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THE CITY OF COLLEGE STATION
APPLICATION FOR A PERMIT TO OPERA1'E A KINDERGARTEN OR CHILD-CARE/D'EVELOP~lENT FACILI1'Y
Pa rt A. . ~ ,.~......:.tM~~ ).~_~J!::.r.~L_lti,~liWJ.arjf':l""~~~il\,
n
Name of Facility:,
Name of o.mer: mM<-r 7? (f./}/J/!-tf?--?r ./
Address: II (J ~ ;::::::- ^d'/7-!<"--<-.~) e <:I.
Location of Street Address
Facility Lot Block
-'
Telephon~ ,& 9h-7~/~
- -- _: . ~ '
r
Addition
Type of Facility:.
( ) Kindergarten
(Y) Child-care or Devel.opment"
---,--' , "
( ) Combination
Facility will "be operated I .9
Will meals be prepared and served?
hours per day, J
(v-)- Yes (
5 days per \-1eek.
) No
Building Const~ction:" (v-)' Brick (
Number of stories" tall?
and unloading of passengers? ( ) Yes
)
Frame ( ) Other (state)
Provisioll for ()ff.:tl1e~street loa<\:tllg
) No
(
Children (Including Inf~n~s) Tb~Be Accepteq.by Facili~y:_ ~ximum Number /~
Ages, from to UJ~ ,J)..& . to 4- l{.w../u:JJ ~ ;. Any physi ca l1y 'or me~t'aYly
,handicapped? ( ) Yes (L--) No
.
t
Is an individual record maintained for each child, including verification of
immunizations and a statement from the child ts physician? (V-Y-Yes", ( ). No
Personnel is to include a minimum of. ~
of part-time employees. "
Name of Director _of !acilit~: rn ~ 11 ~~~)
. Address I (0 ~ J== ~/OJ <E.--< ,..et~u
. Level of Education Completed ./. 0 caM.-J...J(-
~ -'"
full-time employees and a minimum
, "
********
(Important: B'efore._~igning the fol1o\~ing certification, a})plicant Jleeds' t()
complete both sections, Part A.and Part B.) of this application.)
. -.. "
Name. of . App1i~ar;t: :-)77 {4 J1 (~~-;t/v1! ~
Address. f ((./ ~ \ ~Yl.~;~/J._) <i.A"L/'-~-4-.R., ,ITCt;t~,-z..ry~.
Ti tIe ",01.- Pos i t ion: ~1..-'t~~9..".. '/~~JJ}./t2____
"J .."
Telephon'e ~ 70- 1 '+1 a-
In 'recognition of the permit to be granted for operating a kindergarten and/or
child-care facility and the responsibilities implied therein) I certify that I
am aware of the stipulations of Ordinance No. 527 and will abide thereto. 1
further certify that all statements ~this applicatio~ are true and correct to
the best of my kno\~ledge. '
A 0 /' r; ~V ()
.QLJ IT :21 I ,/
Date
. .1?1 UA/,Ar 7t {Vt-1-J/{ t'/~
Signature~f"Applicant
Approved: C-j
~, d-1
Date: ~
PartB.
Indicate in the appropriate block ~.,hich of the fellot-ling items (and number
of each) are located at the facility:
Description
Flus~ Toilets for use by children -
Lavatories fo.ruse by ch,ildren ",..",.', . . . ,,'j."..V..
Cots for use by chi ldren __~___. _~__ ___~__.___-~ .. '_" _ ___
Beds for use by children ,'.. .' " v-.
--------
Cribs for use by infants L-'.
Water-proof self-closing Containers for v/
_~iJ.~d ~iaE-~rs and linen~_#._~ ----.----.. - . --- ..--..-
Locked and Exclusive Storage Area for Med~cine - ~.
4'" ...__~.~_-~_______.--------------.-..-- 4._ -~....-
Separate Room for Isolating Children \-1ho i
::~:i?~~:~~~:~;~~:i;::~~::k K~:~Plernent -~-f=~:= ~.. .-----~ ---- .--
~~~~:~::::df~.s::~~;:~~te~i~~:-----lC~=~-=~~---"-._~
Health Officer, etc. V-.
r------.
Safe and Secure Storage Area for detergents) t
insecticides, and poisons · ,.,/
'.. 14. Fire ~X~.in~~.~s.J:l~~S,(I,11s~ect..~,d,,_~1i,Eiiin".,l~s!=_y.~~x->.._..r--~-.- -- ..., .- -.--..--,-"..-, , ,," -,
15. Unprotected fireplaces or stov'e.g;;: ::L V-'
16. Fenced Play Area '.'--- ___'_._H'. t'- V -.. -..-- .. - .~._.---.---H__--
.
17 . S\.,imrning Pool or wading 'Pool --. ------T----- ~_. ~--._-.---
.7.... W"M:::J !t'~.~.w;t:r'... w rt-r ~;r~. ~.:. . 'L~-:.:...... ."",... l".". ~ .. "........,....... ~..... .". ""... .." ......,.,,, In · .... '" --.:.. '"" I , ..... . ... .. - ... . ..
., ;; '-., "'~";'A ~. I.. ."':~ ......... .,~ "-"I"~_l!< all! _!!II """ .. ""... ....,. .III .. A. . ow.. _ .. .... ............. .............. .... ,.,.........,. -.-. ~"'liIl! lJi"- ..,.- ill N!!~'
Answer each of the follOt-ling questions by marking the appropriate block l.~
<if number is relevant to completing ahs~-l~r~' f>~ate how. maiw) ..... .----.-
~. Yes How No llow'- -~
&~ M.an)!~
Is an individual record maintained for each _. ~
employee, including information on qualifica-. ,
~~::s a:~d ;p~;~:~h:~~t:~;:{c~i :rI>:~:{:i~E.!_- '-j--y ;--- \
disabilities? ..__ .- ----- .-u_ --- ~
~~ :;~? employee U~der 16 or over 65 years __:.-\._.__- _ _' .~:-- .J ~ .._.-----~:
4. .Has any employee completed the American J
I Red Cross Course in First Aid? · ~
)iWilf !L"j,Ip"'lll.\la"tIB 'iJrW',J'-!)i!J..'It?r~' . .-. ." .. -, -.
Item
1.
2.
3.
'4.
5.
6.
9.
10.
11.
12.
13.
'-.
Yes
No
II ow
Many?
J-;
J-,
t Leave"
) lank)
~.
7 .-
8.
.~- - ...._!:{.._--_..._._~-
...5 ,__.___
;L
- ... .. .,------ ..-........-.----..-----~ ~..-...
___ _.. l..-:--- --
1.
,..---
2.
3.
_.-.-- Do Not \vrite in Follmdng Space (For Use by City Only) ~ ·
Approved by
City Building Inspector
Signature
of Official:
Title: Date:
Approved 'by
City Fire ~~rshal1
Signature
of Official:
Title:
Date:
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