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HomeMy WebLinkAboutDaycare Inspection 120 Foster Road ENVIRONMENTAL INSPECTION REPORT ❑ INSPECTION REINSPECTION ❑ COMPLAINT S a l r��5�, Department of Public Health-Child Care Licensing Program Town 410 Capitol Ave.,MS#12 DAC,P.O.Box 340308,Hartford,Connecticut 06134-0308 �a r� Date of Inspqptjon INSTRUCTIONS Check=Compliance, Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable Date of Expirati n icense CapacityLtz Under 3 Endorsements_ #Children Present #Staff Present IS Program Namido FV4,;& w6w License# Telephone Address Operator Licensed for: Vgbder 3 Yrs ❑School Age ❑Night Care ❑Pre-School(3-5 Years) ❑On Site Kindergarten Physical Plant/Indoor Space 19a-79-7a Health and Safety 19a-79-6a ❑ 1 License premises clean/good repair ❑ 11 Refrigeration no more than 45° ❑ 2 Equipment clean,in good repair,safe/non-toxic ❑ 12 Food prep area clean/good repair ❑ 3 Free from observable hazards ❑ 13 Food safely stored ❑ 4 Drinking water available,adequate,safe ❑ 14 Food prep handwashing ❑ 4a Lead Water Test/Date ❑ 15 Adequate dishwashing ❑ Within Limits ❑ Exceeds Limits ❑ 16 Kitchen separated ❑ 4b Public Water Supply ❑ 17 Mark as appropriate: ❑ 4c On Site Well(In compliance with CT Public Health Code ❑ Snacks served ❑ Cold breakfast Sections 19-13-B51a-m and 19-13-11102) ❑ Meals served ❑ Meals transported ❑Local Health verified with DPH Water Supplies Section for ❑ Other facility licensed to serve 25 or more adults and children over 60 days per year ❑ Building: Post 1978 Construction ❑ 4d Private Well—Facility serves less than 25 children&adults ❑ Building: Pre 1979 Construction(Lead Inspection Required) El 4e Other(Please specify) ❑ 5 El No Lead-Based Paint Identified Required toilets/sinks/supplies ❑ 6 Adequate ventilation in toilet room El Lead Hazards Identified and Eliminated ❑ 7 Sewage disposal adequate (Plan of correction on file with Local Health Dept.(LHD)) ❑ Intact Lead-Based Paint Identified (Management Plan on file with LHD) Outdoor Space 19a-79-7a ❑ 8 Swimming pool complies with PHC 19-13-B33b ❑ 9 Playground free from observable hazards "REMARKS" ❑ 10 Drinking water available,adequate,safe ❑ Approval recommended. No code violations identified. ❑ Approval recommended with conditions(see below). ❑ Approval not recommended due to existing serious code violations. S' spIF Date Corrections Due Signed(Person in Charge) s. i ►sio icensur/Grp&ctr/Field Forms/Env Inspection Report 3/05/03 Website form for Local Health ENVIRONMENTAL INSPECTION REPORT PNSPECTION ❑ REINSPECTION ❑ COMPLAINT Department of Public Health-Child Care Licensing Program Town 410 Capitol Ave.,MS#12 DAC,P.O.Box 340308,Hartford,Connecticut 06134-0308 /Y d Dat f I s ection INSTRUCTIONS An Check=Compliance, Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable Date of Exp' ion Licensed Capacity Under 3 Endorsement #Children Present #Staff Present rye Prog am NamgA License# Telephone# Address Operator Licensed for: Under 3 Yrs ❑School Age ❑Night Care ❑Pre-School(3-5 Years) ❑On Site Kindergarten Physical Plant/Indoor Space 19a-79-7a Heoth and Safety 19a-79-6a ❑ License premises clean/good repair E30011 Refrigeration no more than 45' Equipment clean,in good repair,safe/non-toxic if❑ Food prep area clean/good repair Free from observable hazards 13 Food safely stored Drinking water available,adequate,safe 0 14 Food prep handwashing ❑ 4 Lead Water Test/Date JQJA Adequate dishwashing ❑ Within Limits ❑ Exceeds Limits 16 Kitchen separated Vb Public Water Supply ❑ 17 Ma as appropriate: ❑ 4c On Site Well(in compliance with CT Public Health Code 16Snacks served ❑ Cold breakfast Sections 19-13-B51a-m and 19-13-B102) ❑ Meals served ❑ Meals transported ❑Local Health verified with DPH Water Supplies Section for ❑ Other facility licensed to serve 25 or more adults and children over 60 days per year QBuilding: Post 1978 Construction 4d Private Well—Facility serves less than 25 children&adults ❑ Building: Pre 1979 Construction(Lead Inspection Required) ❑ Other(Please specify) fl' Required toilets/sinks/supplies El No Lead-Based Paint Identified 6 Adequate ventilation in toilet room El El Hazards Identified and Eliminated 7 Sewage disposal adequate (Plan of correction on file with Local Health Dept.