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Daycare Inspection 120 Foster Road (2)
STATE OF CONNE CTICUT DEPARTMENT OF PUBLIC HEALTH QV/ �yt1NE4 T�CNST64 S T Ms.Lisa Mannarino February.4,2003 Learning Center-Pierce Road 1250 Ellington Road South Windsor,CT 06074 PUBLIC WATER SYSTEM(PWS):LEARNING CENTER-PIERCE ROAD TOWN: SOUTH WINDSOR PWSID: CT1320243 RE: OPERATOR CERTIFICATION REQUIREMENTS Dear Ms.Mannarino: Community and Non-Transient Non-Community PWS are required to have certified operators per Section 25- 32-7a through 25-32-14 of the Regulations of Connecticut State Agencies(see enclosed). Additional discussion on this requirement is provided in the enclosed pamphlet entitled"Certification of Public Water System Operators". We have made a tentative determination that the water system serving Learning Center-Pierce Road is classified as a Small Water System(SWS). According to Section 25-32-1 la of the Regulations of Connecticut State Agencies, a Small Water System is a'public water system that serves less than 1000 people and has no treatment or has only treatment which does not require chemical treatment,process adjustment,backwashing or media regeneration by an operator.As a result,Learning Center-Pierce Road must contract or employ an operator who is certified as a Small Water System Operator,Water Treatment Plant Operator or Distribution System Operator. Please notify this office by February 18,2003 if this classification is incorrect. You may obtain a list of certified operators who are available for contract work from the web site bZ://www.dRh.state.ct.usA3RS/Water/DV*'D.htrn or by contacting this office. Learning Center-Pierce Road must designate a certified operator by'completing the enclosed"OPERATOR VERIFICATION"form and submitting the form to this office by March 4,2003. Failure to comply with the above cited regulation could lead to an issuance of an order by the Department. If you have any questions,please feel free to contact Jennifer Pagach at this office. Sincerely, Robert Rivard,P.E. Supervising Sanitary Engineer Drinking Water Division Enclosures Section 25-32-7a through 25-32-14 of the RCSA Pamphlet:Certification of Public Water System Operators Operator Verification Form cc: Gerald L. Schwartz,Town of South Windsor Steve Messer, Supervising Sanitary Engineer,DWD Phone: (860)509-7333 Telephone Device for the Deaf (860) 509-7191 410 Capitol Avenue - MS#_ 5_1_WAT P.O. Box 340308 Hartford, CT 06134 Affirmative Action/Equal Employment Opportunity Employer STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH gut, yJ51% OPERATOR VERIFICATION NAME OF PUBLIC WATER SYSTEM (PWS) : Learning Center- Pierce Road TOWN: South Windsor PWSID: CT1320243 OPERATOR VERIFICATION: I verify that I am the certified operator for the PWS named above. Chief Operator Certification No. (print name) Phone #: (Signature of Certified Operator) Check off: ❑ Employed by ❑ Contracted by ❑ Other the above named PWS the above named PWS Operator Certification No. (print name) Phone #: (Signature of Certified Operator) Check off: ❑ Employed by ❑ Contracted by ❑ Other the above named PWS the above named PWS SYSTEM OWNER OR ADMINISTRATIVE CONTACT VERIFICATION: I verify that the persons listed above are the certified operators for this system. (Signature) Title Date (print name) Phone Number Return completed form to: Robert W. Rivard Department of Public Health Drinking Water Division 410 Capitol Ave. - MS#51WAT P.O. Box 340308 Hartford, CT 06134 Phone: Telephone Device for the Deaf (860) 509-7191 410 Capitol Avenue - MS# P.O. Box 340308 Hartford, CT 06134 Affirmative Action/Equal Employment Opportunity Employer ENVIRONMENTAL INSPECTION REPORT [415SPECTION ❑ 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 .6 Date of Inspection INSTRUCTIONS _ —0.-0 Check=Compliance; Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable Date of Expiration Licensed Capacity_ Under 3 Endorsement If #Children Present #Staff Present Program Name License# Telephone# Address Operator Licensed for: ❑Under 3 Yrs ❑School Age ❑Night Care ❑Pre-School(3-5 Years) ❑On Site Kindergarten PP ical Pliant/Indoor Space 19a-79-7a Health and Safety 19a-79-6a License premises clean/good repair �11 Refrigeration no more than 45° ,-, 2 Equipment clean,in good repair,safe/non-toxic 912 Food prep area clean/good repair I�/s Free from observable hazards (�3 Food safely stored Lvf a Drinking water available,adequate,safe 14 Food prep handwashing 4a Lead Water Test/Date 15 Adequate dishwashing ,/ El Within Limits El Exceeds Limits 16 Kitchen separated � ab Public Water Supply 17 Mark as appropriate: r-,� �] 4c On Site Well(In compliance with CT Public Health Code snacks served ❑ Cold breakfast l 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 Building: Post 1978 Construction 4d Private Well-Facility serves less than 25 children&adults ❑ Building: Pre 1979 Construction(Lead Inspection Required) e Other(Please specify) ❑ No Lead-Based Paint Identified Required toilets/sinks/supplies ,hrto r_ vk. Adequate ventilation in toilet room ❑ 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 EE,,,/ Approval recommended. No code violations identified. ❑ Approval recommended with conditions(see below). ❑ Approval not recommended due to existing serious code violations. 11AG�-Irt1 �Li9bs^— O ILt Tv)� p� Ott ©rdv / It ®O1/ livv Vt"D/cI� F Iljkf pool O1/`ffld� a.�' al db�s Signed(Inspector) )ale Corrections Due Vn in C ar ) ore Pr 0 s:/Division/Licensure/Grp& tr/Field Forms/Env Inspection Report 3/05/03 Website fo for oc ealth v STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH py, St NEt rRAN3lU��1 ' September 24, 2003 Ms. Lisa Mannarino The Learning Center, LLC 1250 Ellington Road South Windsor, CT 06074 PUBLIC WATER SYSTEM: The Learning Center,LLC TOWN: South Windsor, CT PWS ID#: CT1320243 SUBJECT: SANITARY SURVEY REPORT Dear Ms. Mannarino: Enclosed is the report for the sanitary survey conducted at the Non-Transient Non-Community Public Water System serving The Learning Center,LLC on May 28, 2003. Please refer to the "Requirements"section of the report for a summary of required system improvements. The "Recommendations"section details potential system improvements to ensure continuous operating service of this public water system. A written response to the requirements and recommendations must be provided to this office by November 28,2003. If you have any questions or would like to discuss this matter in further detail,please do not hesitate to call me at(860) 509-7333. Si c 1j, 1 S1ev Messer Super 11ising Sanitary Engineer Drinking Water Division SM/cr Enclosures: