Department of Code Compliance Services Boarding Home Facilities License Application

Transcription

1 (FOR OFFICE USE ONLY) Receipt No: Date: / / SR#: License Fee Paid: $ Instrument Number: Instrument Type: [ ] CK [ ] MO [ ] CC [ ] CASH Fee Waiver Request (FWR) [ ] Yes [ ] No [ ] FWR Granted [ ] FWR Denied [ ] FEE Reduced Payor: Payor Address: Facility Address: Type of Facility: SF HGDU GRF RH Multi-Tenant Other Code District: Council District: Zoning: This application must be completed by the person who owns, operates or controls the property, and returned with the applicable, nonrefundable annual fee of $ and required documents and information. If the owner or operator is not an individual, an authorized officer or agent of the business entity must file this form. See the Application Instructions for a list of all the required documents and information. An application missing the required documents and information, fee and/or not completely filled out will automatically expire if either the fee or the information requested is not provided within 30 days of the date written notice was issued to the applicant. Any false or misleading information entered on this application will be cause for denial of the application, or revocation of the license if discovered after issuance. The City of Dallas does not accept payments in the field. Section 1: Applicant s Information (Please Print Clearly) a legible copy of the drivers license or other official state or federal identification card and a Texas Criminal History Report and a fingerprint card must be included for the applicant of the boarding home facility. Legal Name of Applicant (If this facility is owned by a business entity, than the business entity s information should be listed here.) Have you lived in a state other than Texas within the last 10 years? Yes No If yes, which state? (If yes,an additional criminal history report for the state is required) Applicant s Street Address (The street address may not be the address of the facility, unless the applicant actually resides full-time at the facility.) City State Zip Code Applicant s Mailing Address (if different than street address) City State Zip Code Area Code and Fax No. Form of Business Entity Type Individual Sole Proprietorship Corporation LLC Partnership Other (specify) (Provide a copy of the documents establishing the business entity, such as the Assumed Name Records, Certificate of Formation, Articles of Incorporation, Certificate of Amendment, Certificate of Correction, etc., if this facility is owned by a business and not an individual.) Page 1 of 6

2 If the applicant is an individual, do not complete section 2; proceed to Section 3 A legible copy of the drivers license or other official state or federal identification card and a Texas Criminal History Report with fingerprint card must be included for the applicant s authorized officer/agent of the boarding home facility. You can schedule an appointment for the criminal history report at the listed website for IdentoGo Section 2: Applicant s Authorized Officer/Agent, if this facility is owned by a Business Entity Authorized Officer/Agent s Name (if applicant is a business entity this information must be provided) Title Authorized Officer Registered Agent Other Have you lived in a state other than Texas within the last 10 years? Yes No If yes, which state? (If yes, an additional criminal history report for that state is required) Street Address City State Zip Code Mailing Address (if different than street address) City State Zip Code Section 3: Facility s Information Facility Name List the current number of residents that are residing at the facility as of today: List the maximum number of residents that will reside at this boarding home facility: (The inspection team will determine if this number is allowed per the square footage of the bedrooms.) Facility Address City State Zip Code Facility (It must be a landline and not a cellphone.) Facility Area Code and Fax No. Facility Page 2 of 6

3 Section 4: Property Owner s Information Legal Name of Business Entity or Individual that owns the property (This information can be found on the Dallas County Tax Office s Website) Business Entity Type Individual Sole Proprietorship Corporation LLC Partnership Other (specify) Property Owner s Address City State Zip Code Property Owner s Property Owner Area Code and Fax No. Property Owner s If the Property Owner is an individual, do not complete section 5; proceed to Section 6 Section 5: Property Owner s Authorized Officer/Agent and Property Management Company, if this Property is owned by a Business Entity Authorized Officer/Agent s Name (if this property is owned by a business entity this information must be provided) Title Authorized Officer Registered Agent Other Authorized Officer/Agent s Street Address City State Zip Code Mailing Address (if different than street address) City State Zip Code Property Management Company City State Zip Code Property Manager Title Page 3 of 6

