APPLICATION FOR AN ADULT DAY SERVICE FACILITY

Name of Facility:
Location Address:
City:	State:	NC	Zip:
Contact Phone #:	Email:
Owner/Operator:
Mailing Address:
City	State:	Zip:
Contact Phone #:	Email:
Please specify the following:
Sewer:	Public/Municipal	On-site Wastewater System
Water:	Public/Municipal	Private Water Supply
Total # of participants on roll:
Total # of employees:
Total # of shifts:
Overnight lodging or care? Yes No If yes, how many beds?
Is the facility already and existing day care? Yes No
If yes, name the facility:
Will the facility be newly constructed or remodeled?
Will prepared meals be received from another facility? Yes No
Will the facility be preparing:
Meals or snacks? Yes No, Fresh vegetables Yes No, Fresh poultry Yes No
Will the facility be frying foods? Yes No
Will the facility be using multi-use eating and drinking utensils? Yes No
Will the facility be providing care for adults in diapers or who may need possible change of clothes
through the day? Yes No
Will participants have kitchen duties? Yes No
Will the facility be providing a dumpster? Yes No

Please submit the following along with a completed application:

A menu of list of possible foods to be served.

A site plan including all structures and property lines, location of solid waste disposal, etc.

A detailed drawing of all rooms, equipment layout of kitchens, bathrooms, location of sinks and diaper changing facilities if provided.

A schedule of floor, wall, and ceiling covering of each room

You will be responsible for obtaining approval from appropriate zoning and building inspection departments. Their numbers are included below to assist you.

ZONING	BUILDING INSPECTIONS

Shelby	704-484-6805	704-484-6805

Kings Mountain	704-734-4599	704-734-4599

Cleveland County	980-484-4975	980-484-4977

If your business will be located in any jurisdiction other than those listed above, please check with your city manager and/or town hall for permitting assistance.

Proposed opening date:
Date Application Submitted:
Applicant’s Signature:

APPLICATIONS CAN BE SUBMITTED IN PERSON OR BY MAILTO:

Cleveland County Permits Office

1333 Fallston Road

Shelby, NC 28150

Rev. 12/23