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HomeMy WebLinkAboutDaycare Inspection 494 Chapel Road (2) KnmvkdW LM ' hm.'ukdw*tawr*g aqw Dear South Windsor Public Health, Here is a copy of the license application for the South Windsor KinderCare. We will need a Local Health Approval form you prior to the expiration of our .license on February 14, 2007. Thank you, Wendy Christensen CHECK BACKGROUND AREA CHANGES COLOR GRADUALLY FROy 4 1 78 ' Bank of.Amerioa of Georgiy.N.A. 61 ' IF TN MULTI-TONE SECURITY pOCUA?EN' Atlagta.DekalbConnty.Georgia VERIFY THE AUTHENTICITY 4( atlonv AMOUNT Knawwge' : g CHECK NO. Where Ulfeti rning Begine� DATE 200.00 DBA 1Cin . rC7 re Learning Centers,Inc. 21-NOV-06 6164282 ***k�*** PO Box63 0 Portland,OR 97228-6330 DOLLARS Two Hundred Dollars And 00 Cents********************************** PAY TO THE ORDER OF: CONNECTICUT STATE OF TREASURER CHILD DAY CARE LICENSING UNIT AUTHORIZED SIGNATURE ,e DEPT OF PUBLIC HEALTH DAY CARE PO BOX 340308 06134-0308 HART-FORD, CT t 6 i1 64 28 2n' 1:06 1112?8 8': 3 29 q 12 E SHADING CHANGES GR THIS DOCUMENT HAS COLOP. ADUAL`Y FROM DARKTO LIGHT. 11000 FD PRINTING ON YJHI_t e PA" ^ ".;-(Applicable For Group/C nter Only) 3. Program Location Address: a aJ_ CT Street dress CitylTown Zip Code 4. Program Phone Number: - L Program Fax Number: 5. License#: ) r°D Expiration Date: (For Relicensure Only) (For Relicensure Only) 6. Mailing Address(if different): , CT Street Address . CitylTown Zip Code 7. Program E-mail Address: ' J IrN lI r ( cm 8. Enclosed Check/Money Order: $ ? ' Check#:_C0 Check Date:I 9. Social Security#: - - or Federal Employer ID#: C29 /9(& (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)dome Family Day Care home (Account#4243 1) (Account#4243 1)- (Account#4243 1) ❑6-month license(new program) ❑6-month license(new program) ❑2-year license(new provider) $50.00 $30.00 2-year license(relicensure) Q 2-year license(relicensure) Q 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 2/24/06 _ + f ` STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Community Based Regulation Section 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 cony 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 No 2. Fee Invoice and Check Yes ❑No 3. Affidavit ®'`Yes ❑No 4. Consultant Data Sheet&Copies of All Current 0 Yes ❑No Agreements(Attachment#I I f)(%jkrj t �,� ID)C,,6C_4(," 5. Proof of Worker's Compensation Formes ❑No 6. Copy of Worker's Compensation Insurance Certificate es No 7. Lead Water Test(Bacterial&Chemical if well) s ❑No 8. Water Supply(Attachment#13b) [ s ❑No 9. Staff Work Schedule 'es ❑No p 10. Please indicate the date you have sent a copy of this application to your Local Health Department I / / 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? El Yes No If Yes,have you had a full Comprehensive Lead Paint Inspection? ❑Yes ❑No If Yes,date of full Comprehensive Lead Paint Inspection 1 / 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 STATE OF CONNECTICUT " DEPARTMENT OF PUBLIC HEALTH Child Day Care Center or Croup 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, fS 11..Ti t t�l'� t'1Cx t •f,being duly sworn depose and say: Name of Legal Rep entative(this is the individual authorized to act on behalf of the operator)or Operator(only if Operator is an individual) 1`, The name