Sanitary Survey Report cc: /Lr. Gerald L. Schwartz, Director of Health, South Windsor Mr. Thomas Ghent, Certified Operator Julie Boscarino, DPH Childcare Licensing Specialist Phone: (860)509-7333 Telephone Device for the Deaf: (860) 509-7191 r a 410 Capitol Avenue - MS# 1 AT P.0. Box 340308 Hartford, CT 06134 A 1rF1' -f;, A r;. / A SANITARY SURVEY REPORT SUBJECT: South Windsor, CT: Sanitary Survey of the Non-Transient Non-Community (NTNC)Public Water System at The Learning Center, LLC (CT1320243) SURVEY DATE: May 28, 2003 FROM: c' Christopher Roy, Sanitary Engineer 2—Drinking Water Division INSPECTED BY: Christopher Roy, Sanitary Engineer 2—Drinking Water Division INSPECTED WITH: Lisa Mannarino, Director, The Learning Center, LLC Polly Buvelot,Director, The Learning Center, LLC GENERAL: A sanitary survey of the water system serving The Learning Center, LLC was conducted on May 28, 2003. PHC Section 19-13-B102e (7)(B)(i)requires a sanitary survey of a public water system using only groundwater sources to be conducted once every five years. This report will serve to document the Connecticut Department of Public Health(DPH) Drinking Water Division's fulfillment of this requirement. The Learning Center, LLC is a Connecticut-Licensed Daycare Center(#15104) located at 80 Pierce Road in South Windsor, CT. The center is licensed for a maximum capacity of 55 children. The Learning Center, LLC meets the definition of a Non-Transient Non-Community(NTNC)Public Water System(PWS) since the water system serving the facility supplies water made available for human consumption to 25 or more of the same people over six months per year. WATER SYSTEM DESCRIPTION: The water system at The Learning Center, LLC is served by a six (6) inch diameter drilled bedrock well. Information on the age and depth of the well was not available during the survey. The well casing extends approximately eight (8) inches above the surrounding grade and is equipped with a Campbell LP-6 watertight well cap with integral shielded and screened air vent. This well cap meets the recommended performance standards for watertight well caps established by the Water Systems Council. The portion of the well casing projecting above grade is severely corroded,preventing the well cap gasket from forming a watertight seal to the casing. The well cap was leaking during the survey. The well is located on the front corner of the lot approximately 17 feet from Pierce Road. An abandoned road drainage gully is located approximately 25 feet from the well. It is believed that the gully was once used as a drainage swale for storm water that collected on Pierce Road. The installation of the storm water drainage system under the road eliminated the need for the swale and it remains abandoned in place. The area appeared to be relatively dry and free of standing water following a rain shower earlier in the day. The location of the new storm water drainage system in relation to the well is not known. 1 Potential sources of pollution and areas of concern near the well are as follows: • Aboveground Fuel Oil Storage Tank(275 gallon)— 85 feet • Sewer lateral from building to sewer main in Pierce Road—Unknown • Sewer main along Pierce Road—Unknown • Stormwater catch basin(closest in road)—63 feet • Stormwater drainage line in road—Unknown • Roof drain—43 feet • Pierce Road— 17 feet • Parking lot— 15 feet Water is withdrawn via a jet pump with an unknown rated capacity which is located in the basement of the facility. The well supply line enters the building below grade into a small utility closet in the basement. An 82-gallon Flotec pre-pressurized pump tank provides approximately 10.7 gallons of water storage when operating in the range of 30-50 psi. A pressure switch activates the jet pump to re- pressurize the system when the water pressure reaches the preset minimum. The floor of the closet was wet, caused either by excessive condensation on the pipes or a small leak in the system piping. The moisture has corroded the jet pump,Dayton motor, and associated electrical boxes and conduits. TREATMENT: The water system serving The Learning Center, LLC currently meets the definition of a small water system since the water system serves less than 1000 persons and has no treatment or has only treatment which does not require any chemical treatment,process adjustment,backwashing or media regeneration by an operator. The current operator of record for The Learning Center, LLC is Thomas P. Ghent, Class 1 Water Treatment Plant Operator, Certificate Number 2002520. CROSS-CONNECTIONS (NON-POTABLE WATER USE): The Learning Center, LLC uses the potable water system as a source of makeup water for its boiler heating system. The RCSA Section 19-13-B38a(c)(3) requires a reduced pressure principle backflow preventer (RPD), an air vent type backflow preventer or an air gap on water supply lines to all boiler systems where chemicals are not added. A backflow prevention device could not be located on the potable water line serving the boiler during the survey. WATER QUALITY: Recent water test results indicate that the water quality meets the drinking water standards set forth in (PHC) Section 19-13-13102 (e) for the parameters tested. The Learning Center recently incurred a monitoring and reporting violation for failing to monitor for lead and copper during the January 1, 2003 to June 30,2003 monitoring period. The results of the samples collected for lead and copper analysis on August 8, 2003 were below the applicable 90th percentile action levels. PUBLIC HEALTH CODE VIOLATIONS: 1.) Well Construction (Casing Material)—RCSA Section 19-13-B51f(a) 2.) Well Location (Withdrawal Rate Unknown)—RCSA Section 19-13-B51d 2 3.) Backflow Prevention—RCSA 19-13-B38a(c)(3)(A) 4.) Vacuum Breaker—RCSA Section 19-13-B38a(e)(3) CONCLUSIONS: The requirements and recommendations as a result of this sanitary survey are itemized below. Immediate attention should be given to those required items. The Drinking Water Division strongly suggests evaluating the recommended or suggested items listed below as these items will improve water quality and bring about better system operation. Requirements: 1) Well Construction (Casing Material)—RCSA Section 19-13-B51f(a)— "Pipe used for casing a well other than a dug well shall be made of steel or other material approved by the commissioner of health. They shall be free from flaws or defects and shall have watertight connections." The portion of the well casing projecting above grade is severely corroded,preventing the well cap gasket from forming a watertight seal to the casing. The faulty seal is allowing water to leak from the well cap and further corrode the casing, as witnessed during the survey. At a minimum, The Learning Center must determine the extent of the corrosion of the well casing below grade. If the casing below grade is free from flaws and defects, the corroded materials above grade should be removed and the casing should be coated with a protective finish. Depending on the extent of the damage,the casing may need to be replaced. Au work to the primary casing of a well must be performed by a well driller registered in Connecticut. 