(LHD)) ❑ Intact Lead-Based Paint Identified (Management Plan on file with LHD) Outdoor Space 19a-79-7a 8 Swimming pool complies with PHC 19-13-B33b Playground free from observable hazards "REMARKS" '0710 Drinking water available,adequate,safe ❑ Approval recommended. No code violations identified. ❑ Approval recommended with conditions(see below). (� �a I ❑ Approval not recommended due to existing serious code I violations. 0671\- rVT Ode.A, l�j L4-JAP&A- Ile ST �" NWJ beast t4g�" ^ d-,7,Z) Signed s cto to Cor cti ns Due � Si tt( erson i ar ) 1 s:/Div on/Licensu / rp tr/Field Forms/Env Inspection Report 310510 Website form for cal Heafth ENVIRONMENTAL INSPECTION REPORT INSPECTION ❑ REINSPECTION ❑ COMPLAINT Department of Public Health-Child Care Licensing Program Town (y 410 Capitol Ave.,MS#12 DAC,P.O.Box 340308,Hartford,Connecticut 06134-0308 Date of Inspecti0 INSTRUCTIONS q1� Check=Compliance, Circle=Non-Compliance; 3=Not Observer!; 4=Not Applicable Date of Expiration Licensed Capacity Under 3 Endorsement 1� #Children Present #Staff Present_ / /� 'Program Name License d Telephone# ap Address Operator Licensed for: � Under 3 Yrs ]School Age ❑Night Care Pre-School(3-5 Years) El Site Kindergarten Pal Plant/Indoor Space 19a-79-7a Heath and Safety 19a-79-6a 1/-License premises clean/good repair 1 Refrigeration no more than 450 quipment clean,in good repair,safe/non-toxic [ is Food prep area clean/good repair j 3 Free from observable hazards 13 Food safely stored Drinking water available,adequate,safe �4 Food prep handwashing ❑ 4aV4b Lead Water Test/Date t15 Adequate dishwashing Within Limits ❑ Exceeds Limits 1 tchen se arated Public Water Supply 17 Mar appropriate: 4c On Site Well(In compliance with CT Public Health Code Er Snacks served ❑ Cold breakfast Sections 19-13-B51a-m and 19-13-11102) ❑ Meals served ❑ Meals transported ❑Local Health verified with DPH Water Supplies Section for ❑ Other facility licensed to serve 25 or more adults and children over 60 days per year Building: Post 1978 Construction 4d Private Well—Facility serves less than 25 children&adults Building: Pre 1979 Construction(Lead Inspection Required) � 4 Other(Please specify) si-- Required toilets/sinks/supplies El No Lead-Based Paint Identified Adequate ventilation in toilet room El Lead Hazards Identified and Eliminated Sewage disposal adequate (Plan of correction on file with Local Health Dept.(LHD)) ❑ Intact Lead-Based Paint Identified (Management Plan on file with LHD) Qutdoor Space 19a-79-7a 148 Swimming pool complies with PHC 19-13-B33b j 99 Playground free from observable hazards "REMARKS" F2iu Drinking water available,adequate,safe Approval recommended. No code violations identified. �E ``Approval recommended with conditions(see below). ❑ Approval not recommended due to existing serious code violations. sQ19 �A /, - -?tsd u v a� sco)/ 0- p��5 1 , 56c-e� yte� 5�.�''e�°-�r� -Ir tzulzor mac- gn sM Date Cor ec ions,pue\ Signed in harge) A� s: ivision/Licensure tpttiffiield Forms/Env Inspection Report 3/05/03 Website form for cal ealth • ' STATE OF CONNE�TICUT DEPARTMENT OF PUBLIC HEALTH .. Community Based Regulation Section - rralY� Note: This Cover Letter/Check List MUST BE RETURNED With Your Renewal Application Dear Operator: The license for your child day care facility is due to expire shortly. Enclosed is a copy of the Newly Revised and simplified renewal package for relicensure of your child day care license. Make three (3) copies of your completed renewal packet. It is.required that one completed packet be submitted to the Department of Public Health (DPH), SIXTY(60) DAYS PRIOR TO THE EXPIRATION date of your license. Send one copy to your local sanitarian or health director's office, and retain one copy of the packet for your files at the facility with your complete initial licensinL-application. THE NON-REFUNDABLE LICENSING FEE of $200.00 for a Center License or $100.00 for a Group Day Care Home License and ALL required documents, MUST BE INCLUDED WITH YOUR RENEWAL PACKET OR IT CAN NOT BE PROCESSED. Please make your check payable to Treasurer - State of Connecticut. A license cannot be issued for your child day care facility until Local Health Department approval is received by the Department