of the child day care center/group is 1 1—� es� C 'e c' Leaves nip-r �..I'� Name of Child Day Care Center/ up Day Care Home The application is made to conduct this child day care center/group day care home at: ,Iqq Cho-pt.I P-0 0-� l Location Address: Street City/Town State Zip Code The Operator of the above named facility is a: (please check one of the following and include the name) ❑ Individual/Sole Proprietor ❑ Limited Liability Company /' (name of C) I Individual/Sole Proprietor) (name of LL Corporation nd y- w mm►tim A4'C, ❑ Partnership (name of Corporate (name of Partnership) ❑ Limited Partnership ❑ Limited Liability Partnership (name of LP) (name of LLP) I aim 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(i'i��77>2✓_ ®®D� My address is�lll1 I yl& l� �� � 1�, G� d��gv? Street,City/Town,State,Zip Code 1 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 punishable in accordance with Sectio -157b. .� i L ) ) Sig hire of Oper for or Legal Representative Ved7dso before me on the day ofDay Month Year ic,ute Section 1-24 (('l ,• C T:\Gip&Ctr\Application\G_C_Affidavit.doc 6/22/06 i �ji+�4 "' �� CT Department of Public Health (Attachment IM) 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:-)C `1D'rP_,C_4t-) Date form completed: —7 y Program Name: Kd/18 /11 C G y-I�� , p�-}�/ License# ! �8 Street Address:y 9 4 C_j-�ra,1 Town , VUirj� CT Zip:QtS®'7� Telephone#: � Fax#: &AD �S_E-mail 3 Health Consultant(Required) Last name: r r al "� First or-, Middle initial: Resident Street Address: & Town: State:( _Zip: Telephone#: &o )GC9 -0 Fax E-mail: Work Address: Y) Town: State: Zip: Telephone#: Fax#: (_� E-mail: (� _l Professional license held: []Physician❑Physician Assistant❑AP Registered Nurse) egistered Nurse Professional License#: L4C>Q � License Expiration Date: , \\� Early Childhood Education Consultant(Required) t Last name: _cy" ) l First:��n rli Middle initial: Resident Street Address �;���,'� V 'own: State: Zip Telephone#:O -- r-- 9&_Fax#: (^� 1f� E-mail: i)- WI Work Address: Town: l State:D]f_Zip: }{� Telephone#: Fax#: E-mail: DPH approval on file Yes ❑No Name at time of approval ifif different: - PLEASE BE SURE TO COMPLETE THE REVERSE SIDE OF THIS FORM Dental Consultant(Required) Last name: ( e— First e\)► 01 Middle initial Resident Street Address: fN Town: State: r- -Zip: D)j Telephone#: - Fax#: E-mail: -mail: Work Address: _To,% ; ate: _Zip: CXG b-71� ilia Telephone#: )�lt'(-- I 1 Fax#: - E-mail: Professional license held:' Licensed Dentist []Dental hygienist Professional License#: 0��'��'0 5qT�:I Expiration Date: `> 3 a Jo 7 Social Service Consultant(Required) Last name: L-01-1Q7_\A First: --- Middle initial: Resident Street Address:0% Town: oirr ,n State:_ Zip: Telephone#: (fin � - _1Fax#: - E-mail: E f-' Work Address 4� rrr:,���t�n VP_ Town:� �n }'state: i� I Telephone#: (c6��) -I� - )a Fax#: ( ) --�j —E-mail:I� �, G 1X . J l) Professional degrees held: ❑BSW NBA/BS -Field of study:Q"1,'r d D e1 ,I rt.Q �" ❑MSW IVI MA/MS-Field of study'CC .