Form 2960 Attachment A TEXAS July 2013-2 Health and Human Services General Residential Operations Documentation Required at Application Use this attachment to help evaluate whether the required documentation is present with an application. Directions: This attachment is a guide for applicants and Residential Child Care Licensing (RCCL) staff when reviewing documents presented with an application for licensure. If there are any questions, email Documentation that Must Be Submitted to Licensing to Apply for a License Document Form Number Application for a License to Operate a Residential Child Care Facility, or child-placing agency 2960 Floor Plan of the building and surrounding space to be used, showing the dimensions and the purpose of all NA rooms. Child Care Licensing Request for Background Check 2971 Controlling Person - Child Care Licensing 2760 Personal History Statement, for each applicant that is sole proprietor or partner unless you are also a licensed administrator. 2982 Proof the for-pro?t corporation or limited liability company is not delinquent in paying the franchise tax. For information on the franchise tax, see Texas Administrative Code (TAC) 5745.245. NA Veri?cation of Liability Insurance, or documentation that you are unable to obtain liability insurance and a 2962 copy of the written notice informing the parents that there is no insurance. See TAC ?745.249 and ?745.251. Residential Child Care License Fee Schedule (with payment sent to Austin and a copy submitted with the application). 3011 Policies, Procedures and Documentation Required by the Minimum Standards Must Be Submitted with Application,? as Applicable Operation plan TAC Fiscal plan and requirements ?748.161 Floor plan and emergency evacuation/relocation plan General record requirements ??748.103; 748.341; 748.343; 748.345; 748.347; ??748.105; Subchapter E, Divisions 2, 3, 4;748.1009; 748.1339; Personnel policies and procedures 748.1345; 745.4151 Con?ict of interest policies ?748.107 Admission policies 748.109 Child-care policies ??748.111; 748.1305; 748.1481 748-1941(1) ??748.113; 748.1823; 748.2451; 748.2751 Emergency behaVIor intervention policies RECEIVED 2019 RECEIVED JUL 22 2mg Form 2960 Attachment A Page 2 I 07-2018-E Policies. Procedures and Documentation Required by the Minimum Standards Must Be Submitted with Application.? as Applicable Discipline policies ?748.115 Transitional living program policies {5748.117 Volunteer policies ?748.119 Abuse neglect policies ?748.121 Vaccine preventable diseases policy ?748.123 Tobacco use policies ?748.1661 Recreational plan, including weaponsl?rearms. etc. 748.3701(b) *Subchapters B-R - are applicable for all GRO and *Subchapter 8 - is applicable if the operation offers emergency care services; *Subchapter - is applicable if the operation offers an assessments services program; *Subchapter - is applicable if the operation offers therapeutic camp services; and *Subchapter - is applicable if the operation offers traf?cking victim services. mm rorrn new A I Mum Ind Minn-n SUM Application for a License to Operaie a Rosldenlial Child Care Use this ionn to epply ior a license to operale resldentiel child care iao'lity. including oniloplaoing agency. Aiier oomoleling form, mail it and any olher maieriels requested to your neerest Licensing omce. For iniorrnarion an local Licensing dices sea: Fm --Ahout Vnur Operstion Name 01 Opemllon APSE Cnde and N04 Slaniord House stroller -- Address Apamnenl N0. Olly Counly Stale ZIP Code Los Fresnos - Texas - Mailin Address i' different) Apartment N0. (3in County Slate ZIP Code More no. Type olGoverning Body: 0 Sole (C) Corporalion Nonywfil Corporation 0 Pannership 0 Limited Pemership 0 Limited Liabilily 0 Political Subdivision 0 Limited Liabilily Company 0 State Operated Nonprofit Corporation wiih Rengious Alfilixlim Nonprolit Association wilh Religious Part II - lnfannallon Section 1 -- Complete lhis seolion li your type oi governing body is Sole or (General. Limited Partnership, or lelleo Liaoiliiy Partnership. If you have marl Mo allaoh (he raquaslsd here Inf each. Name oi Entity (Required (or a lelled Pamership Dr Limiled liability Partnership.) Name 0' Sole Froprlelnr nr Parlner Area Code and Phone No, streel Address or PD. Box Aparlmenl No. City Counly Slate ZIP Code Name Di Semnd Partner Area Code and Phone No. Street Address or F.0o Box Apanmenl Nu. Cily county Slate ZIP Code Check here it you are (or a penner is) a military rnernoer. spouse, military veteran or veteran spouse. This applies only it your governing body is sole prooneiorsnip or 2 Complete this section ii your lype ol governing body l5 an assooiallon. corporalion. association, nonprofit corporaiion, political subdivision. nonprofil oorporatlon with religious alhlietion. nonprofit wilh religious alfil oompany. or state operated. Nome oi organizalion or Governing Body Area Code and Phone No. Comprehensive Heallh Services. LLC (321) 368-8500 sneei Address or no. Box Aperirnent No. City Coumy Slale ZIP Code 8600 Astronaui Blvd. Cope Ceneverai Brevard Florida 32920 Part -- Child Populltlon 0 Boys I Girls Age Range: 0 To: 17 Expecied Numbeini Children: 54 RECEIVED JUL 22 Form 2980 Page 2 04-2019-E Part IV Operation Type and Services Operation Type (Select one type of operation.) Programmatic Services (Select all that apply for your type of operation.) Treatment Services (Select all that apply for your type of operation.) 