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HomeMy WebLinkAboutDaycare Inspection 150 Nevers Road CHILD CARE GROUP/CENTER INSPECTION FORM A INSPECTION ❑ 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 T1 -1 -Q& Date/Time o I s INSTRUCTIONS (x, � a.pec0on Check=Compliance, Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable Date of Expiration Licensed Capacityc Under 3 Endorsement #Children Present #Under 3 Present #Staff Present Pro ram,jame 1�-�LC A/ -i--t try, L' ense# Telephone# . 1V 2a/ t 12 r, VCL X 1-e (v(C Address ONe�raator ry-%%O,t1 CIO Licensed for: ❑Under 3 Yrs V School Age ❑Night Care ❑Pre-School(3-5 Years) ❑On Site Kindergarten \A-dministration 19a-79-3a 32. Exits,hallways and stairs unobstructed �J 1. Staff attendance records 33. Individual storage of bedding and clothing 2. Children attendance records �+--I�'�. Approved safety outlets/cove Items posted: ����- ❑ 35. Required toilets/sinks/supplies Licensee_.) ,iS � LJ ❑ 36. Ventilation in toilet room 4 Fire marshal certiflcawpp37. Air temp 68°,thermometer affixed 5. Department complaint procedure Hot water 115°,maximum d -G-6-- Food service certificate 39. Walls, s ceilin ,floors clean? �® 7. Menus g ,rugs g good repair ❑ 40. Working phone on each level 18. Emergency plans(fire,weather, ❑ 41. Emergency phone numbers posted �?dical,evacuation) 4 42. Lighting 50 ft.candles/sq.ft./protected 9. No smoking signs Potentially hazardous substance health 44. Gar locked< ► FGLD�L9iL� t1 UQ Staffing 19a '❑v bage,rubbish properly disposed daily 1 blt ,r) ❑ 10. Staff health records ❑ 45. Stairs in good repair and protected,hand rails ; ❑ 11. Continuing education ❑ 46. Animals maintained A l2. Two people present 47. Radon test conducted/posted 13 Ratio: 1 staff to 10 children "9 48. Program space 35 sq.ft.per child �q 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 Keepine 19a-79-5a Outdoor Space 17. Enrollment information '�R] 51. Usable square footage outside(75 sq.ft./per child) -2 18. Authorized emergency medical permission 52. Area fenced to 4 feet or protected '­0 19. Authorized released permission 53. Playground free from hazards No - lu�PrY,�►��-^ 20. Authorized field trip permission 3❑ 53a. Peeling paint observed,sample taken (�,� , t 21. Authorized transportation form -9 El 53b. Lead Management Plan reviewed b "`` O'ka ., t5 22. Child health records '-1;.[3 54. Shock absorbing materials under equipment C.JQA<A$�% Health.and Safety 19a-79-6a t -4a] 55. Walkways maintained 2 First aid kit mob n�q ! j t�t�JC � ❑ 56. Equipment anchored/safely arranged Physical Plant/Indoor Space`19a-79-7a l %Educational Requirements 19a-79-8a 24. License premise clean/good repair N 57. Written plan for daily program available to parents 25. Equipment clean,in good repair,safe/non-toxic The program shall include: 26. Free from observable hazards 58. Child-initiated and teacher-initiated activities ❑ 26a. Peeling paint observed,sample taken 59. Exploration and discovery ❑ 26b. Lead Management Plan reviewed 60. Choices for children in materials and equipment 27. Sanitary drinking fountains/disposable cups 61. Individual and small group activities 27a. Lead water test/DATE �Li-6 q 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 -C4 64. Nutritious snacks and meals (Contact DPH Water Supply Section) 65. Toileting and clean up �® 28. Adult toilet available/designated Li❑ 29. All openings for ventilation screened Written corrective action plan due to DPH by: 30. Glass protected to 36" *Ir`�1 ❑ 31.