� Professional License#(if applicable): Vy Expiration Date: Registered Di itian Consultant(Required for programs that serve meals) Last name : :-De [) First: Middle initial: Resident Street Address: c ( d. �own: to e: Cr— Zip:AZ?1)� Telephone#: Fax#: E-mail: [ 1(4 Work Address Town:_j-\ State: Zip: 1 Telephone#: Fax#: (_ E-mail: j � - Professional license held: C RD License/ID#:0Q!Z(a Expiration Date: (o � t� 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: A-ha First: (Dn ujy-� Middle initial: t - Resident Street Address ` S� lilt Town:�t�c `r State: Cif Zip: i Telephone#: Fax#: E-mail: d To n:Is c,k)i/iC6(�"State: X Zip: L)�LI Work Address. �.� �---- Telephone#:(=) - ��� Fax E-mail: F Dept.of Public Health approval on file: Yes ❑No ❑Under 3 Years ❑Preschool ❑School 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 MSM12 DAC,P.O.Box340308,Hartford,CT 06134-0308 or Fax(860)509-7541 T:/.Grp&Ctr/Application/G_C_Consultants.doc 12/3/2003 DEC:-6,-8006 12:56P FROM:YWCA GROWING TREE 860-240-7008 T0:86100645 P. 1/1 UCl.-b e-Mb UU:bb t-KU11:H YHNUbY 1-dW-bIO-Ub'Fb r-1'1 Attachment*t t b Consul nt Agreement Registered NILse: 1, SueA,nn Uccella, agree to act as a Nurse consultant fear the South Windsor KlnderCare Learning Center. I will be available to the operator and staff to provide advice regarding the physical well being of the children and review policies as needed. The Center is required to have an on site visit for one hour per week, and be available on an on call basis to provide services/training as needed. The attached Observation form will be used during the weekly visit, returned to the Center Director and retained on file for a period of two years. Consultant Signature: Date: Director Signature: bate: DEC-6-2006 WED 00:59 TEL:1-860-610-0645 NHME:H YANOSY P. 1 d ASONHA H;3WUN Sb90-OT9-098-T;-131 2S:TO I23 9002-8-93a I THE NURSE IS ffERE., LLC• Pa BOX 75 . . CANTON, CT 06019 CELL ( 6 ) 836-64 Z HOME 186 ) +693-0896 FAX (860) 693-617 E-MAIL NVRSElSHERE@COMCASTNET STATE 0I• CO NNECTICU I DEPAR71VEN T OV PUBLIC HEAUM ,PUR$UANT TO TtIS PROYISIONS Oft THE CGNERAL STATUTES Or•CONNE ICUT TliE INDIVIDVAI.NAMED BELOW IS LIGT:NSED BY THIS bFYARTMtKT AS A • .•REGISTE.RFD NURSE LICENs6 No. Ire F-4068 f CURRENT THRMoaa SUE ANN Ca.u0 �►.i.4`RN- 11 J Sty I as VAUDATION No. 03-229504 • - 9 I xIGNAz'Wca ati e 9fS:d Im-b900T9:01 850b219098 OIJNIWNU-d 32U3d30NIN:W0'd3 20:TO 9002-8-930 12/07f2006 15:09 FAX 860 679 1388 UCHC CREATIVE CHILD CTR [d]0ol DEC-7-2006 00;22 FROM:H YONOSY 1-SQ-610-0645 TO:G(9139EI P:2/2 iArtathrnent#11 e I Cons 11tant A r'eement Social Services: i I, Tony LaPenta, agree to act as a ,Social Services Consultant for The South Windsor KinderCare Learning Center. I will be available to the operator and the staff to provide advice regarding the emotional reeds of the children and families of the Center, and review policies as needed. I will be available by phone and in person to provide these services to the Center. Consultant Signature: Date: i Z/ 7/0(v- Director Signature. Date: I DEC-7-2006 THU 03:47 TEL:1-e60-610-0645 NAME:H YRNOSI' P. 1 62127/1996 21:46 8603465653 WESLEY SCHOOL PANE 52 Fin December 6, 2006 My signature below certifies that 1, Jennifer D. Cecarelli, have agreed to be the Education Consultant for: KinderCare Center#301247 494 Chapel Road South Windsor, CT 06074-4107 Services may include: (A)Annual review of policies (D)Annual review of in-service education programs (C)Availability by phone for advice regarding center issues involving any educational components (D) Availability for advice in person, as needed Fees for the above services and