APPLICATION FOR A CHILD CARE FACILITY
Name of Facility:
Location Address:
City:	State:	NC	Zip:
Facility phone #:	Email:
Owner of Business:
Mailing Address:
City:	State:	Zip:
Contact Phone #:	Email:
Owner of Building:
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
*Facilities connected to an on-site wastewater system may require an existing systems inspection.
Total # of children on roll?	Total # of employees?	Total # of shifts?
New construction or remodel?
Is the facility already an existing daycare? Yes No
If so, name the facility
If remodeling or moving into an existing building, please provide the year built.
Will you be preparing:
Fresh vegetables? Yes No Fresh poultry? Yes No Frying foods? Yes No
Will you be using multi-use utensils or disposable single service items for foodservice? Yes No
Will you be providing food service in individual rooms for infants/children? Yes No
Will you be providing care for children in diapers in classrooms? Yes No
If so, please list classrooms:

Please submit the following along with the completed application:

Zoning approval for facility to be licensed as a child care facility.

a menu or list of possible foods to be served

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

a detailed drawing of all rooms (including age groups of the children housing each classroom), equipment layout of kitchens, bathrooms, location of sinks and diaper changing facilities,

a schedule of floor, wall and ceiling coverings 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 INSPECTION	FIRE MARSHALLS

Shelby 704-484-6805	704-484-6816

Kings Mountain 704-734-4599	704-734-0555

Cleveland County 980-484-4975/4997	980-481-4841

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