- Overhead doors equipped with loc' king devices •REMARKS Go1�it1�P�Q � 1� ► , t r Signed(Inspe tor) Date Corrections Due S►g in arg d ) --� - X k.sADivision\Licensure\Grp&ctr\Field Forms\Group&Center Inspection Form 10/8/03 Fbc5�t-f.r db4 5 CHILD CARE GROUP/CENTER ENDORSEMENT INSPECTION FORM j,,-r� re'�D t A q INSPECTION ❑ REINSPECTION ❑ COMPLAINT Wow ��5 i�i rr 6a Department of Public Health-Child Care Licensing Program- Town 441,,0nCapitol Ave.,MS#12 DAC,P.O.Box 340308,Hartford_,Connecticut 06134-0308 Y t w INSTRUCTIONS Dat /Ti i oI>}spe�ti4n Check=Compliance, Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable Date of Expiration Licensed Capacity__ Under 3 Endorsement #Children Present #Under 3 Present - #Staff Present 01 I ndian Val I"eu `! ►y-rG- otl rn� I ( a� �� e% �2 1 Progra Name License# T e phone# Address Operator�A-T � 17 Licensed for: ❑Under 3 Yrs School Age ❑Night Care ❑Pre-School(3-5 Years) ❑On Site Kindergarten Under Three Endorsement 19a-79-10 Administration of Medication 19a-79-9a i. Ratio 1:4 ❑ 30. Approved written order �� M ❑ Group size no larger tha ❑ 31. Medications administration form ❑ Physical barriers/group of 8 ❑ 32. Medications locked cabinet or locked in refrigerator ❑ 4 Adequate sinks in pro am space ❑ 33. Original labeled containers ❑ 5. Free-standing cribs ats no more than 2-3/8"apart) ❑ 34. Trained person present-Copy of Certificate _ ❑ 6. Washable cots for ddlers ❑ 35. Training outline on file ❑ 7. High chairs w/str ps and locking tray Night Care 19a-79-12(8:00 P.M.-6:00 A.M.) ❑ 8. Adult rocking c it ❑ 36. Head teacher on premise-60% 9. evelopmental appropriate tables/chairs ❑ 7. Quiet activi es ❑ 10. frigerators nd food prep facilities ❑ 3 Supervisi plan ❑ 11. N -porous apering area with rail ❑ 39. Evacuat' n plan ❑ 12. Dis osable aper sheets ❑ 40. AVdn awake ❑ 13. Cove ed w ste receptacle ❑ 41. Judial coticribs ❑ 14. Hand as ing procedures posted/followed ❑ 15. Diaper Zing procedure posted/followed ❑ 42. appropriateflaundered ❑ 43. iletries appropriate ❑ 16. Childre 's clothing stored individually ❑ 44. A ient air 650 ❑ 17. Cribs/ t cleaned ❑ 45. Fire arshal approval ❑ 18. Toys ash d ❑ 49. Healt director approval ❑ lChild's t s less ban I"diameter Sc ool Age 19 -79-11 ❑ 2 is bags, alloons,Styrofoam _2 47. Activity choices available: cts not ac ssible to children free 1jme creative_self-concept ❑ 2 .consultan log on site s 11 group homework quiet ❑ 2ants held for ottle feedings snac special events physical_ ❑ 2osed portions for. discarded 48. Ages 5 years attending school ❑ 2an bottles prow ed by parent �Q 49. Ratio 1 staff to 10 children ❑ 2proved bottle wa hing system `{� 50. Group size/20 ❑ 2d served from di /whole jar served ❑ 2ld's bottle individ lly identified with name _ ❑ 2door play space fe ced ❑ 2elopmentally appropriate outdoor equipment c'REMARKS": Written corrective action plan due to Department of Public Health by: U 1 L ja5 Si ned(Speci 'st) Date Corrections Due Sign er n1p e l ivision\Licensure\Grp&ctr\Field forms\Group&Center Endorsement Inspection Form 10/ /0 ENVIRONMENTAL INSPECTION REPORT INSPECTION ❑ 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 3 _y( Date of Inspection INSTRUCTIONS —t-L-0 4 Check=Compliance, Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable Date of Expiration Licensed Capacity JV Under 3 Endorsement 0 #Children Present_ #Staff Present—3 Program Name License# `` .. Telephone# ltS`b�t.P� J Ra J4E �10 l 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 He th and Safety 19a-79-6a ©x License premises clean/good repair 11 Refrigeration no more than 45° [���✓ Equipment clean,in good repair,safe/non-toxic 1 Food prep area clean/good repair UG'3 Free from observable hazards U� r�C 13 Food safely stored ❑ 4 Drinking water available,adequate,safe