statinz that your facility meets the public health code requirements for licensure as a child day care center or a zroup day care home. Please note that a current fire marshal's certificate must be posted at the facility at all times. It is your responsibility to contact your local fire marshal and local health sanitarian immediately and arrange for these inspections and certificates for your child day-care facility. .. Please reply directly to: Child Day Care Licensing Unit Department of Public Health—Day Care 410 Capitol Avenue,MS#12-DAC P.O.Box 340308,Hartford,CT 06134-0308 1-800-28276063 or 1-800-439-0437 or(860)509-8045. ALONG WITH THE APPLICATION YOU MUST INCLUDE: i. Cover Letter/Check List Yes ❑No 2. Fee Invoice and Check Yes ❑No 3. Affidavit Yes ❑No 4. Consultant Data Sheet&Copies of All Current Yes ❑No Agreements(Attachment#I If) 5. Proof of Worker's Compensation Form Yes ❑No 6. Copy of Worker's Compensation Insurance Certificate Yes ❑No 7. Lead Water Test(Bacterial&Chemical if well) Yest ❑No 8. Water Supply(Attachment#13b) Yes ❑No 9. Staff Work Schedule Yes ❑No �j 10. Please indicate the date you have sent a copy of this application to your Local Health Department /� l / and be sure to include verification of the Local Health Inspection upon completion of the Inspection. r • Was the building/structure in which you provide or will provide child care constructed prior to 1979? ❑ Yes No If Yes,have you had a full Comprehensive Lead Paint Inspection? [:]Yes [:]No If Yes,date of full Comprehensive Lead Paint Inspection Phone: (860) 509-8045, Fax: (860) 509-7541 'Telephone Device for the Deaf (860) 509-7191 p 410 Capitol Avenue-MS#12CBR P.O. Box 340308 Hartford, CT 06134 An Equal Opportunity Employer T:\Grp&Ctr\Relicensure\G_C_RelicAppLtrCklist.doc 2/24/06 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Community Based Regulation Section ��raWr Child Day Care Licensing—Fee Invoice Form The licensing fee is due with-your application to obtain or renew a child day care license. THE FEE IS NON- REFUNDABLE. Please complete items 1 through 10 of this form. If you have questions, call the licensing office at 1-800-282-6063, 1-800-439-0437 or(860) 509-8045. Make your payment by check or money order payable to: TREASURER-STATE OF CONNECTICUT. Mail this form along with your payment and application to the Department of Public Health at the address on the bottom of this form. 1. Name of Licensee or Applicant: (Lea Operator) 2. Program Name: 7M 0 Lj a I An 00 (Applicable For GrouplCenter Only) 3. Program Location Address: —7 tut CT Street Address i /Town Zip Code 4. Program Phone Number: l01 V _ ���Q Program Fax Number: 5. License#: Expiration Date: 9 (For Relicensure Only) (For Relicensure Only) 6. Mailing Address(if differect): a. Ej 1 I ram ed ULff , CT W4— Street A d ss Crty/7own Zip Code 7. Program E-mail Address: " 8. Enclosed Check/Money Order: $c�iOQ a Check#: l q3 Check Date: 9. Social Security#: - or Federal Employer ID uz j S (3 digits) (2 digits) (4 digits) g ) (2 digits) (7 digits) i 10. Payment is for the following type of license: (check one box below) Child Day Care Center Group Day Care Home Family Day Care Home (Account#42431) (Account#4243 1) (Account#42431) ❑6-month license SO.00new program) ❑6-month license(new program) �. 2-year license(new provider) $30.00 $20.00 j t 2- ear license(relicensure) j $200.00 ❑2-year license(relicensure) ❑2-year license(relicensure) $100.00 $20.00 r Phone: (860)509-8045, Fax: (860)509-7541 �.. Telephone Device for the Deaf(860)509-7191 to 410 Capitol Avenue-MS#12CBR P.O. Box 340308, Hartford, CT 06134 An Equal Opportunity Employer T:\Fam&Ctr\Application\CDC_FeeFonn.doc 2/24/06 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Child Day Care Center or Group Day Care Home AFFIDAVIT • NOTE: This form must be completed by the Operator or the individual authorized to represent and act on behalf of the Operator. �-nAA, no being duly sworn depose and say: Name of IDpiFiat6r(if Operator is an individual)or Legal Representative The name of the child day care center/group is Name of Child Day Ca e n er nru'plbai Care Home The application is tryade to&ct this child day care center/group c e Location Address: U—n— Street City/Town State Zip Code The Operator of the above named facility is Name of Oper for and is a(check one): ❑ Individual/Sole Proprietor corporation ❑ Partnership ❑ Limited Liability Company ❑ Limited Partnership ❑ Limited Liability Partnership If applicable,the individual authorized to act on behalf of the operator of the above name facility is: Name of Legal Representative I am the Operator and am legally responsible for the operation of said program or I am the Legal Representative and am duly authorized and empowered to act as of this date on behalf of the Operator. My phone number is Das k � �--� My address is ' l o � Al .