any additional will be billed at a rate of$35.00- $40.00 per hour, plus additional sales tax. Signature0 7 J ife D. Cecarelli, S., M: ., C.A.G,$,,�NBCT 2002 E ucat Consultant B. Date �c t Jennifer D. Cecarelli 396 Quinnipiac Avenue Phone:203.234.7598 North Haven, CT 06473 rnrs_cecar�Ifis_clarsf�yaHbO.com DEC-6-2006 WED 03:00 TEL:1-860-610-0645 NAME:H YANDSY P. 2 d ASONUA HedWUN St?90-0T9-098-T:-I3l S2:00 nH1 9008-�--98t0 AetachMent#11 c Cons t A rleernent Dental Consul t, Kevin Norige D.M.D., agree to act as a Dental consultant for The South Windsor KinderCare Learning Center. I will be available to the staff and families to provide advice regarding the dental health of the children, and review policies as needed. I will be availa;bl� by phone and in person .to provide services/training to the Center. Consultant Signature: , Date: Director Signature: � ?ate: 2d WdG'2:ZT 900E Z0 8GZ9Vt79098 'ON xa-� E10I 6ON NCI: W06=1 2 d ASONUA H:3WHN St;-90-OT9-098-T -131 00:20 NOW 9002-TT-330 �'c^ - .�DLr'9I(]'K1ERL.: �('�U.�tr3.�;StY,(�ll1�.;1'•�i� - i - `�U_L,�U:4I11"(`.�'U.'YfiiE`•.h .:f,: -,,ts�. H. - •i�.:. _ , -'��•;;�;; ,gyp',; L• :;1+As�DA•TlfllVl�tli":ix ::3:• r :,rc_ ,. ;«i}"a�•' �.s{ Y' ;`�,Y l� art ra. l''4�, ,...J i ;" Hw f^.r,°�,pt`�i s-v,•e•w, — _ rrw�,.:��±icy.:aW ti.f:r — Jr. 4 h�yY r� �'.rsrs ,,:�i-� :•fit(-:�Y•-.'-.�:"��.�. ..nr ..hv. Zd WdSO:SQ 900C��TT '�aQ.. . ._ 8S�S1�b.909B: ON Xti3 A91NON NG: WON-d 2006-1213 09:09 Y »1-850-610-0645 PW zt iS'IArME OF CONNECTI UT DEPARTMENT OF PUBLIC HEALTH Community Rascd Regulation Section ALL FAMILY DAY CARE HOME% GROUP D.4Y CARE ROMM AND CHILD DAY CARE CENTERS PROOF O> WClit'f rlt"►; OMMIS M11MIlIt® C- E IF YOU HIRE EMPLOYEES TO WORK IN YOUR PROGRAM State Law (COS Section 31- 2t16a(b)) • it that no state department, board or agency many issue or renew a Dicense, or permit tp operate a business in this stag unlCss the appli4�nt first presents sufficient evidence of current compliance with the workers'ct►mpensation insurance coverage requirements of Section 31.284. This means that if you hire employees to work in your tkmily day We home, 8roup day care* home or child duty 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 alsplicrtiol], sufficient evidence of compliance with iliis law. Far More Inforanxtion Contact, _ 9 Your Insurance.Agent or The Workers'Coinpellsation Con►mission: 1.800.223-9675 or 1-860-493-1734 x,ww*r��r*��-rxx�r���x**•w�+r�wr+war***wr�wr,��ax,�*r*w�M**#rt**Mr��;*�**w,r*w*aw********#�+*a* Ty"4 FORM'M11ST BE COMPLETED Al�lI1 RI;'dU'RNED•WIT11 YOUR APPLICATION FOR A CHILD DAY CARR LICENSE LL_V>EN IF Yt7 t r][7 i1 QT PMu1 t. Program/ProviderN'ame, r, l r. 1 n NewApplicatinn Address: Relictltsuro Applicali()n Town/State/Zip- 4c '' Tell: hone, " A 1�q License#- Do you hire employees in your program thal requires you to obtain Workers' Compensation Insurance? I-Mycs © No 1f "Yes", please chock (Wf which of the required certificates you have, As indicated below, and enai i a cagy of the certificate to the Departmeut of Public Health,Day Care Licensing ptogre111. Sufficient evidence means:(Check off and enclose a copy) (1) a certificste of self-insurance issued by a wrsrkt,x'componsatii�rt section 31-,284-or crrmmissioger pursuant to (2) a certificate Of compliance issued by the insurance commissioner