Pb PeWJ 6--/ 14 Food prep handwashing ❑ 4a Lead Water Test/Date 15 Adequate dishwashing E � ❑ Within Limits ❑ Exceeds Limits 16 Kitchen separated L{,d�4b Public Water Supply 17 Mark appropriate: ] 4c On Site Well(In compliance with CT Public Health Code packs served ElCold breakfast Sections 19-13-B51a-m and 19-13-BI02) ElMeals served ❑ Meals transported ❑Local Health verified with DPH Water Supplies Section for ElOther 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) Other(Please specify) ❑ No Lead-Based Paint Identified Required toilets/sinks/supplies 6 Adequate ventilation in toilet room ❑ Lead Hazards Identified and Eliminated 2'7 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 A Pe-Approval recommended. No code violations identified. Q... fear pal �-c��Cc� "�`u ❑ Approval recommended with conditions(see below). ❑ Approval not recommended due to existing serious code R r1 violations. Signed(Inspector Date Corrections Due Signe (Person in har e) s:/Division/Licensure/Grp&ctr/Fief Forms/Env Inspection Report 3/05/03 Website form for Local Health Y We build strong kids, strong families, strong communities. 3/8/06 YMCA of Greater Hartford Julie Boscarino DPH Fax 509-7541 Julie: Attached you will find the re-licensing packet for South Windsor SACC, license# 14129. The lead water test results have not yet been received, and will be forwarded to you as soon as they are received from the lab. If you have any questions or concerns,please feel free to contact me at 872-7329 x 23. Theresa Robin son Program Director Indian Valley YMCA Indian Valley Branch YMCA 375 Hartford Turnpike,Vernon,CT 06066-4820 Tel: 1-860-872-7329 Fax: 1-860-875-5245 E-mail:indian.valleyymca@ghymca.org http://www.ghymca.org "Gifts to the YMCA Endowment Fund ensure services to future generations." STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Division of Community Based Regulation 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: YMCA of Metropolitan Hartford, Inc. (Legal Operator) 2. Program Name: Indian Valley YMCA South Windsor SACC (Applicable For Group/Center Only) 3. Program Location Address: 150 Nevers Rd South Windsor , CT 06074 Stree t Address City/Town Zip Code 4. Program Phone Number: 860 644 -9678 Program Fax Number: C860 ) 875 - 5245 5. License#: 14129 Expiration Date: 6 / 12 / 06 (For Relicensure Only) (For Relicensure Only) 6. Mailing Address(if different): 375 Hartford Turnpike Vernon , CT 06066 Street Address CT Zip Code 7. Program E-mail Address: theresa.robinson@ghymca.org 8. Enclosed Check/Money Order: $ 200 Check#: /d-5"5-2, 7 Check Date: 2- / 23 9. Social Security#: - - or Federal Employer ID#:06 - 0881325 (3 digits) (2 digits) (4 digits) (2 digits) (7 digits) 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#42431) (Account#42431) 06-month license(new program) ❑6-month license(new program) 2-year license(new provider) $50.00 $30.00 $20.00 ❑✓2-year license(relicensure) []2-year license(relicensure) ❑2-year license(relicensure) $200.00 $100.00 $20.00 Phone: (860)509-8045,Fax:(860)509-7541 Telephone Device for the Deaf(860)509-7191 410 Capitol Avenue-MS#12CBR P.O.Box 340308,Hartford, CT 06134 An Equal Opportunity Employer T:\Fam&Ctr\Application\CDC_FeeForm.doe 3/22/04 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. I, Hyari nth DLul l a� Ba i 1 Py Operator or Legal Representative ,being duly sworn depose and say: The name of the child day care center/group is Indian Valley YMCA South Windsor SACC Name of Child Day Care Center/Group Day Care Home The application is made to conduct this child day care center/group day care home at: 1 ';0 Severs n,a S_. Windsor CT Location