�--� Street,City/Town,State,Zip Code I have read the Connecticut General Statutes and Regulations of Connecticut State Agencies(Public Health Code)relating to the licensure and operation of a child day care center/group day care home. Y The information contained in this application is true and indicates compliance with the aforementioned Statutes and Regulations. I will ensure that this program will be operated in compliance with the aforementioned Statutes and Regulations and with any Consent Order executed with the Department of Public Health or any successor agency. I give my permission for a full unannounced inspection of the facility and a comprehensive review of the program and staffing plans for the child day care center/group day care home by the State Department of Public Health, and the local health department for the purposes within their authority,at any time throughout the period for which the license is issued. I understand that the Department of Public Health must be immediately notified of any change in the plan of operation affecting any condition contained in the application upon which the license is renewed and of any change in the legal representative. I understand that the license is time limited, is subject to review, and that renewal is necessary for continued operation of the child day care center/group day care home. Any false statements made herein a pu s able ip accord c with Section 53a-157b. r a ure of perator o Legal Representative Subscribed and sworn to be a me on the day of Day onth Year Signature of to t isstoner of s perior court o o er r r official as noted in Connecticut atute Section 1-24 At+ICY E. BERM T:\Grp&Ctr\AppIication\G C_Affidavit.doe 121205 NOTARY PUBLIC MY COMMISSION EXPIRES NOV.So.2008 . ` STATE OF CONNECTICUT V DEPARTMENT OF PUBLIC HEALTH Community Based Regulation Section . ALL FAMILY DAY CARE HOMES, GROUP DAY CARE HOMES,AND CHILD DAY CARE CENTERS PROOF OF WORKERS'COMPENSATION INSURANCE IF YOU HIRE EMPLOYEES TO WORK IN YOUR PROGRAM State Law (CGS Section 31- 286a(b)) requires that no state department, board or agency may issue or renew a license, or permit to operate a business in this state unless the applicant first presents sufficient evidence of current compliance with the workers' compensation insurance coverage requirements of Section 31-284. This means that if you hire employees to work in your family day care home, group day care home or child day care center on a part time or full time basis, you must submit to the Department of Public Health as part of your initial license application or relicensure application, sufficient evidence of compliance with this law. For More Information Contact: Your Insurance Agent or The Workers' Compensation Commission: 1-800-223-9675 or 1-860-493-1534 THIS FORM MUST BE COMPLETED AND RETURNED WITH YOUR APPLICATION FOR A CHILD DAY CARE LICENSE(EVEN IF YOU DO NOT EMPLOY STAFF) Program/Provider Name: ❑ New Application Address: ❑ Relicensure Application Town/State/Zip: Telephone: v License#: Do you hire employees in your program that requires you to obtain Workers' Compensation Insurance? Yes ❑ No If "Yes", please check off which of the required certificates you have, as indicated below, and mail a copy of the certificate to the Department of Public Health, Day Care Licensing Program. Sufficient evidence means: (Check off and enclose a copy) ❑ (1) a certificate of self-insurance issued by a workers' compensation commissioner pursuant to section 31-284; or ❑ (2) a certificate of compliance issued by the insurance commissioner pursuant to section 31-286; or a certificate of insurance issued by