pursuant tp section 31-286;or (3) a certificate of insurance issued by Oily stack or mutual insurance cjjrnp$ny or mutual assc ciat uthurixtd to Writt wt►rkt-rs'compensation insurance ill this state or its a►tent. +grtulur r O rafrarif'rr�vrdxrJ } � >; ( } (printed IVamh1 T:'�Orn&CU'1ApplioptiunlCDC WC:1nsFurm.tlnc 2l24106 PhOnv;(860) 509-8045, P xx(860)509-7541 :u hlephone Device f r the Degf'(860)509-7191 910 f pF,.r�,1 q.,�nr,4-Ays#1.?CWR P.O. Box 340308 Hartford, CT 06134 Ain Equal 0PP0rl9rr111y EMplc;yer DEC-12-2006 TUE 22:02 TEL:1-860-610-0645 NRME:H YANgSY P. 1 ORD e4C_. CERTIFICATE OF LIABILITY INSURANCE Pa,e j of 3 11/2DATE 7/2006 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Willis North America, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 26 Century Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Knowledge Learning g g corporation INSURER A:Discover Property and Casualty Insurance 36463-002 Attn: Kea Wood 650 NE Holladay St. INSURERS:Discover specialty Insurance Com an 10213-000 Suite 1400 INSURERC:New 8 shire Indemnity Co. Inc. 23833-000 Portland, OR 97232 INSURER D:American Home Assurance compan 9380-006 INSURER E: 1 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 D' POLICYEFFECTNE POLICYEXPI TON LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MM D DA MM/DD LIMBS A GENERAL LIABILITY D003Q00081 12/1/2006 12/1/2007 EAC�OCCURRE�NCE $ 1 000,000 X COMMERCIAL GENERAL LIABILITY O $ 1 000 000 CLAIMS MADE [il OCCUR MED EXP(Anyone person) $Excluded PERSONAL BADVINJURY $ 1 000 000 GENERALAGGREGATE $ 5 00Q OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,000 POLICY PROT X LOC a A AUTOMOBILE LIABILITY ADS D003AO0238 12/1/2006 12/1/2007 A X ANY AUTO COMBINED SINGLE LIMIT MA D003AO0239 12/1/2006 12/1/2007 (Ea accident) $ 2,000,000 8 ALLowNEDauros TX 1)003A00240 12/1/2006 12/1/2007 SCHEDULED AUTOS BODILY INJURY (Per person) $ HIRED AUTOS NON-0 BODILY INJURY WNEDAUTOS (Peraccident) $ PROPERTYDAMAGE $ (Peraccident) GARAGE LIABILITY [- I ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHERTHAN EAACC $ AUTO ONLY: AGO S EXCESS LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ L+ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY AOS 2920639 j2/1/2006 12/1/2007 X WORYTIMIU-S O D ANY PROPRIETORIPARTNERIEXECUTIVE CA 2920641 12/1/2006 12/1/2007 E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? 11000,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ j 000 000 SPECIAL PROVISIONS below OTHER E.L.DISEASE-POUCYLIMIT $ 1,000,000 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS See Attached CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$0 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Posting Notice - AIDS REPR TATIVES. AU 7H0 REPRESE TATI Ali d ACORD 25(2001108) C011:1815743 TVI-5.68-985 'Cert:8107481 CORDCORPORATION1988 WII1IS CERTIFICATE OF LIABILITY INSURANCE Pa. DATE PRODUCER ge 2 Of 3 11/27/2006 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION THE Willis North America, Inc. HOLDER. THISY ANONFERS CERTFICATE DOES NOTNO RIGHTSOAM ND,CCATE EXTENID OR 26 Century Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Knowledge Learning Corporation INSURER A:Diseover Pro Attn: Ken Wood perty and Casualty Insurance 36463-002 650 NE Holladay St. INSURERB:Discover Svecialty Insurance company 10213-000 Suite 