Address: Street 06074 City/Town State Zip Code The Operator of the above named facility is YMCA of Metropolitan 7Hartford, Inc Name of Operator and is a(check one): Individual/Sole Proprietor P -x Corporation Partnership Limited Liability Company Limited Partnership Limited Liability Partnership If applicable,the Legal Representative of the above named facility is- Hyacinth Douglas—Bailey 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(M0, 7 -2-2 2 My address is 160 Jewell Street Hartford CT 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. 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 are p is a e in accordan with Secti n 53 157 . Signatu erator al Representa e Subscribed and sworn to before me on the—1��lay of „ Day HOPE A. COPE on =Year Notary Public,State of Connecticut Signatu a of notary public,commissi Connecticut General Statute Section 1-24 �cial as noted in r:\Grp&Ctr\Application\G_C—Affidavit.doc 7/05 CT Department of Public Health (Attachment 11f) Division of Community Based Regulation 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: Theresa Robinson Position: Program Director Date form completed: 2/17/06 Program Name:_Indian Valley YMCA South Windsor SACC License# 14129 Street Address: 150 Nevers Rd Town: S. Windsor CT Zip: 06074 Telephone#: 860 )644 - 9678 Fax#: (860 ) 872 -5245 E-mail gh theresa.orginson@ Health Consultant(Required) Last name:Lahman, M.D. First:Jerome Middle initial: E Resident Street Address: Town: State: Zip: Telephone#: ( ) - Fax#: _ Work Address: 357Hartford Turnpike Town: Vernon State: CT Zip: 06066 Telephone#: 860 871 -2102 Fax#: _ Professional license held:P Physician[]Physician Assistant QAP Registered Nurse registered Nurse Professional License#: 018092 License Expiration Date: 11/30/06 Early Childhood Education Consultant(Required) Last name:-Etre First:Ann Middle initial: Resident Street Address:107 Brookview Dr Town: Vernon State:CT Zip:06066 Telephone#: 860 ) 871 - 9595 Fax#: _ Work Address: Town: State: Zip; Telephone#: ( _ ) - Fax#: _ —) E-mail: DPH approval on file:Z✓ Yes ❑No Name at time of approval if different: PLEASE BE SURE TO COMPLETE THE REVERSE SIDE OF THIS FORM Dental Consultant(Required) Last name:Tandy First: Bruce Middle initial : Resident Street Address: Town: State: Zip: Telephone#: 860 742 - 7065 Fax#: (__) - E-mail: Work Address: 281 Hartford Turnpike Town: Vernon State:CT Zip: 06066 Telephone#: 860 875 . - 2881 Fax#:(�� - E-mail: Professional license held: Q✓Licensed Dentist ❑Dental hygienist Professional License#:5632 Expiration Date: 5/31/06 Social Service Consultant(Required) Last name: Campellone First: Gina Middle initial: Resident Street Address: 54 Edith Rd Town: Vernon State: CT Zip:06066 Telephone#: 8( 60 ) 875 - 8468 Fax#: ( _) - E-mail: Work Address: Town: State: Zip: Telephone#: (_ - Fax#: (_� - E-mail: Professional degrees held: QBSW ❑BA/BS -Field of study: QMSW QMA/MS -Field of study: Professional License#(if applicable): Expiration Date: Registered Dietitian Consultant_(Required for programs that serve meals) Last name: First: Middle initial: Resident Street Address: Town: State: Zip: Telephone#: (_� - Fax#: (_) - E-mail: Work Address Town: State: Zip: Telephone#: (_ - Fax#: -mail: Professional license held: aD 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 than(1)Head Teacher,please submit this information as an attachment. Last name:Ambrose First: Megan Middle initial: Resident Street Address 3(a 1AW n 5� Town: Uh OY1 State: C7 Zip;C)Ca C�(o Le Telephone#:C-AU) i6q�) _ P 3S Fax#: Work Address:jo IN ey 'ram p( Town: 51(1/t ti do(State: C-7 Zip: ©tip o -7 Telephone#:(%0 ) Gqq _ #; 4�rmail: Dept.of Public Health approval on file: Yes o Under 3 Years eschool V chool Age 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 Attachment to Consultant Data Sheet Additional Head Teacher: Last Name: Ambrose First: Marcia Street Address: 36 Main Street Vernon, CT 06066 Telephone: (860) 614-2421 Work Address: 150 Nevers Rd South Windsor, CT 06074 Telephone: (860) 644-9678 March 18,2005 Indian Valley YMCA 375 Hartford Tpke. Vernon, CT 06066 Attn: Cathy Ouellette Dear Cathy, This is to confirm my position as the Educational Consultant for the Indian Valley YMCA's childcare programs now through 2007. I agree to offer my assistance with any questions or concerns you may have in the area of education. Sincerely, Ann Etre 107 Brookview Drive Vernon,CT_46066 871-9595 f qd-t h,n-Q ant 54 Edith Road Vernon,CT 06066 January 2,2006 Suzanne Appleton Indian Valley YMCA 375 Hartford Turnpike Vernon,CT 06066 Dear Suzanne Appleton: As a follow-up to our phone conversation on 12/31/05,I am writing to confirm that I would be pleased to serve as the Social Service Coordinator for the Indian Valley YMCA,effective January 3,2006--January 3,2008. I hold a Master's Degree in Social Work from Springfield College,and have experience working with both youth and families for a social service agency. If I can be of assistance in answering questions or providing consultation for any of the Indian Valley YMCA's licensed child care programs,please do not hesitate to call me at(860)875-8468. Sincerely, awl� Gina Campellone,MSW 3 - i } 4.c\AMA ,L Q'We build strong kids, strong families, strong communities. YMCA of Greater Hartfo: January 3,2006 Suzanne Appleton Indian Valley YMCA 375 Hartford Turnpike Vernon,Ct.06066 Dear Suzanne Appleton, I am writing to confirm that I have agreed to serve as the Dental Consultant for the Indian Valley YMCA,effective January 3,2006-January 3,2008. During this time,I will be available to answer questions and provide consultation for any of the Indian Valley YMCA's licensed childcare programs. I may be reached at 875-2881 or 742-7065. S' rely, Dr.Bruce Tandy _ Indian Valley Branch YMCA 375 Hartford Tumpike,Vemon,Cr 060664820 Tel: 1-860-872-7329 Fax:1-860-875-5245 i E-mail:indian.valleYYrnmOgbY bttp://vvw'w shymca.or8 -Gifts Sep►Aw YMCA£ndrmvownt Fund 4murr srn*rs to fWare X~rwFaMrs. _ v We build strong kids, S strong families, strong communities. YMCA of Greater Hartfor March 18,2005 Indian Valley YMCA 375 Hartford Tpke. Vernon, CT 06066 Attn: Cathy Ouellette Dear Cathy, This is to confirm my position as the Physician Consultant for the Indian Valley YMQVs childcare programs now through December 31,2008. I agree to offer my assistance with any questions or concerns you may have in the area of medical needs. Sincerely, Jer me E. Lahman, MD Indian WHO Branch YMCA 375 Hartford Turnpike,Vernon,CT 06066-4820 Tel:14W472-7329 Fax: 1-860-875-5245 E-mail:indiaA.valkYYnwaf ShYrnca org httpaAv'W 8'hyrnca-a8 -Gifts to the YMCA En&P% wn'Fang ensure services to fafare xeneraNeai.' STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH «. � Division of Community Based Regulation 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)) re uires 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 r elicensure 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 STAFFI Program/Provider Name: Indian Valley YMCA South Windsor SACC ❑ New Application Address: 150 Nevers Rd ❑✓ Relicensure Application Town/State/Zip:South Windsor, CT 06074 Telephone:860-644-9678 License#:14129 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 insura e issued by any stock or mutual insurance company or mutual association