2) Well Location (withdrawal rate unknown)—RCSA Section 19-13-B51 d—"Each such well shall be located at a relatively high point on the premises consistent with the general layout and surroundings; be protected against surface wash; be as far removed from any known or probable source of pollution as the general layout of the premises and the surroundings will permit; and, so far as possible, be in a direction away from ground water flow from any existing or probable source ofpollution." RCSA Section 19-13-B51d establishes separating distance requirements between drinking water supply wells and potential sources of pollution based on the actual withdrawal rate of the well pump. These requirements are summarized in the table below: Surface Water Surface Water/ Withdrawal Sources of Body High Foundation Rate m) Pollution Water Mark Drain <10 75 25 25 10-50 150 50 50 >50 200 50 50 Information about the withdrawal rate of the existing jet pump and the exact locations of some potential sources of pollution and areas of concern near the well was not available during the survey or could not be determined. The Learning Center must submit the following information to determine compliance with RCSA Section 19-13-B51d: 3 1 • Jet Pump manufacturer and model and depth of intake within well • Withdrawal rate of jet pump • Depth and maximum yield of well • Location of sewer lateral from building to sewer main in Pierce Road and its distance from the well • Location of the sewer main along Pierce Road and its distance from the well • Location of the stormwater drainage line in Pierce Road and its distance from the well The Learning Center is currently operating with a monitoring waiver for pesticides, herbicides and PCBs (SOCs). Waivers may be granted to public water systems if the requirements of Section 19- 13-B 102(e)(7)(C)(xiv) of the PHC are met. This regulation requires that"the source of supply is constructed and protected pursuant to Sections 19-13-B32 and 19-13-B51d of the Regulations of Connecticut State Agencies". This monitoring waiver will be revoked if the required information is not submitted to this office in writing. 3) Backflow Prevention—RCSA 19-13-B38a(c)(3)(A)— "Unless otherwise required by sections 19- 13-B38a(b) or 19-13-B38a(c) of the Regulations of Connecticut State Agencies, the owner shall install either an RPD or an air vent type backflow preventer or an air gap in the following instances: (A) Water supply lines to all boiler systems where chemicals are not added• (B) Water supply lines to carbonators for beverage machines, water conditioning systems, and commercial ice making equipment; (C) Water supply lines connected to solar heating systems where chemicals are not added and heat exchangers where chemicals are not added; (D) Water supply lines to storage tanks used for fire protection where chemicals are not added." The Learning Center, LLC uses the potable water system as a source of makeup water for its hot water heating system. A backflow prevention device could not be located on the potable water line serving the boiler during the survey. The facility must confirm that the boiler supply line is currently equipped with an adequate backflow prevention device or plan for the immediate installation of such a device to protect the potable water system from potential contaminants. 4) Vacuum Breaker—RCSA Section 19-13-B38a(e)(3)—"The owner shall install either an atmospheric vacuum breaker or a pressure vacuum breaker or an air gap on inlets which are or may become submerged." Hose bib vacuum breakers should be installed on all threaded hose bibs that are located throughout the water system to prevent back siphonage of unsanitary water in the event of a system pressure loss. The exterior hose bib must be equipped with a hose bib vacuum breaker. Recommendations: 1. The closet containing the jet pump and pressure tank should be cleaned and not used for storage of equipment and/or cleaning products. There appears to be a small leak that is causing the closet to remain damp and promote the corrosion of the metal electrical fixtures and jet pump. The leak should be repaired to eliminate further corrosion of the water system equipment. For security, the closet door should remain locked at all times. 4 1 2) Installation of an instantaneous and totalizing flow meter is recommended to monitor water use. These readings are important in determining actual water use at the building and can be used to assist in the sizing of future water system facilities and other design elements of the water system as upgrades become necessary. The readings may assist personnel in diagnosing problems such as line breaks, leaks and faulty plumbing fixtures, which may result.in above average water use. The meter can also be used to determine the actual withdrawal rate of the jet pump as listed above in Requirement#2. 3) A smooth end (e.g. threadless chrome) sampling tap should be installed on the main water supply line after the pressure tank. This new sampling location should be used to collect Entry Point water samples prior to entering the distribution system. This type of sampling tap is easier to maintain and sanitize during sampling events. 4) The existing jet pump, motor and electrical fixtures are corroded and should be replaced. Installation of a submersible well pump will enable The Learning Center to determine the actual withdrawal rate from the well as listed above in Requirement#2. 5) The DWD recommends replacing the existing well since the casing is severely corroded and it is located close to the road. It is believed that the sanitary and storm sewer lines located in the road may not meet the required separating distance requirements for this well which will result in increased water quality monitoring requirements for total coliform, and pesticides, herbicides and PCBs (SOCs). FOLLOW UP ACTIONS: A written response addressing the Public Health Code Violations/Required Actions and Recommendations sections of this document is requested no later than November 28,2003. 