1400 INSURERC:Now Hampshire Indemnity Co. Inc. Portland, OR 97232 23833-000 INSURERD:American Some Assurance Company 19380-006 INSURER E: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Knowledge Learning Corporation centers operated under the following names: children's Discovery Centers Children's World Learning Centers EdSolutions, Inc. Education Station, LLC Kindercare Learning Centers Knowledge Beginnings Knowledge Learning Corporation School Partnerships (Champions) Learning Universe Magic Years Child Care and Learning Centers Mulberry Child Care Centers Science Enrichment Services, Inc., dba: Science Adventures AZ/MD/VA Workers Compensation: -- Carrier: American Home Assurance Company/19380-006 Policy #2920640 --- Effective: 12/1/06 Expiring: 12/1/07 EL Each Occurrence: $1,000,000 EL Disease Each Employee: $1,000,000 EL Disease Policy Limit: $1,000,000 MO/NY/WI Workers Compensation -- Carrier: New Hampshire Insurance Co./23841-003 Policy 2920642 --- Effective: 12/1/06 Expiring: 12/1/07 EL Each Occurrence: $1,000,000 EL Disease Each Employee: $1,000,000 EL Disease Policy Limit: $1,000,000 MA Workers Compensation: -- Carrier: Insurance Company of the State of Pennsylvania/19429-002 Policy #2920643 --- Effective: 12/1/06 Expiring: 12/1/07 EL Each Occurrence: $1,000,000 EL Disease Each Employee: $1,000,000 EL Disease Policy Limit: $1,000,000 OR Workers Compensation -- Carrier: American Home Assurance Company/19380-001 Policy #2920644 --- Effective: 12/1/06 Expiring: 12/1/07 EL Each Occurrence: $1,000,000 EL Disease Each Employee: $1,000,000 EL Disease Policy Limit: $1,000,000 FL Workers Compensation -- Carrier: Illinois National Insurance Company/23817-001 Policy #2920645 --- Effective: 12/1/06 Expiring: 12/1/07 EL Each Occurrence: $1,000,000 EL Disease Each Employee: $1,000,000 EL Disease Policy Limit: $1,000,000 Workers Compensation for all States except Monopolistic and Maine Coll:1815743 Tpl:568985 Cert:8107481 Page 3 of 3 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, extdnd or alter the coverage afforded by the policies listed thereon. ACORD25(2001/08) Co11:1815743 Tp1:568985 Cert:8107481 Water Supply (Attachment# 13b) Program Name: irlt�es � �,rain License#: ) Location Address: Capacity: L/ City or d (If New program, indicate "New"next PLEASE BE SPECIFIC: to license#.) • Months of Operation(i.e. September-June): • Days/Hours of Operation: Monday � (V Tuesda "! y�.0 CV Wednesdaytl���`°� Thursday(�—(, Friday Name of Property Owner: Address: q 9. City or Town: r Phone#: 'i(a Q Section 1 LY you or your landlord a Customer of a Water Company- No es, complete Section 2 and provide the name of the Water Company.o, complete section 3 - ct 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; If you answered yes to Section I and completed Section 2, ,DD 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 lead water test and bacterial & hemical 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 rogram'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 facilitj meets the classification of a Public Water Supply System and will be Referred to the Department of Public Health,Drinking Water Division. Dead 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& bacterial and chemical test , T:\Grp&Ctr\Application\G_C WaterSupplyAttach.doc 12/4/04 Dec 6 2006 11 :28 P. 01 64`64:6.2 -RQAFIE L�AANINQ CFNTER INCI POPF ,olstolct r. 71-12746. Dao Uato m 6unt NnmbO 494 C- H-Apla-RD 5S... ain.,qt-mot, IBPX A SenAco Ad'dfe;gs* 11-10112ow. iktddrd, 10onm4tiltut 001-42-0000 200 tbor, 1,7-25 it-is sp mtev use."Wr RL Tat-18) culrrqo";�"098,1, :Iellrkrv.g SOMM.IkTV.",' Off:-off ........... 