any stock or mutual insurance company or mutual association authorized to write workers' compensation insurance in this state or its agent. r R (Signature Operator/Provider) (Date) (Printed Name) T:\Fam&CtrWpplication\CDC_wClnsForm.doc 2/24/06 .Phone: (860) 509-8045, Fax (860) 509-7541 C: Telephone Device for the Deaf (860) 509-7191 410 Capitol Avenue-MS#12CBR P.O. Box 340308 Hartford, CT 06134 An Equal Opportunity Employer ACOR' '1' 'II"'r" I PRODUCER -P,. CERTIFICATE OF LIABILITY INS U RANCE DATE-(MWDONYY-�j (860 S �1 8 (86,0 I+-z:I vsl+ FAX (860)1�:�;'I' l��� ?7 03/31/2008 Thom, �1. Burgess & Co. , 111-8500 11:::11 TT—EIS�ISSUED A! iX'FFE i_NFOR_MAT05N 'I I I, III 11:�:!'OF Inc. ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE 82�8 Sullivan Avenue HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 903 ALTER THE COVEEAGEAFFORDEQ BY THE POLICIES BELOW. South Windsor, CT 06074 - 500 71,INS URERS AFFORDING COVERAGE e .Learning enter, Inc ------------- _ 1, 501 West Middle Insurance Company - - -_ i NAIC:# 1-urnpike Philadelphia Insu'raaCe Compan'y Manchester, CT 06040 Hartford Insurance T_ COVERAGES I Ell 1111 --f— f THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AB TWITHSTANIDING NT WTH RESPECT TO WHICH THIS CERTIFICATE AVY REQUiREhIENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUME FOR THE POLICY PERIOD' 'MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCR ATE MAYBE ISSUED OR ,!,IBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS S4OIA14MAY HAVE BEEN REDUCED PAID CLAIMS. TYPE OF .......... GENER41.LIABILITY POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS Ts 08/11/2007 08/11/2008 Et,,I ocQ:JRRLr9.L 1,()00 00 DAMAGE IQ RENTE E 00:1.4i I A L�j 5,00 1,0()0,00 6-PEGA71E 7,1717 AL AC I X • 3 000,00 'Z'- Cl"W'ICI AC.- 3,000,00 AUTOMOBILE TOM0BfLE L[ABILITY PHPKI84439 0811112007 08/11/2008 SiNq.,LE UVT 1,000,00 A 1 X F C.Ij X (Per X GARAGE LIABILITY (Re,acuj.vtj AUTO 0-NI-Y-F.A.ACCIDENT i ,OT,j iER THAN ACC EXCESSiUMBRELLA LABIQ ITY A; ACH QCC:; ',IA' PHUB068360 08 '1112007 08/11/2008 1 000 00 1,000,00 'Er i X =;TTF T Cj;, 10,00 WORKERS COMPENSATION AND 02WECRH5774 08/11/2007 EMPLOYERS'UABILIT'v, 08/11/2008 X S ATLI 7�I 1)F I.. 500,00 17 1. rk_EA.SE F4 EMP OTHER 500,00 0,00 OE3CMPTION OF OPERATIONS I LOCATIONS j VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROvI3I0Ns 20 Foster Road, S. Windsor CT 0 Pierce Road, S. Windsor CT 250 Ellington Road, S. Windsor CT CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIESAE CANCELLED BEFORE THE State-of Connecticut EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 -DAYS WRITTEN NI TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Department of Public Health BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR I 165 Capitol Ave Hartford, CT 06134 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD25(2001/09) Vincent @ACORD CORPORATION 1988 CT Department of Public Health (Attachment 11f) Community Based Regulation Section Consultant/Head Teacher Data Sheet PLEASE PRINT-Please enter complete information for each Consultant and Head Teacher. Enter N/A(not applicable)for questions that do not apply CURRENT AGREEMENTS FOR ALL CONSULTANTS MUST BE SUBMITTED WITH THIS FORM Name of Person completing this form: Position: Q(„ Date form completed: _ Program Name: lk License# Street Address: I �.lo) 1 m Townl&YJ�MCT Zip:_ APO Telephone )(0 Fax E-mail Health Consultant(Required) Last name: 4� Middle initial: Resident Street Address: State: Zip: �^^((\\ Telephone#: (Ol�y) a� Q1 Fax - E-mail: Work Address: �JI�J1W1� �11X�� ► \"`-To State: Zip ��� r Telephone#: ("M US- Fax E-mail: Professional license held: ❑]Phyyssician []Physician Assistant DAP Registered NursAmegistered Nurse `I— � Professional License#: J To License Expiration Date: Early Childhood Education Consultant(Required) Last name:baeld First: Middle initial: Resident Street Address: �Q I �qws,� Town State:�_Zip: Telephone#: u��l(�3-4C� �- Fax#: C. ) - E-mail: Work Address: �l Town: -1— t �1 ZipaJ�Va lv — �— Telephone#: - 03� Fax#: L_) - E-mail: DPH approval on file: es ❑No Name at time of approval if different: PLEASE BE SURE TO COMPLETE THE REVERSE SIDE OF THIS FORM Dental Consultant(Required) Last name: � First:_ Middle initial : Resident Street Address: Town: State: Zip: Telephone#: (_� - Fait#: E-mail: Work Address: n• e: Zip_ Telephone# —E-mail: Professional license held- icensed Dentist ❑Dental hygienist Professional License#: (Y)l—7 S Expiration Date: Social Service'Consultant(Required) ic Last name: 10 First. Middle initial: Resident Street Address: Town. State: Zip: Telephone#: - Fax ) E-mail: - Work Address: 1 Town I�C6tate: T Zip: Telephone#: (&0 -�0 _Fax-#: (_ E-mail: Professional degrees held: E]BSW ❑BA/BS -Field of study: SW ❑MA/MS-Field of study: rSLLkZn( WU�� Professional License# if a licable) r: ^ Expiration Date: ( rr . Registered Dietitian Consultant(Required for programs that serve meals) Last name : First: Middle initial: Resident Street Address: Town: State: Zip: Telephone#: E-mail: Work Address Town: State: Zip: Telephone#: Fax#: E-mail: Professional license held: ORD License/ID#: Expiration Date: CURRENT AGREEMENTS FOR ALL CONSULTANTS MUST BE SUBMITTED WITH THIS FORM Head Teacher(s)(Required) Please complete this section for each Department Approved Head Teacher at this program. If your program has more th (1)Head Teacher,please submit this information as an dttachlent. Last name: irst: - -Middle initial: Resident Street Address M QJ!(C,� ate: Q1 Zip: Telephone#:(a w) (29�� Fax#:L E-mail: Work Address: Town: tate: 0 Zip: Telephone#:&0) (f)LO- ax#: - E-mail: Dept.of Public Health approval on fi es No der 3 Years [ eschool chool Age T'V Name at time of approval if different: Please return this form to: Department of Public Health,Division of Community Based Regulation, 410 Capital Avenue MS#12 DAC,P.O.Box340308,Hartford,CT 06134-0308 or Fax(860)509-7541 T:/.Grp&Ctr/Application/G_C_Consultants.doc 12/3/2003 The Learning Center 1250 Ellington Road South Windsor, CT 06074 NURSE CONSULTANT AGREEMENT My signature below certifies that I agree to be the nurse consultant for The Learning Center located at 1250 Ellington Road, 120 Foster Road, 80 Pierce Road, South Windsor, CT 06074. My responsibilities will include: I. Visiting the facility once a week. 2. Maintaining first aid kits. 3. Maintaining health records. 4. Evaluating toys and/or equipment for safety. 5. Observing diaper changing area and diaper changing procedures. 6. Observing and providing health screening for individual children. 7. Sharing supplementary materials with staff and parents. 8. Communicating with staff and parents about specific problems. 9. Providing consultation and acting as a resource person to staff and parents. 10. Providing in service education. 11. Identifying child abuse or neglect. A r#Aj ignature and License # Date 4 • The Learning Center 1250 Ellington Road South Windsor, CT 06074 860-282-8020 Dental Consultant I Dr. Robert Burstein, D.D.S., located at 15 Morgan Farms Drive, South Windsor, CT agree to serve.as the dental consultant--for The Learning Centers, Inc. located at 1250 Ellington Road, 80 duties . Pierce Road, and 120 Foster Road, South Windsor, CT CT.. My dut and will include phone consultation on related dental matter will be professional guidance to staff if needed. These services will ongoing unless otherwise notified to the State of es icut Department of Health. . License # 14523, 14157, 15104 Y . Date Signature 1 f , The Learning Center 1250 Ellington Road South Windsor, CT 06074 860-282-8020 EDUCATIONAL CONSULTANT I, Polly Suvelot, agree to be the Early Childhood Education Consultant for The Learning Center located at 1250 Ellington Road, 120 Foster Road, and 80 Pierce Road, South Windsor, CT 06074. As needed, I will provide educational guidance to all staff. Sign ure Date w. 1� .e The Learning Center•. v 501 West Middle Turnpike Manchester, CT 06040 860-643-8639 Social Service Consultant My signature below certifies that T agreed to be the social service consultant for The Learning Centers located at 1250 Ellington Rd, 80 Pierce Rd. and 120 , Foster Rd, South Windsor, CT 06074. My responsibilities include giving professional guidance to staff. Signature r Date r Water Supply r (Attachment# 13b) Program Name: f� License#: Location Address: Ck� _ . Capacity: �3 City or Town: �,Q�� (If New program, indicate "New"next PLEASE BE SPECIFIC: to license#.) • Months of Operation (i.e. SeptembeYune : • —Days/Hours of Operation: Monday 3 Tuesday 3� Wednesday 30 Thursday 2— 3') Friday 3 Name of Property Owner:— � L Address: City or Town: , Phone Section 1 FAre you or your landlord a Customer of a Water Company? Yes No es, complete Section 2 and provide the name of the Water Company:o, com lete section 3 Section 2 Lead Water Test—Required for all programs every two years and when there are changes in w]1cation Along with this form you YOU MUST ATTACH the following: *A copy of the program's most recent water bill or other documentation, for v purposes, with the program location address on it; * A copy of the program's first draw lead water test; 1 ou answered yes to Section 1 and completed Section 2, DO NOT continue on to Sections 3 a Section 3 Facility has an on site well and serves less than 25 adults and children Yes Lj No If YES, you are required to submit both a lead water test and bacterial & chemical test If NO, complete Section 4 r � Lead Water Test—(Required for all programs every two years and when there are changes in water supply) Bacterial & Chemical Test(Required every 2 years for all programs with on site wells serving less than 25 adults and children) Along with this form, YOU MUST ATTACH the following: *A copy of the program's first draw lead water test *A copy of the program's bacterial and chemical test CONTINUED ON BACK PAGE he Ulf.JUN, 3. 200$�11 ;29AM CUSTOMER SERVICE: ROBMT MANNARINO NO, 44619 PeP, 1 55 Main Street, P.O. Sax 800 Account Number: 7070404 ��,�3l200% ..,,i18120oe artford, Connecticut 0$142-0800 Service Address: 120 FOSTER RD Due Date slei5mne ($60) 278-0127 invoice Number: 200012147600 05l0t12QQ8 Invoice Date: 04/01/2008 Amount Due $ 706.80 Meter Number: 15359047 Previous Meter Reading 1,365 Current Meter Reading 1,409 Water Use CCF 44 Meter Number: 15359047 Previous Meter Reading 1,409 Current Meter Reading 1,674 Water Use CCF 265 Current Charges: Water Consumption Charge 0 $1.960 X 44 CCF 86.24 Water Consumption Charge @ $2.210 X 265 CCF 585.66 Water CSC Domestic Charge 1.84 Water CSC Domestic Charge 12.30 Water NMT Surcharge 2.70 Water NMT Surcharge 18.07 Total Current Charges: $706.80 Billing Summary: Past Due $0.00 Current Charges $706.80 r: : Current Balance: $706.80 r, , If this is a catch-up bill due to an actual reading after a series of t'•, estimates you may be eligible to extend the payments over additional •,t;Tr,.•:t time # please call us at 860-278-0127. M Pieeae return this portion with your payment. Fiesse bring entire bill when paying in per9on. Service Address: 120 FOSTER RD Make Check Payable to MDC Account Number: 7070404 Due Date: 05/01/2008 Invoice Number: 200012147600 Please Pay this Amount Due: $706.80 Invoice Date: 04/01/2008 t% PENALTY ADDED IF NOT PAID BY DUE DATE Pay Online at www.themdo.com ROBERT MANNARINO Send Payment To: 120 FOSTER RD The Metropolitan District SOUTH WINDSOR, CT 06074 PO Box 990092 Hartford, CT 06199-0092 00000000706800501200600010766044000007070404400300425847451 ENVIROTECH LABORATORy, LLC MARYELLEN DiGUZIO 77 COOK HILL.ROAD • WINDSOR, CONNECTICUT 06095 . TELEPHONE March 31, 2008 (860) 688-7249 The Learning Center - 1250 Ellington Rd. South Windsor, Ct. 06074 Dear Sir, We have the following to report on the sample submitted to this Laboratory on March 14, 2008. Sample Number: 71766 Mark: water sample collected 3/14/08` by Nikki Mahan from . Lot No. , 120 Foster Rd. , South .Windsor Ct. Lead < 0.005 mg/L None Detected Please note that < less than, none detected. The lead content is below the recommended 0.015 mg/L actioru.level established by the Conn. State Health Dept. If there _are any question we would be pleased to discuss them with you. Very truly yours, EnviroTech Laboratory, LLC Maryellen DiLuzio, a member PH 0464 cc: one enclosed if Si 1 N �f Y Prvgl and Nam Loca�{ion Adds �., I Phone#s+ + Y� •,- � - •Town: { t_ a: r ;Mai�ng Address:t• t Licensg p :; Zi Town: p state iicad®(_ � -- ' f,Pr aced Bye ry� j � � '_ , { STAFF WORK SCHEDULE FORM t r J DATE OF 1 W(J j . r 44 POS DI 1 • f EDAYS t` OURS ti ATE•.H[RED Fx� > -41 l qf lei A. r '• t j.�� �I••ri ifs, _� j( _ � .. -_ t ( �.rl�„ S ` 1 � j ` ' � ��+'"'i"i�•� {�• t�-J .�.dy'{f' '.'�`� ��iyary 5^! u�1£= Y^ tl� f f f A `lilr_- { _ !