5 SANITARY SURVEY A. Inspection Information Public Water System: The Learning Center,LLC PWS ID#: CT1320243 Water System Address: 80 Pierce Road Town: South Windsor (DPH Childcare License# 15104) Date of Sanitary Survey: May 28,2003 Inspector's Name/Title: Christopher Roy, Sanitary Engineer 2 Inspected With(Name/Title): Lisa Mannarino,Director,The Learning Center,LLC Polly Buvelot,Director,The Learning Center,LLC B. Water System Administrative Information Ownership Type:Private Administrative Contact: Ms.Lisa Mannarino Organization: The Learning Center,LLC Title: Director Address: 1250 Ellington Road South Windsor,CT 06074 Business Phone: 860-648-2068 Ext: Emergency Phone: 860-289-5725 Fax: Certified Operator: Thomas P. Ghent Certificate Number: 2002520 Designation: Certified Operator Certification Type: Water Treatment Plant Operator Certification Classification: Class 1 C. General Water Svstem Information Daily Population Served: Transient: Non-Transient: 55 Residential: Total Population: 55 Water System Season of Operation: 1/1 through 12/31 Public Restrooms: ❑Yes ❑No Q Non-Transients/Residents Only Food Service Establishment(s)on-site: No Number of Service Connections(Buildings Served): 1 Estimated distance to the closest municipal or private Community Water Systems(if known): Are there any permanent water treatment systems installed? No (if Yes—complete section G) Additional Notes: Daycare License# 15104. Population listed is maximum allowable capacity per daycare licensing. Population does not include employees(est. 6). 1 D. Water Sources: Status (A-Active,S-Seasonal,E-Emergency,I-Inactive) A N/A N/A Type (B-Bedrock,GP-Gravel Packed,D-Dug,S-Spring) B Entry Point(C-Common,D-Different) C Well Casing Diameter(inches) 6 Well Depth(feet) Unknown Height of Well Casing Above Grade(inches) g Well Pump(S-Submersible,C-Centrifugal,J-Jet,T-Turbine) S Well Pumping Capacity(gallons per minute) Unknown Well Vent(G-Shielded,S-Screened,N-None) G,S Well Cap(W-Watertight,NW-Not Watertight) W,Campbell LP-6 Water Meter(IT-Instantaneous and Totalizing,T-Totalizing,C- Common,I-Individual,N-None) No Sampling Tap(Y-Yes,N-No) No Well Pit(indicate all that apply) (L-lighting,V-vented,W-Watertight,GD-Gravity Drain, None SP-Sump Pump,K-Locked Access Hatch,N-None) Well Pit Condition(S-Satisfactory,U-Unsatisfactory) N/A E. Sources of Pollution/Cross Connection EMINEM Fuel Storage Tank(s)(Aboveground 275 gallon) 85 N/A N/A Septic System Sewer lines- Includin septic tanks,sewer lines,and leachingfields location unknown Surface Water N/A Storm Drainage System(In road catch basins/pipes) Catch basin in road 63';Location of road drain lines Foundation Drain unknownN/A Other Sources Of Pollution(includes:farmland,landfill, chemical tanks,dum ster, arkin lot,road,cemete ,etc. Road 17' Hose bibbs Needed on outside faucet Boiler Feed Line Air Vent Irrigation System N/A Fire Protection Systems N/A Other: F. Water Stor a Facilities 7Numbberanks N/A N/A1ons or make/model for diaphragm tanks) Flotec,82 gallonlSteelge(S-Satisfactory,U-Unsatisfactory,N-None) S Sight Glass/TLI(S-Satisfactory,U-Unsatisfactory,N-None) Sampling Tap After Storage Vessel(Y-Yes,N-No) Vent(G-Shielded,S-Screened,N-None) Fill Pipe(P-Present,C-Capped,L-Locked,N-None) Access Hatch(W-watertight,NW-Not Watertight,L-Locked) Transfer Pumps(Qty/HP/Rating in gpm) Transfer Pump Operation A-Alternating,LL-Lead/Lag Additional Notes: Well casing is severely corroded. Watertight well cap is present however it was leaking during the survey. Needs to be adjusted. There is a small dry gully on the side of Pierce Road near the well. Presumed to be abandoned drainage swale which was used for road surface water drainage prior to the installation of the stormwater drainage system. It was dry at the time of the survey. 2 G. Water Treatment Facilities r ent(S-Softening,F-Filtration,C-Chemical Feed, N/A N/A N/A NMI 1111 Li ht,CF-Cartrid a Filter,N-No Treatmentatment(P-pH,D-Disinfection,V-Organics Removal,I-Iron,M-Manganese,H-Hardness,N-Nitrate,X- Oxidation,O-Other-provide descri tion State Certified Operator(Y-Yes,N-No) Make and Model Backwashing(A-Automatic,M-Manual,N-None) Backwash Discharge(S-Subsurface Sewage System,ML-Municipal Sewer,D-D well,O-Other- rovide description) Air Gap on Backwash Discharge Line(Y-Yes,N-No) Regenerant(S-Sodium Chloride,P-Potassium Chloride) Brine Tank Condition(S-Satisfactory,U-Unsatisfactory) Softener Installed on Hot Water Line Only(Y-Yes,N No) Sampling Taps(B-Before Injection,A-After Injection,N-None) Number of Filters Filter Size(each-cubic feet or dimensions) Media Type(GAC-Granular Activated Carbon,C-Calcite,G- Greensand,B-Birm,M-Multimedia Iron Filters,O-Other Arrangement of Filters(P-Parallel,S-Series) Filter Backwashing(A-Automatic,M-Manual,N-None) Backwash Discharge(S-Subsurface Sewage System,M-Municipal Sewer,D-Drywell,O-Other provide description) Air Gap on Backwash Discharge Line(Y-Yes,N-No) Sampling Taps(B-Before,T-Between,A-After) Can filtration system be by-passed?(Y-Yes,N-No) `Chen ieal Type(.C-Chlorine,SA=Soda Ash,PC-Potassium Carbonate,H-Potassium Permanganate,.O-Other proulde cf �t tJ�zrt Chet al Nrand Name and Identification Code ._c Metcrtng,Pump(make and model) No Flow Cutout Switch(Y-Yes,N-No); Solution Tank Volume"(gallons) olut'o Tank Condition S-Satisfactory,tI-Unsatisfactory) " Gslttt�uaus Agitator(Y=Yes,ITT-No} Hart s( Audtl le,V-Visuai,W44,igh pH,LP Low l I G- Igti chlorine,LC=I aw Chlorine,O.Other provrdsdscrsptiort, lYNotse C� --;Recorder:(�-pl=i='C Ghl<a>`me Residual,NNone). al :' tttgsJLt�g I pok X'-"H,lire:tesidtl etJi ge(S;S tasla tort' O ,U-iJnsatls tbry) . _.` p1�t► daps(�Beare InJeciion,A.41`fter Itrjectinn,NNonej AS Make and Model Number Intensity Meter(Y-Yes,N-No) Alarms(A-Audible,V-Visual,R-Remote,L-Lamp Out,I-Low Intensity,N-None) Lamp Viewing Port(Y-Yes,N-No) Mechanical Quartz Jacket Wiper Assembly(M-Manual,A- Automatic,N-None) Spare Lamp On-Site(Y-Yes,N-No) 5-Micron Pre-Treatment Cartridge Filter(Y-Yes,N-No) Other Treatment: 3 STATE OF CONNECTICUT G DEPARTMENT OF PUBLIC HEALTH rRANST`"T July 30, 2004 Ms. Lisa Mannarino Learning Center, LLC. 1250 Ellington Road South Windsor, CT 06074 PUBLIC WATER SYSTEM: Learning Center, LLC, South Windsor PWSID: CT1320243 Re: Consent Order DWD-03-132-214 Dear Ms. Mannarino: Due to your recent re-classification to a non-public water system status,this letter will serve to confirm that the Consent Order is hereby closed. Thank you for your continued cooperation in this matter. Sincerely, 9 olanda R. Cravinho nvironmental Analyst 2 Drinking Water Division cc: /Dr. Gerald L. Schwartz,Director of Health-South Windsor