auth zed t w ite w rkers' compensat' n i suranc in t state or its agent. (Signature perator r vided (Date) (Printed Name) T:\Fam&Ctr\Application\CDC_WCInsFomi.doc 01 1/04 Phone: (860) 509-8045,Fax(860) 509-7541 .: Telephone Device for the Deaf (860) 509-7191 410 Capitol Avenue-MS#12CBR P.O. Box 340308 Hartford, CT 06134 An Equal Opportunity Employer Client#: 10384 YMCOF 1ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/30/05 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION RC Knox&Company,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE One Goodwin Square HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Hartford,CT 06103-4305 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 860 524-7600 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: New Hampshire Insurance Company Indian Valley Branch YMCA INSURERB: Landmark American Insurance Co. Vernon,CT 06066 Hartford Turnpike INSURERc: Hartford Insurance Co.of the Midwes INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.'NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD POLICY EFFECTIVE EXPIRATION LTR NSR TYPE OF INSURANCE POLICY POLICY NUMBER DATE MMIDD/YY DATE MM/DD LIMITS A GENERAL LIABILITY 01 LX32955003 12/31/05 12/31/06 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED n $1 OO OOO CLAIMS MADE OCCUR PREMIRPS(Ea MED FRCP(Any one person) $5 OOO PERSONAL&ADVINJURY $1 QQQ QQQ GENERAL AGGREGATE $2 00Q QQQ GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OP AGG $1000000 M POLICY PRO- JECT LOC A AUTOMOBILE LIABILITY 01 LX32955003 12/31/05 12/31/06 COMBINED SINGLE LIMIT X ANY AUTO (Eaacofdent) $1,000,000 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) X HfREDAUTOS X NON-OWNED INJURY WNED AUTOS (Per accident) $ X Physical $500 Comp.Ded. PROPERTY DAMAGE Damage $500 Coll.Ded. (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESSIUMBRELLA LIABILITY 01 UD46589473 12/31/05 12/31/06 EACH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE AGGREGATE $5,000.000 B LHA033133 12/31/05 12/31/06 Ea.Occ.: $10 nnn 000 DEDUCTIBLE A re ate: s10,000,000 X RETENTION 110,000 $ C WORKERS COMPENSATION AND 02WBKJ5497 01/01/06 01/01/07 X WCSTATU- OTH- EMPLOYERS'LIABILITYDRYANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT s500,000 OFFICER/MEMBEREXCLUDED? If yes,describebeunder E.L.DISEASE-EA EMPLOYEE $500,000 und SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Evidence of Coverage for Child Care Center. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION State of Connecticut DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _3Q_ DAYS WRITTEN Department of Public Health NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Day Care Licensing Program IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 410 Capitol Avenue REPRESENTATIVES. MS#12DAC AUTHORIZED REPRESENTATIVE Hartford CT 06134-0308 AGORD 25(2001108)1 of 2 #S353783/M326925 LAO 0 ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-5(2001108) 2 of 2 #S353783/M326925 Water Supply (Attachment# 13b) Program Name: Indian Valley YMCA South Windsor SACC License#: 14129 Location Address: 150 Nevers Rd Capacity: 30 p ty: City or Town: South Windsor (If New program, indicate"New" next to license#.) PLEASE BE SPECIFIC: • Months of Operation(i.e. September-June): September-June • Days/Hours of Operation: Monday 7-9 AM and 2:3o-6 PM Tuesday 7-9 AM and 2:30-6 PM Wednesday 7-9 AM and 2:30-6 PM Thursday 7-9 AM and 2:30-6 PM Friday 7-9 AM and 2:30-6 PM Name of Property Owner: Town Of South Windsor Address: 150 Nevers Rd City or Town: South Windsor Phone#: (860)648-6355 Section 1 Are you or your landlord a Customer of a Water Company? Yes No If