_. st*" 1 +iGT• t �, sKci '4 Ft� T77— f 1 it ss r77ck 17 W. t_i �*Place",""terlsk b each � Y person s uMe who has been First Aid Traified wi 1 a ' h Place♦(A heart)by each person's.naine who lies valid CPR T,,,,��t� the last 3 years' N � Fwk ,4rr�� +n+itilllg T� PAC aliCa SM\G,C_RelicStaffWarkSCh.doc J O/23/03 RETURN TO: HILD CARE GROUP/CENTER INSPECTION FORM INSPECTION ❑ REINSPECTION ❑ COMPLAINT �r,U'th W\h r Department of Public Health-Child Care Licensing Program Town 410 Capitol Ave.,MS#12 DAC,P.O.Box 340308,Hartford,Connecticut 06134-0308y $'0� / Date/Time of Inspection INSTRUCTIONS Q-i 1_p s Check=Compliance, Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable Date of Expiration Licensed Capacity Under 3 Endorsement15 #Children Presenf='�5' #Under 3 Present #Staff Present Lcnc1)Imp Ganj= 14\5Q gw - 3l1� Program Name License# Telephone# lam C_±4 Inc Address Operato?'J Licensed for: V Under 3 Yrs (A School Age ❑Night Care \K Pre-School(3-5 Years) ❑On Site Kindergarten Administrat 32. Exits,hallways and stairs unobstructed J 1. Staff attendance records 33. individual storage of bedding and clothing 2. Children attendance records ,�, 34. Approved safety outlets/cover Items posted: \�J 35. Required toilets/sinks/supplies 3. License ) 36. Ventilation in toilet room 4. Fire marshal certificate 37. Air temp 68°,thermometer affixed ' 5. Department complaint procedure 3 . Hot water 115,maximum Ll Im Food service certificate Walls,ceilings,floor rugs lean/good repair 7. Menus 40. Working phone on each evel 8. Emergency plans(fire,weather, 41. Emergency phone numbers posted medical,evacuation) 42. Lighting 50 ft.candles/sq.ft./protected 9. No smoking signs 'Q 43. Potentially hazardous substance locked Staffina 19a-79-4a � �® 44. Garbage,rubbish properly disposed daily 10. Staff health records -, 'g�L + hA5 A 45. Stairs in good repair and protected,hand rails 11. Continuing education� y^�t - (' 46. Animals maintained 12. Two people present f'U C�(T-e_r) 47. Radon test conducted/posted o 'L1 PLl ti �9 Li 13. Ratio: 1 staff to 10 children 48. Program space 35 sq.ft.per child 14. Group size no larger than 20 ��� 49. Cots stored/maintained/adequate number 15. First aid certified person 50. Developmentally appropriate equipment 16. CPR certified person and materials available and used Record Keeping 19a-79-5a Outdoor Space 17. Enrollment information 51. Usable square footage outside(75 sq.ft./per child) '-a 18. Authorized emergency medical permission 52. Area fenced to 4 feet or protected 19. Authorized released permission Playground free from hazards:S[.O( 20. Authorized field trip permission 53a. Peeling paint observed,sample taken}r� 21. Authorized transportation form R 53b. Lead Management Plan reviewed �t-o�� 22. Child health records 54. Shock absorbing materials under equipment Health and Safety 19a-79-6a y®® 55. Walkways maintained 23. First aid kit 56. Equipment anchored/safely arranged ogkyAcal Plant/Indoor Space 19a-79-7a Educational Requirements 19a-79-8a 24. License premise clean/good repair "IA "%..V 57. Written plan for daily program available to parents Equipment clean,in good repair,safe/non-toxic \,T.,he program shall include: 26. Free from observable hazards `hC1 58. Child-initiated and teacher-initiated activities _3E] 26a. Peeling paint observed,sample taken 59. Exploration and discovery `3 l 26b. Lead Management Plan reviewed 60. Choices for children in materials and equipment -;-{ 27. Sanitary drinking fountailns/dis osable cups 61. Individual and small group activities 43 27a. Lead water test/DATE I -013 62. Active and quiet play Within acceptable limits(<.015 ppm or 15 ppb) 63. Rest,sleep or quiet activity ❑ Exceeds limits/on bottled water ❑ YES ❑ NO 64. Nutritious snacks and meals (Contact DPH Water Supply Section) 65. Toileting and clean up 28. Adult toilet available/designated e 29. All openings for ventilation screened "'-Q Written corrective action plan due to DPH by:4 2 �� 30. Glass protected to 36" U�G (� `�h cc�/(w in !�t-f V) r ❑'� Overhead doors equi ed with locking devices � 1 Ce(1 1 �.J,��� 1 t�_ !5 -REMARKS,,: #Zy 3 bvl b5 h c ab%nveii na+su c3 r igned(Ins ector) 6 Dgte C2or'ecti©sue d Per r e) s. ivision\Licensure\Grp&ctr\Field Forms\Group&Center Inspection Form 1 8/0