Phone: (860) 509-7333 Z; Telephone Device for the Deaf: (860) 509-7191 410 Capitol Avenue - MS#51WAT P.O. Box 340308 Hartford, CT 06134 7 i STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH September 29, 2004 Taawsr e° �trt Ms. Lisa Mannarino Learning Center 1250 Ellington Road South Windsor, CT 06074 PUBLIC WATER SYSTEM: Learning Center,LLC. PWS CLASSIFICATION: NTNC PWS TOWN: South Windsor, CT PWSID: CT1320243 SUBJECT: LEAD AND COPPER RULE -REDUCED MONITORING FOR SMALL OR MEDIUM-SIZE PUBLIC WATER SYSTEMS (POPULATION<50,000) Dear Ms. Mannarino: The Regulations of Connecticut State Agencies(RCSA) Section 19-13-B102(e)(8)(G) states that a small or medium-size Public Water System (PWS)that meets the lead and copper action levels of 0.015 MG/L and 1.3 MG/L,respectively, during each of two (2) consecutive six (6)month monitoring periods qualifies for reduced tap water monitoring. The Department has reviewed the lead and copper tap water sampling results reported for compliance purposes during the two (2) consecutive six (6)month monitoring periods of July 1,2003 to December 31, 2003 and January 1, 2004 to June 30, 2004. The requirements for sample site location, sample collection methods and number of samples set in the RCSA Section 19-13-B102(e)(8)have been met. The calculated 901h percentile concentrations for both lead and copper also meet the respective action levels. Therefore, Learning Center, LLC. can reduce the number of tap water lead and copper samples collected for compliance purposes to five(5) and reduce the frequency of sampling to once per year. Small and medium-size PWSs on reduced monitoring for tap water lead and copper sampling.are required to conduct such sampling during a sampling period consisting of the months of June, July,August, or September. Additionally, the sample site locations to be used for reduced monitoring must be selected from the same sample site locations that were used during the two (2) consecutive six (6)month monitoring periods, and the same sample collection methods followed. Note, if the calculated 90th percentile values for either lead or copper exceeds the respective action level during the reduced monitoring period, the required number of water samples must be collected from distribution locations and all entry points to the distribution system, and tested for water quality parameters (WQPs), during the same sampling period in which the action level(s)were exceeded. As a reminder, the results of the above outlined sampling must be submitted to this office no later than 9 days after the end of the applicable monitoring period in which tap water sampling is Phone: (860)509-7333 Telephone Device for the Deaf: (860) 509-7191 410 Capitol Avenue - MS#51 WAT P.O. Box 340308 Hartford, CT 06134 Affirmative Action/An Equal Opportunity Employer conducted(i.e. received at this Department no later than January 9, 2005). Failure to comply with this requirement will result in a violation that requires a formal notification to all customers, and could lead to the imposition of civil penalties and other enforcement activities. If you have any questions regarding this matter,please feel free to contact Eric McPhee at this office. cerel , ave Co le _ anitary Engineer 2 Drinking Water Division GJ/dc cc: ,Dr. Gerald L. Schwartz,Director of Health, South Windsor Envirotech Laboratory s:I dwdformsWbCu.SM.reduction.6M-YR 11197 2 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH , „p5'N�f March 31, 2005 R4N5T h Ms.Lisa Mannarino Director,The Learning Center 1250 Ellington Road South Windsor, CT 06074 PUBLIC WATER SYSTEM: LEARNING CENTER,LLC CLASSIFICATION TYPE: NTNC TOWN: SOUTH WINDSOR PWSID: CT1320243 SUBJECT: Public Water System General Application for Approval or Permit Project#: 2005-0095 Dear Ms.Mannarino: The Department has received for review and approval a proposal for installation of a cartridge filter on March 30, 2005 for the above water system. At this time the Department cannot initiate a review for the following reason(s): [X] Public Water System General Application for Approval or Permit was not submitted [ ] Public Water System General Application for Approval or Permit was incomplete: [ ] The following specific application(s) as required in Section C of the General Application were not submitted: The above noted deficiencies must be satisfactorily addressed prior to the Department initiating a review. All forms and applications may be obtained from the DPH Drinking Water Division's web page at www.dph.st-,ite.et.us/"B-RS/Water,DWD.htm. If you have any questions please contact this office. Sincerely, n � , Sara A.Ramsbottom,P.E. Sanitary Engineer 2 Drinking Water Division Cc: Steve Klobukowski—Aqua Compliance Specialists Gerald L. Schwartz—Direetor of Health, South Windsor S:\CRS Unit\Sara Ramsbottom\General Application letters\CT1320243—missing GA Phone: '160)509-1333 jj Telephone Device for the Deaf.- (860) 509-7191 410 Capitol Avenue - MS# 51WAT P.O. Box 340308 Hartford, CT 06134 Affirmative Action /An Equal Opportunitv Emnlover STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Qv,'RAN. yJStNEt RANST July 18, 2005 Ms. Lisa Mannarino Learning,Center 1250 Ellington Road _ South Windsor :CT,06074 PUBLIC WATER SYSTEM: Learning Center,LLC. PWS CLASSIFICATION: Non-Transient Non-Community PWS TOWN: South Windsor P W SID: : CTi 320243 RE: LEAD AND-COPPER RULE EXCEEDANCE Dear Ms. Mannarino:: The Regulations of Conrecticut;State Agencies(RCSA) Section 19-13-B102(e)(8)requires that all Community and Non-Transient Non-Community Public Water Systems monitor for tap water lead and copper levels at representative sampling sites throughout the distribution system. Based on the first-draw tap water lead and copper sample'results reported from Learning Center,LLC. you are hereby notified and issued Lead-and Copper-.Rule.Exceedance for the January 1,2005 to December 31, 2005 monitoring period and the.following Actionlevel(s): Lead Action Level.