Yes, complete Section 2 and provide the name of the Water Company: If No, complete section 3 Section 2 Lead Water Test—Required for all programs every two years and when there are changes in water supply Along with this form you YOU MUST ATTACH the following: *A copy of the program's most recent water bill or other documentation, for verification purposes,with the program location address on it; * A copy of the program's first draw lead water test; I ou answered yes to Section I and completed Section 2, DO NOT continue on to Sections 3 and 4 Section 3 Facility has an on site well and serves less than 25 adults and children ® Yes No If YES,you are required to submit both a first draw lead water test and bacterial & chemical test If NO, complete Section 4 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 Section 4 (Facility has on site well and serves 25 or more adults and children at least 60 days of the year) Please Note: Your facility meets the classification of a Public Water Supply System and wiil,be Referred to the Department of Public Health,Drinking Water Section. Lead Water Test—(Required for all programs every two years and when there are changes in water supply) Along with this form, YOU MUST ATTACH the following: *A copy of the program's first draw lead water test and bacterial and chemical test. T:\Grp&Ctr\Application\G_C_WaterSupplyAttach.doc 2004 Date: 2 / 23 / 06 Program Name: Indian Valley YMCA South Windsor SACC Phone#: @ 60 ) 644-9678 Location Address: 150 Nevers Rd Town:South Windsor License# 14129 Mailing Address: 375 Hartford Turnpike Town: Vernon State: CT Zip Code 06066 Prepared By:Theresa Robinson Date: 2/23/06 STAFF WORK SCHEDULE FORM DATE OF WORK SCHEDULE STAFF NAME * BIRTH POSITION DAYS AND HOURS DATE HIRED Megan Ambrose *r 12/24/81 Site Director/Head Teacher 7-9 AM T,R;2-6 PM T,R,F 5/4/98 Marcia Ambrose * 1' 13)61 Head Teacher 2-6 PM W C q 8 Erica Keaveny * V 12/9/87 Aide., 7-9 AM M-F;2-6 PM M,T,R,F 9/28/05 Erin Keaveny * r 9/20/84 Assistant Director 2-6 PM M-F 8/27/01 Brittany Buser 6/11/86 Aide 2-6 PM M,W 2/10/04 Lauren Miner 2/23/88 Aide 7-9 AM M,W,F 10/10/05 *Place*(an asterisk)by each person's name who has been First Aid Trained within the last 3 years v Place v(a heart)by each person's name who has valid CPR Training T:\Grp&Ctr\Relicensure\G_C_RelicStaffworkSch.doc 10/23/03 RETURN TO: ENVIRONMENTAL INSPEe40N REPORT ❑ REINSPECTIQN;j ❑ COMPLAINT Ef"INSPECTION Department of Public Health-Child Care Licensing Program Town aa; 410 Capitol Ave.,MS#12 DAC,P.O.Box 340308,Hartford,Connecticut 06134-0308 Date of Inspection INSTRUCTIONS , — 1-7. Y.0 Check=Compliance, Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable Date of Expiration Licensed Capacity 4""' Under 3 Endorsement #Children Present 15 #Staff Present vo Vi(.te,d t i.. ,t-- , 1, 1 r t�'i.s'# •'i 1 ' ./',8 Program Name Lpicensger�# Tyele hone# 4.1 E °awe - .*,�.++ �4+Y+' € �8 i,�'? " `&'i' i m 'i j g f ;:rS fi"'+��- , Address Operator Licensed for: ❑Under 3 Yrs 210School Age ❑Night Care ❑Pre-School(3-5 Years) ❑On Site Kindergarten Phn .sical Plant/Indoor Space 19a-79-7a H lth and Safety 19a-79-6a License premises clean/good repair 1 Refrigeration no more than 45° LI Equipment clean,in good repair,safe/non-toxic ®®®r�w12 Food prep area clean/good repair 3 Free from observable hazards a sty 13 Food safely stored ❑ 4 Drinking water available,adequate,safe p f i t�l t't 14 Food prep handwashing ❑ 4a Lead Water Test/Date 15 Adequate dishwashing ❑ Within Limits ❑ Exceeds Limits 16 Kitchen separated (b Public Water Supply ❑ 17 Mark s appropriate: Q' 4c On Site Well(In compliance with CT Public Health Code Snacks