4 A legible copy of the drivers license or other official state or federal identification card and a Texas Criminal History Report and a fingerprint card must be included for each owner, operator, employee and/or volunteer of the boarding home facility. You can schedule an appointment for the criminal history report at the listed website for IndentoGo Section 6: Additional Owners, Operators, Employees and/or Volunteers Legal Name: Have you lived in a state other than Texas within the last 10 years? Yes No If yes, what state? (If yes,an additional criminal history report for the state is required) Home Address: Mailing Address: : Telephone Number: Driver s License or State identification provided - Yes No # Position (please circle one): Owner, Operator, House Manager, Cook, House Keeper, Other (list below) Legal Name: Have you lived in a state other than Texas within the last 10 years? Yes No If yes, what state? If yes,an additional criminal history report for the state is required Home Address: Mailing Address: : Telephone Number: Driver s License or State identification provided - Yes No # Position (please circle one): Owner, Operator, House Manager, Cook, House Keeper, Other (list below) Legal Name: Have you lived in a state other than Texas within the last 10 years? Yes No If yes, what state? (If yes,an additional criminal history report for the state is required) Home Address: Mailing Address: : Telephone Number: Driver s License or State identification provided - Yes No # Position (please circle one): Owner, Operator, House Manager, Cook, House Keeper, Other (list below) Section 7: Please check all services to be offered or provided to the residents of this boarding home facility: Page 4 of 6

5 Community Meals Light Housework Meal Preparation Transportation Grocery Shopping Money Management Laundry Services Assistance with Self-Administration of Medication List any other services offered or provided not listed in Section 7: Section 8: Disabilities Report How many residents do you have today? How many residents do you have with a disability? It is not necessary to identify the impairment, only the number of residents with the impairment should be listed Vision Impairment: Hearing Impairment: Mobility Impairment: Dementia: Other: Please do not List the disability Page 5 of 6

6 Section 9: Emergency Contact (any changes to this information must be updated within 5 days of change being made) Emergency Contact s Name Does this person have any involvement with the day to day operation of this facility? If yes, they must be added to the Additional Employees Form. Yes No Street Address City State Zip Code Section 10: Required Information 1. Is the property owned by the applicant? Yes No If no, you must provide a letter signed by the owner of the property along with this application, stating that the applicant has permission to operate a boarding home facility as set forth in Chapter 8A. If the owner of the property property is a business entity, the letter must be on official letterhead and signed by an officer of the business entity or other person with the authority to make binding representation regarding the use of the property. 2. Will the facility house residents with an addiction to or recovery from alcohol or a controlled substance? Yes No If yes, the applicant will need to provide a copy of the Substance Abuse Recovery Plan along with this application. 3. Proof that the proposed use of the property complies with the Dallas Development Code can be obtained from the Boarding Home Facility s Office. I am the person who owns, controls, or operates the Boarding Home Facility that is the subject of this application. I have read the completed application and know the same is true and correct and hereby agree that, if a license is issued, I will comply with all applicable provisions of Chapter 8A and Chapter 33 of the Dallas City Code, as amended, and all applicable ordinances and state laws. I accept responsibility for payment of all fees and fines that may result from the operation of the Boarding Home Facility. Any material changes in the information contained in this application will be updated with the boarding home facility s office within 10 days of the change according to Sec. 8A-7 and any changes to the emergency response information will be updated with the boarding home facility s office within 5 days of the change according to Sec. 8A-17(b). By signing below I swear or affirm under penalty of perjury that, to the best of my knowledge, all information contained in this application is true and correct and that the application is complete and includes all information required to be disclosed under Section 8A-6 and 8A-8. Signature of Owner/Operator/Person in Control (Required) Date Driver s License or Identification Number Issuing State (Required) Page 6 of 6