ❑ ❑ Cooperative ❑ ❑ Other Explam Other III. FOOD SERVICE Street or Box No. for the hours to f site b belpw30 6: 00 p m Monday: Tuesday: from am tom Wednesday: from6: 30 am to 6:00pro Thursday: from6: 30 elm to 6: oopm Friday: from6 : 30 all) to -6— Saturday: 1romcl oiled to _ Sunday: fromC1osed to [rector's phone number Changes in terms of license county Henn., _ il �F eci's phone 78�_.fi2 llity--- County 4.5 Indicate your request for licensed capacity i.e. maximum num- ber of childr n present a ny one time. Infant)C7ERf9f1RhCSiRR737C'R3�: o Toddler (16 months thru 30 months): 14 Preschool (2% years thru 5 years): 30 - 10 15 School age (6 years thru 1@ t: TOTX.eS 12 month - yrs 67 Children M als served Site(s) of preparation 9' Break!ast ❑ Meals Prepared on site Q Morning snack ❑ Meals catered only uncooked d'Cunch )(❑-, Meals taken at separate location 6 Afternoon snack L' Bag lunches ❑ Dinner foods are ser ❑Ye ❑ Therapeutic diets Is any child in care nine or more hours per day? No Name and address of caterer or off -site food preepared by Staff Name and title of person who has reviewed menu for nutritional adequacy in the Past 12 months Henn. Cty Comm. Health Dept. Date ofJir , 18 1986 Debra Anderson nvironmenta ist Status of boarding license: ❑Not required ❑Apolied for kelCurrent license IV. HEALTH AND SAFETY Name of center's source of emergency medical care€meraency Squad Henn. Name and title of health consultant who has reviewed health policies: Kathy Pfpi Public Health PJurse Henn.CtY- Date ofreview,8ug. 13 1986 Namgg of ph sician who has approved health policies for infants: not worked ou L ye 1 Date of approval: Name and title of infant care consultant V. EQUIPMENT Tfie program meets the required minimum indoor and outdoor equipment for each applicable age group. ❑Yes ❑No Explain all "No" answers: t"' 00368 04 OHS 368 (4-841 IP Code 55391 IP Code 11. WAIVERS _ Are you requesting ❑ A new waiver (Please attach written request) ❑ A renewal of waiver regarding V1. TRANSPORTATION Does the program provide transportation: VII To and/or from home and the center? ❑Yes No Types of vehicles. For outdoor play? ❑Yes No Types of vehicles Field tripsP )PYes ❑No Types of vehicles: 1985 Sub. Ehevr For children under 2%>2 ❑'ees)QNo If yes, are infant/toddler safety seats used" ❑Yes ONO Do any children ride longer than one hour? ❑Yes (NNo Is there more than one adult accompanying the driver: For five or more children 2'S years ; f .ioe or older? QYes ❑No For each five infants/toddlers ❑Yes QNo N.A. INSURANCE_ —.— Is the program insured for general tiability at the minimum of 5100.000 5300 OGO le,ei o' coverage? ®Yes ❑Na Name of insurer: I S I i h / Mt Vera= Policy #: G1 AR4122 Expiration date 6/ 1 8/87 Is the program insured for automobile liability at the minimum $100,000.1S300.000 level of coverage? K]Yes ❑No Name of insurer: t ff Policy#: 596- - - 7-2 Expiration date: 1An_ 27 19R7 Are staff covered by Worker's Compensation? ilYes ❑No UnemploymentCompensation7 Ayes ❑ May t No ❑N/A Ins. only Social Security? WYes ❑No ❑NIA May 0 October f rom DHS USE ONLY: Date Zoning Notice sent ❑NA Date of Fire Approval:---=ytiA--- Date of Building Code Approval: — ❑NA Date of Boarding License Approval: ____-- ❑NA Licensino Fee Rpreived by Cashier __ - -__ fINA —