served ❑ Cold breakfast Sections 19-13-1356-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 ,��' b0 days per year Imo'Building: Post 1978 Construction 4d Private Well—Facility serves less than 25 children&adults Q��e Other(Please specify) El Building: Pre 1979 Construction(Lead Inspection Required) E "5 Required toilets/sinks/supplies ❑ No Lead-Based Paint Identified ®` Ade'quate ventilation in toilet room ❑ 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 8 Swimming pool complies with PHC 19-13-1133b 9 Playground free from observable hazards "REMARKS" ❑ 10 Drinking water available,adequate,safe ��,,�'''' L-"Approval recommended. No code violations identified. f ` . Vje oJii V, Approval recommended with conditions(see below). ❑ Approval not recommended due to existing serious code ir'•¢ °; ,r V1 violations. �l Signed(Inspectol) Date Corrections Due Signed,(Person in Charge) s:/Division/Licensure/Grp&ctr/Field Forms/Env Inspection Report 3/05/03 Website form for Local Health t . . f d a � sC mattes HkFCTFaRa� Tfi41 F`sf� � l �C11�f41J1t1 F . strand;�ei�xmxuut�es u - .. MCA ttf roe..�Harf4rt# �� a z 2�'O.QO WO SIGNATURES REQUIRED .�a-kF $t R /•L `'s `�rre, Uit(f�r@ � 7� f /-C1� C3�,�f1.'�5f t9ifi # l "ltt^r �aa Ff " t4. - - x $ sd x DRY � h ��� ram•- a.�,, ag r � £ {l � �;. rr � t "as �Sa � r� ��r� �� � r-. �,� � � � � s �{c3P��flCC�r�+� ���+�� �"; ��- � i � �zy � �, Al1THaFi}Z�l)Sl 1�A�4,1(•iES ' ftlf Sats a t �,..� ,.. ..... z�,� „4 m :£�..... �.. .. -� ,.> .,� t �t1��tlRyE'A��bORBWBAf�G�?ROUN4a8XiRR>R60b}TAINS:FAICR>;1PF11RFf141G;. u' L 2 5 5 2 ?u' i:0 L L 900 5 ? O: 0000800 2 68u' E .. i .,. r +� � .I f 1 � .., yy.. r r 1'�� 1 1 �, !. - _ t i 4 is_. J �M1'K Sys s� 'r��Mi'.'srtsx'�'' ;�s�r a 5 I pp..M i► 9 ! _ � Y � i7 � r•/ Jfr}F """L"i L :i .,-I... y _I ""�li...�s:r S�S�L�.���^ � ■■ ` { � �.� r i ,i � .; _ _i. .. .... .lam .--3 yam_ } _ - _ -' -. <� - __ -. � :... - _ f _ ,. ',r�-'—.try .. = _ _ .. _ - - 7 - c.i - _. - ii ;. '.'i'Jt }fit. ..:Y:tF.�: y.� �.. _ _ - - -- - 1'F'..�{t 7i s,.:��.� '".,Gy-„ aF.,x .r�'+�-C,.�'F."ear '''�' a�-.,- _ .. - _ .. _ -.. tea.._ , _ .2.��.x ._. _.., _ - E r _ _ - - ? ny- � _�.� ,v',-r ^'����� ,.,fit ��' .- .. ... _... _ .�... ..., �r. .�.i �� k �i a � STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH -�- Community Based Regulation Section are ryrAm . 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 licensing 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 stating that your facility meets the public health code requirements for licensure as a child day care center or a group 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 1-800-282-6063 or 1-800-439-0437 or(860)509-8045. ALONG WITH THE APPLICATION YOU MUST INCLUDE: 1. Cover Letter/Check List Q Yes No 2. Fee Invoice and Check ✓ Yes No 3. Affidavit ✓ Yes LjNo 4. Consultant Data Sheet&Copies of All Current ✓ Yes r No Agreements(Attachment#110 5. Proof of Worker's Compensation Form Q Yes No 6. Copy of Worker's Compensation Insurance Certificate ✓0 Yes [A No 7. Lead Water Test(Bacterial&Chemical if well) M Yes No 8. Water Supply(Attachment#13b) r7lYes No 9. Staff Work Schedule ✓ Yes No 10. Please indicate the date you have sent a copy of this application to your Local Health Department 3 / 17 /2006 and be sure to include verification of the Local Health Inspection upon completion of the Inspection. • Was the building/structure in which you provide or will provide child care constructed prior to 1979? Yes 0 No If Yes,have you had a full Comprehensive Lead Paint Inspection? dYes []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 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