4!ft 217 Ei. SiO v-cl 11.1 Mvlsi qd pow it- -7:k i,-. m A Wo jrvJ in ... - .ry Nl . ...... o". m 11> m l ` k� . MEkp-44 w 4" US- N, no h WYK% Z....1•ilk • 7 At Aft i �g. MR. lit U19 A` P. I DEC-6-2006 WED 03:22 TEL:1-860-610-0645 -NAMEH YANOSY _ --- CHAINOF CUSTODY ECORD testing ° _- -------.. laboratories; o_ab Tracking#; �_ � Pq y --" -- R. nested Analyses i {^ i. C.I P.FI['.��—iPr�tA� �..�°%�_. s�&�tv .�S.�v-�S.f3'.__--- ,'• � ;� �•• `• i ,'� � �"? 01 11� L am„$ C-T �i6 d ¢ r,-i �� , �1; i^ '�''•, -"ram. �'. �� .r j' /• r r �', /'I M1 .< r^ �� vanrplEr{GJ. ''i�_-�-i�.�,•.��SL-�` •.°�k t�..•�,, —„ _—(:,gr.?.n:ra; f' 1 ,L',QfcfEfSCc + -tip 1 Lab Use acid it)(please print) Date T itne M.at.,i; i.ritena Jr � d 6/ gyp®� ` ,v}i ...�— —__ i Q- h ._. --- ----- -. - _ - f- - I - �. -• _ -___ _ _...____.__ ` + o i iSt�nAtlwa) i Date r :aria, '1"Zeceived B}:(aiCnatl!r'"d--_x_..__ tJc+iw`r TIFTIE ?.��iVF.(7 b:;Lat'� f S. '-..at T Ti r ) J;c'J� t., yRaf,J'� :.'1t8 i^.:n I; I � I { � � Relinquished 2v:(Si-gnaNra? 'Date ?::ric- 'Received EDy:lS,ensturz). ,a, i,r! _ Turn Aouund Time I f � i IlReiiiryc,fs ted i?'y (Sioilatttrei Date Tulle Received By:(Signalure) 148 H'R` 4 Oav' l , V' 'Turnaround times less than"5 Days"maybe^Lobbed t0 riorl 'te2 C d' eS. E�?Will nOf�P,i Ci'EI'! F L'! il1C Cift@G°I"tflle .t Ii l.f yE^ o r nn rrl� C-- p f y 1 P 9 <i 1 , w .usi.dy Reco ds. :ar .,: c..� Jaya k?airicos=A •Aff?jeQL;>-1;-Saif/Soild H-Hydrocarbon jOM r' Coonecticut Testing Laboratories,tr?c. 165(Tracey A„a.'Meriden,CT 0.645 i Te'.t203!-o34-37:5. =wx(203)630-12''R r Dec, 06 06 05: 43p Andrew Miller OGO-633-3330 p. 1 12/06/06 WED 17.03 FAX 203 630 1336 CONN TESTING ILAB c�oa1 page 1 Date Samples Received: 12101/06 Client Name: CT Lead Paint Sgiutions CTL Lab No. : 1206DO1 Report Date: 12106/06 P4/Job No. ; KinderCare Learning Center RESVILTS OF ANALYSIS EPA Method 235.2 Matrix Type' W CTL Sample No,: 21777 Field ID; 16`Draw Kitchen Faucet 494 Chapel Rd, South Windsor,CT Parameters MDL Tatal Lead rn AL V OOa' BDL Note:This water meets the requirement for lead content in drinking water based on the State of Connecticut Action Levels of 0,015 mg/L. MDL=Method detection Level BDIr Below Detection Level Matrix Type:W=WaterlAqueous S=Soh/Solid 0--oil/Hydrocarbon Stephen J.Franco Laboratory Director PH-0547 Connecticut Testing Laboratories,inc. 166 Gracey Avenue 1 Meriden.CT 06451 (2031 634-3731 (Fax)630-1336 Certification CT-PHOS471 MA-CT036 DEC-6-2006 WED 06:42 TEL:1-860-610-0645 NAME:H YANOSY P. 1 Date: ! / / Program Name: Phone 0: � "7� Location Address: LA 9 Li Town License# Mailing Address: ,p Town: State: Zip Code Prepared By: �( (� I -�t�t�r` (� _ Date: c STAFF WORK SCHEDULE FORM DATE OF WORD SCHEDULE STAFF NAME * v BIRTH POSITION DAYS AND HOURS DATE AIRED e (100, loll �i`� (MI7 ! _ �rn_W) of jc--, 23 s� { ^Cs C-Cra LQ—)A4 -z pask Irn R", — * 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 RETURN TO: T:\Grp&Ctr\Relicensure\G_C_RelicStaffWorkSch.doc 10/23/03