(0.015 mg/L): 0.021 mg/L As a result of this.Lead and:Copper Rule Exceedance,Learning Center, LLC. is required to comply with all of the following requirements,unless otherwise being deemed optimized pursuant to RCSA Section 19-13-B 102(7)(B). Monitoring for Water Quality Parameters Pursuant to.the RCSA Section 19-13-B I 02(e)(9)Learning Center,LLC. is required to collect two(2) samples.wiihin the distribution-system and two(2)samples at each entry point to.the distribution system for applicable water quality paranii ters during the January 1, 2005 to December 31,2005 monitoring period. Please note that any Public Water System on reduced monitoring(annual or triennial monitoring) shall monitor for water quality,parameters during the same designated four consecutive month sample collection period,in which'-the Public Water System exceeded the lead and/or copper action level(s). Lead Public Education Requirements Pursuant to the RCSA Section 19-13-13102(i)(6)Learning Center,LLC. is required to perform Lead Public Education tasks meeting the content and delivery requirements within 40 Code of Federal Regulations(CFR) -141.85 prior-to August 30,2005. Learning Center,LLC. shall submit a written documentation that Learning Center, LLC. has delivered the Lead Public Education materials that meets the content and delivery requirements with 40 CFR 141.85 prior to September 9,2005. The written documentation must include a list of all the newspapers,television stations, and facilities and organizations to which the Public Water System delivered public education materials,however Phone: (810)119-7111 j� Telephone Device for the Deaf. (860) 509-7191 • 410 Capitol Avenue - MS# 51 WAT P.O. Box 340308 Hartford, CT 06134 Affirmative Action/An Eaual Onnnrtunitv F.mnlnvar r applicable. Enclosed is a copy of the Lead Public Education-Lead Public Education Materials summary document for your reference. Source Water Treatment Steps STEP 1: SOURCE WATER MONITORING A PWS exceeding the lead and/or copper action level shall collect one(1)source water sample at each entry point to the distribution system with six(6)months after the end of the monitoring period in which it exceeded the action level(s). Learning Center, LLC, is required to complete this step prior to June 30, 2006. Corrosion Control Treatment Steps STEP 1: PWS PROPOSE OCCT The PWS shall conduct Standard/Initial tap water monitoring for lead and copper until the PWS either exceeds the lead and/or copper action level(s)or becomes eligible for Reduced Monitoring. A PWS exceeding the lead and/or copper action level(s)shall propose optimal corrosion control treatment, as required, within six(6)months after the end of the monitoring period in which the exceedance occurred. Learning Center,LLC. is required to complete this step prior to June 30, 2005. At this time, further tap water lead and copper monitoring is not required until after the installation of source water or corrosion control treatment pursuant to RCSA Section 19-13-B 102(e)(8)(E). Learning Center,LLC. is required to comply with all of the preceding requirements unless otherwise being deemed to have optimized corrosion control pursuant to RCSA Section 19-13-B IO2(7)(B). This section outlines the various ways a Public Water System may be deemed to have optimized corrosion control. The most common way in which a small or medium-sized Public Water System is deemed to have optimized corrosion control is meeting the lead and copper action levels during each of two consecutive six month monitoring periods conducted in accordance with RCSA Section 19-13-B 102(e)(8). In which case the Public Water System shall collect the proper number of samples under standard monitoring from approved sample site locations beginning with the first six month monitoring period following the end of the monitoring period in which the current Lead and Copper Rule Exceedance occurred. If you have any questions regarding this matter, please feel free to contact David Cooley at this office. Sincerely, Gary Johnson Supervising Environmental Analyst Attch: Drinking Water Section Encl: Water Quality parameters list �ead Public Education-Lead Public Education Materials cc: r. Gerald L. Schwartz, Director of Health, South Windsor Ms. Julie Boscarino, DPH Childcare Licensing Specialist, CTDPH Childcare Licensing Program S:\DWDFORMS\PbCu Exceedance 7/44 2 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Oyu r Jst`Ng< December 7, 2005 V(IT Lisa Mannarino The Learning Clinic Center 1250 Ellington Road South Windsor, CT 06118 PUBLIC WATER SYSTEM: Learning Clinic, LLC PWSID: CT1320243 TOWN: South Windsor DPH PROJECT#: 2005-0095 RE: Installation of a filter cartridge Dear Ms. Mannarino: A letter dated September 28, 2005 was sent to you and copied Steve Klobukowski of Aqua Compliance Specialists, requesting additional information to support your application for the above-referenced project (see attached copy of the letter). As indicated in the letter, you were given until October 31, 2005 to submit the required information; otherwise, your application will be denied and closed. The Department of Public Health(DPH)has never received the requested information until this writing. Therefore, you are notified that your application for installation of a filter cartridge at the Learning Clinic, LLC is denied and closed. You must resubmit an application and the supporting documents to the DPH if you wish to pursue the installation of the filter cartridge. Failure to obtain approval from DPH before initiating any treatment installation is a violation of Section 19-13-B102(d)(2) of the Regulations of Connecticut State Agencies (RCSA). Should you have any questions regarding this matter, please do not hesitate to contact me at this office. Sincerely, t Ra 1 . T nitary Engineer 2 Drinking Water Section 1 MH/RMT CC: Ste a Klobukowski,Aqua Compliance Specialist,371 Hills Street,East Hartford,CT 06118 rector of Health,Town of South Windsor Phone: 860-509-7333 jp Telephone Device for the Deaf: (8gjA�VAA, 9-7191 410 Capitol Avenue - MS# P.O. Box 340308 Hartford, .CT 06134 Affirmative Action/An Equal Opportunity Employer The Learning Center 1250 Ellington Rd. South Windsor, CT 06074 860-282-8020 Dear Bob I Deptu la, _ -Enclosed you will find a copy of our re-license packet for 1250 Ellington Rd. The license number is 14523. We are due for our local health inspection for state re-license. Please let me know if you have any questions or concerns. Thank you. Sincerely, st,-lJ�T4.a ���• J t Y -- STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Division of Community Based Regulation Cover Letter/Check List 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: l. 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#11 f) 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) Yes ❑No 8. Water Supply(Attachment#13b) Yes ❑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 / 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? S�es O No J 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 ' 410 Capitol Avenue-MS#12CBR P.O. Box 340308 Hartford, CT 06134 An Equal Opportunity Employer' TA(;mk('tr\Relirrncnrr\C, C RrlirAnni.tr('klict Ann A/7/fK I IN H`� I „•x su,ru�aar�,*mF� t4ss+a'a4'�f�r av " i �` Ana n� iµ Ery ra - +' �.k•8 8�, ` WlL�fS� I 4 BB�'�����5,�r�Y�y r q� pp N.A f . I D6Q� a-a 1x,e � F v ravoak a e 4 t a y .„a „� \ "#xwuggxumaw, nN' QMc�X�� t ,. ���� 'jr � `rri a; •�,q�da�yyc�w� 'xem �,\� e >t esw .,� •u.M�,+�irun� •�,G,^,y�. a ?�. �k� #�so«.sd ax�.r xX �:a',�^ � '��� >r � •�• •5a"�.svanr. a.r� i�ax� ono I :' wra r A^g NkCP.. s d91MEWhr'+t YA',y+, .+mnKesyYe x �!t 'a>m.�w m.e,�r ram,er.a segnxv, ° i° h n k ek A, li'!. W(W`dC > (•Y+` #'Vtl'wN ^aVi �»"vd '. t 1 xM1.ck ti Y'<�niw 9 h Wb.v;k'oh �.:r°7 Z nw.a.'rta FYnS v 4rerh wk � r:,�k r �� �� �� a r �u a y �a".�ka ,nli 4v wa»# +iw+ek :a a 'y w,r� `h'�+.�f'mLg�,rSc.•aw+"°i�* 'M�t`�w��>knyd.*� � r � kte�, ab t t z %e;, kaa 3"V^ary •xk an^e" t,N wFt htmr *,tM,�ip-* tium.1> � `" ; l,K�€"+�"�+""+^A 8 W.w}• n, K '� ��"a }d}G.h @A 6u4,W d t ' Ip 'xa",. e +i ! 'a r m ndi„ s to•Saar" >dy.v� .. >v he R�h ay�a"C-a y'^, � �„,�ap I P� 4NM i .ca#Ga(M. '.y`.�'. ^yar � e.„t� •m"' I t .^„ 3 1 t ku'W`NCsrv;� a ne a v air wsy �r t �� + ''xy`�p', v :�ilw� .,�°i�?e"• v+sn"k <+:t��5�r A � •x r sdgq��, +t;nw'��A'�4�Cc d�aA , I II�aQa � `fir �^■ � � � � ti , � T�� '� �a�Y, „�,� ��� �, I „w, a t� as '` vv. �; � k � t ,• Y•I 'F"a.n � T, "..�w J tk++a�.^Wxei+ c `�o.dara t^"Satti�M.A4w �'rsa 3a`ixmY.;,n9�ik',1n•+' "° a+y,ryP,RY `yr' t c sn awhceka w.itti�'�nax ,�Pt»:eY1:n4n,>k`whsv+.�AaW M .�t,�r_tm u.xy^xe,.n.W����imJh,�nmi,F�'�.ri..A..x.k�~•�r,.x,i STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH .6 Division of Community Based Regulation �R+w 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 it 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-ofPublic Health at the address on the bottom of this form. 1. Name of Licensee or Applicant: 1 (Legal erator) 2. Program Name: L. (Appli able For Group/Center Only) 3. Program Location Address: E%n(�-On CT 4 tre Address City/To n Zip Code 4. Program Phone rNumber: OL - C� �C Program Fax Number: dam ° _- Q 2- 5. License#: ) b QC, Expiration Date: (For Relicensure Only) (For Relicenssure nly) 6. Mailing Address(if different) -, CT �arL_!C' Street Address l City/Town Zip Code 7. Program E-mail Address: A/ / 8. Enclosed Check/Money Order:J$ C Check#: 3 5_ Check Date: 14 / / 9. Social Security#: JV!4 - or Federal Employer ID#: O�O - 13 9W6 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 Home Family Day Care Home (Account#42431) (Account#42431) (Account#42431) ❑6-month license(new program) ❑6-month>license w program) ❑2-year license ew provider) $50.00 . 0 0.00 2-year license(relicensure) ❑2- ar li ecense(relicensure) ❑ -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:\Fatn&Ctr\Aonlication\CDC FeeFonn.doc 3/22/04 STATE OF CONNECTICUT DEPARTMENT OF PUBL'•IC HEALTH Child Day Care Center or Group Day Care Home • r- AFFIDAVIT `This form must be completed by the Operator or the individual authorized to represent and act on behalf of the Operator. being duly sworn depose and say: Operator or Legal Representative The name of the child day care center/group is I r Name of thild Day Care Ce er/Group Day Care Home The application is made to conduct his child day care center/group day care home at: lOqno Location Address: e City/Town •State Zip Code The Operator of the above named facility is Z ea/-n I t7 Name of Operat and is a(check one): Individual/Sole Proprietor ,�. Corporation Partnership Limited Liability Company Limited Partnership Limited Liability Partnership If applicable,the Legal Representative of the above named 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. r.. Y P �`�PA orn L �_ M hone number is �� Y address isI Y-�3� M 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 here ';ire p ish le in ac ance with Section 53a-157b. t° ure of Operator or Legal Representative Subscribed and sworn to before me on the j/ZI day of 14PR I z- _ 077 6 Day Month Year Signa re of notary public,*commissioner of superior court or other proper official as noted in Connecticut General Statute Section 1-24 GOLAM K AHMED ':\Grp&Ctr\Application\G_CTAffidavit.doc 7/05 NOTARY.. PUBLIC M'GOMMISSION EXPIRES NOV. 30,2006 CT Department of Public Health (Attachment llf) 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 thi form: \JC�r 1 c!f_- Ma n Y-1 Position: C1fY111�1 C1 1��- !?T-40Cpate form completed: 1(S' Program Name: - 6 ze�arl7l , ,e- - i License# Street Address: �ja�50 El TC4 t 0 _Town CT Zip: Telephone#: 2q2-- q`C12-0 Fax#: - E-mail - Health Consultant(Required) Last name: ! ,1Cd /�` . , ' First:49 r4 Middle initial: Resident Street Address: Town: State: Zip: Telephone Fax#: L_) - E-mail: Work Address:: Town: JState: Zip: Telephone#: - Fax#: ( ) - E-mail: Professional license held: ❑Physician[]Physician Assistant[_]AP Registered Nurser[ egis-tered Nurse `(J Professional License#: 913 L� ��7 License Expiration Date: 3 o Early Childhood Education Consultant(Required) Last name:-- �� ! First: Middle initial:P 9 Resident Street Address: 212rr Town: tate: r_Zip: ' � Telephone#: &jo - L Fax#: (_� - E-mail: Work Address:Mi }i '1 i1 ���i ;�,) Town: --State: Zip: c Telephone#: b/ ) - §° �= Fax#: (� - E-mail: DPH approval on file�` /J 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: I 7(11 zo First: j�') �'"_ Middle initial : Resident Street Address: Town: State: Zip: Telephone#: (�� - Fax#: - E-mail: Work Address: State _ 1.� � own: Zip:� Telephone#: = 70 Fax#. - �, E-mail'- Professional license held: ❑Licensed Dentist 'Mental hygienist Professional License#: `/ _cT Expiration Date: I Social Service Co sultant(Required) 4� Last name: First: Middle initial: Resident Street Address: Town: State: Zip: Telephone#: - Fax#: (_� - E-mail:_ Work Address: z Town�-I& nebg State: (` Zip: Telephone#: C& ) 0Fax#: E-mail: Professional degrees held: ❑BSW ❑BA/BS-Field of study: MSW DMA/MS-Field of stud S IL�ld toolox- Professional License#(if applicable): Expiration Date: Registered Dietitian Consultant(Required for programs that serve meals) Last name : First: Middle initial: Resident Street Address: own: State: Zip: Telephone#: (_) - F #: - E-mail: Work Address n: State: Zip: Telephone#: (_� - Fax#: E-mail: Professional license held: ❑RD 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 a attachment. Last name: First: 4 Middle initial: Resident Street Address 17 Town: State: Zip: " Telephone#: Fax#: �) - E-mail: Work Address: Town '7 '' ��E � a'Z State: Zip: �0 7 7 Telephone#: . - Fax#: (� - E-mail: Dept. of Public ealth approval on file: 'es ❑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 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 Rd. 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 Rd. South Windsor, CT 06074. As needed, I will provide educational guidance to all staff. L ` Signature 3 rJNQ Date The Learning Center 1250 Ellington Road South Windsor, CT 06074 (860) 282-8020 FAX (860) 282-8020 a _ I, MaryAnn Townsend, hereby agree to serve as the nurse consultant for THE LEARNING CENTER, INC, located at 1250 Ellington Road, South Windsor, CT 06074. My duties shall include, but not be limited to: review of child records and physical forms, supply related medical information, answer questions from staff and parents, visit the facilities on a weekly basis offering suggestions and comments. Signature Date U 4 52 The Learning Center �. 1250 Ellington Road South Windsor, CT 06074 (860) 282-8020 FAX (860) 282-8020 Consultant Agreement My signature below certifies that I agree to be the social service consultant for THE LEARNING CENTER, INC. located at 1250 Ellington Road in South Windsor, CT 06074. My responsibilities include, yet are not limited to, giving professional guidance to the staff as needed. l' �Svti Signature Date D' Urg The Learning Center 1250 Ellington Road South Windsor, CT 06074 (860) 282-8020 FAX (860) 282-8020 I, Dr. Tamara J. Goodman, located on 836 Farmington Avenue, Suite 225, West Hartford, CT agree to serve as the dental consultant for THE LEARNING CENTER, INC. located at 1250 Ellington Road in South Windsor, CT My duties will include phone consultation on related dental matters and professional guidance to staff if needed. Signature Date rrr vN L.1^Cjrl`'1 I 7*04%i2j2606 PRODUCER (960)644-2534 FAX (860)644-8500 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Thomas M. Burgess & Co. , Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR S26 Sullivan Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 903 South Windsor, Cr 06074 INSURERS AFFORDING COVERAGE NAIC# INSURED The Learning Center, Inc. INSURERA; Philadelphia Insurance Company 501 West Middle Tpke INSURERS- Virginia Surety Manchester, CT 06040 —INSURER C; INSURER D' INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A60VE 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,EXCLU5101NS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR DD'L TYPE OF INSURANCE POUCY NUMBER FOLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIAMIJI Y PNPKI23 309 06/06/2005 06/06/2006 EACH OCCURRENCE 11000,001 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,OOI CLAIMS MADE Q OCCUR MED 10(Any one person) $ 5,00t A PERSONAL&ADV INJURY 8 11000100( GENERAL AGGREGATE 6 3.000 00( GEIVL AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMP/OF AGG S 3,00O 0OC POLICY 7,jPER0T 7 LOC AUTOMOBILE LIABILITY PHPKI23309 06/06/2005 06/06/2006 COMBINED SINGLE LIMIT ANY AUTO (es awasni) 1,000,00( ALL OWNED AUTOS BODILY INJURY 6 A Xi, SCHEDULED AUTOS (Par person) X HIRED AUTOS BODILY INJURY 6 X NON-OWNED AUTOS [Per accident) PROPERTY DAMAGE 6 (Pet accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC 6 AUTO ONLY; AGG s EOICESS/UMBRELLA LIABILITY MUS046062 06/06/2005 06/06/2006 EACH OCCURRENCE 6 1.000 000 OCCUR Q CLAIMS MADE AGGREGATE 5_ 1,000,00C A DEDUCTIBLE $ RETENTION S 6 WORKERS COMPENSATION AND WVS0002914-02 06/06/200S 06/06/2006 X we sTATU. OTH. EMPLOYERS'LIABILITY B ANY PROPRIETORIPARiNER"ECUTNE E L.EACH ACCIDENT 6 100,000 OFFICERIMI;MBER EXCLUDED? E.L.DISEASE.EA EMPLOYEE 6 100.000 Ir yes,dmoribe under SPECIAL PROVISIONS beio- 151,DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLU%ON*ADDED BY ENDORSEMENT/SPECIAL PROVI610NS 20 Foster Road, South Windsor 0 Pierce Road, South Windsor 2SO Ellington Road, South Windsor CERTIFICATE OLDER CANCELLATION SHOULD ANY OF THS ABOVE DESCRIBED POLICIES ad CANCELLED BBFORG THE EXPIRATION DATE THEREOF,THE ISSUING INSURRR WILL ENDEAVOR TO MAIL State of Connecticut 10 DAYS WRnTEN NOTIPA TO THE CERTIFICATE HOLDER NAMED TO THE LEFT Department of Public Health BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO oDUGATION OR LIABILITY 165 Capitol Ave OFANY KIND UPON THE INSURER,ITO AGENTS OR REPRESENTATIVES. Hartford, CT 06134 FMMchael THORIZEDREPAESENTATIVE i LaFleur/ML � "— ACORD 25(2001/08) ©ACORD CORPORATION 1981 Phe Metropolitan District Customer Name: MANNARINO BUILDERS i55 Main Street, P.O. Box 800 Account NumbeP ' 71`06105 BiIIIng Period iart#ord, Connecticut 06142-080.0 Service Address: 1250 ELLINGTON RD 09/17/2005 - 12/16/2005 'elephone (8601 278-0127 Invoice Number: 200011218952 Due Date Invoice Date: 01/03/2006 02/02/2006 Amount Due Current Charges: S 21.75 Water CSC Domestic Charge Water NMT Surcharge 11.57 Total Current Charges: 9.96 $21.53 Billing Summary: :Past Due. . - .Current Charges _ $0.22 Current.:Balance..: $21.53 . 21.;7:5. ENVIROTECH LABORATORY, LLC 77 COOK HILL ROAD • WINDSOR, CONNECTICUT 06095 MARYELLEN DiLUZIO TELEPHONE (860) 688-7249 April 4, 2006 The Learning Center 1250 Ellington Ad. South Windsor, Ct. 06074 Dear Sir, We have the following to report on the sample submitted to this Laboratory on April 4, 2006. Sample Number: 66087 Mark: water sample collected 4/-4/06 by .Pol.ly Buvelot from Lot No. , 1250 Ellington Rd. , South Windsor, Ct. Toddler Room 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 action level established by the Conn. State Health Dept. If there are any questions we would be pleased to discuss them with you. Very truly yours, EnviroTech Laboratory, LLC Y & �. Maryellen DiLuzio, a member PH 0464 cc: one enclosed Water Supply (Attachment# 13b) Program Name: ,, Pf License#: Location Address: Capacity:. City or Town: i (If New program, indicate "New" next to license#.) PLEASE BE SPECIFIC: • Months of Operation(i.e.'September-June): io 'r — • Days/Hours of Operation: Monday ' �Tuesday t Wednesday Thursday � Friday-30 w � Name of Property Owner: Address: J10 City or Town: � r ? �e Phone#: _' �- We :3 Section 1 Are you or your landlord a Customer of a Water Company? es 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 you answered es 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 Lj No If YES, you are required to submit both a lead water test and bacterial.X''chemical test If NO, complete Section 4 Lead Water Test—(Required for all programs eve"ry 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 CONTDWED ON BACK PAGE Date: 3 /, 6 0(p ell Program Name: Phone#: / Location Address; J'? Town: License Mailing Address: Town:,I)) ' State; Zip Code, Y Prepared By: Date: STAFF WORK SCHEDULE FORM` DATE OF WORK SCHEDULE STAFF NAME * BIRTH. POSITION DAYS AND HOURS DATE HIRED r Lvu o �- - y � (701,0_ #k/ 17,75e— IA, 7 bVRA " 06 s 3 _- * 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 persons.name wh-o has valid CPR Training RETURN TO: T:\Grp&Ct�\Rclicensure\G_C_RelicSiaftWorkSch.doc 10/23/03'