0 General Residential Operation operating as a Residential Treatment Center Child Care Services Emergency Care Services Respite Child Care Services Transitional Living Program Assessment Services Therapeutic Camp Services Emotional Disorders Intellectual Disability Autism Spectrum Disorder Primary Medical Needs 0 General Residential Operation offering Emergency Care Services only Child Care Services Emergency Care Services Respite Child Care Services Transitional Living Program Assessment Services (Select one of the following treatment services only if your Emergency Care Services program is limited to a speci?c target population.) El Emotional Disorders Intellectual Disability Autism Spectrum Disorder Primary Medical Needs General Residential Operation offering Child Care Services only El Child Care Services Transitional Living Program (Treatment services are not permitted for operations that provide Child Care Services only.) 0 General Residential Operation offering multiple services Child Care Services Emergency Care Services Respite Child Care Services Transitional Living Program Assessment Services Therapeutic Camp Services Emotional Disorders Intellectual Disability El Autism Spectrum Disorder Primary Medical Needs Child-Placing Agency Foster Care Adoption Child Care Services Transitional Living Program El Assessment Services Respite Child Care Services Emotional Disorders Intellectual Disability Autism Spectmm Disorder Primary Medical Needs Form 2980 Page 3 I 04-2019-E Part - Permit History Do you (the applicant) have either a permit to provide any other type of child care or child-placing services, or a pending application to provide such services? ?Yes ONO If yes, specify the name of the operation and type of permit: GRO-Norma Linda Shelter,San Benito Shelter Have you (the applicant) ever been denied a permit to provide child care or child-placing services? OYes ?No If yes, provide the date of denial: Type of operation denied: Operation's address (Street, City, State, and ZIP Code) County What was the reason for the denial? Have you (the applicant) ever had a permit for child care or child-placing services revoked? OYes ?No If yes, provide the date of revocation: Type of operation revoked: Operation's address (Street, City, State, and ZIP Code) County If the revocation occurred in another state, list the name and address of the regulatory body that issued the revocation. What is the reason for the revocation? Have you (the applicant) ever been prohibited or barred from operating any other type of child care operation? OYes ?No If yes, provide the date of the prohibition or bar: Type of operation barred: Operation's address (Street, City, State, and ZIP Code): County: If the bar occurred in another state, list the name and address of the regulatory body that issued the bar: What was the reason for the prohibition or bar? Have you (the applicant) ever been a controlling person at an operation? OYes ?No If yes, provide the dates: Was the operation's permit revoked? OYes If so, provide the date of revocation Name of the Operation Operation's address (Street, City, State, and ZIP Code) County Part VI Additional Information for Publication on the Child Care Licensing (CCL) Website Web Address http:/l Email Address RECEIVED win 2 2019 krigdon@chsmedical.com or maguilar02@chsmedical.com Name of Administrator or Executive Director: Melissa Aguilar, Administrator Behavior Interventions: (Check all that apply): Seclusion Personal Restraints Mechanical Restraints Emergency Medication Form 2960 Page 4 l04-2018?E Part Vi -- Additional Information for Publication on the Child Care Licensing (CCL) Website Devices: (Check all that apply). Protective Devices Supportive Devices Special Services Provided: (Check all that apply): Young Adult Care Interstate Compact on the Placement of Children (for children from another state) international Adoptions [j Physically Challenged (provides accommodations for children with physical disabilities) Human Traf?cking Services Part VB For Child-Placing Agencies Attach a complete list of your of?ces and agency homes. and indicate which of your of?ces regulates each home. Part - Designating 1 Governing Body Name of Chief Executive Of?cer or Head oi the Governing Body: Area Code and Phone No.: Keith Rigdon (321) 868-8500 Mailing Address: City: County: State: ZIP Code: 8600 Astronaut Cape Canaveral Brevard Florida 32920 Name of Designated Governing Body. Area Code and Phone No.: Melissa Aguilar (956) 233-0812 Mailing Address: City: County: State: ZIP Code: 31201 State Highway 100 Los Fresnos Cameron Texas 78566 hereby designate the person stated above as the official representative ldesigneel to speak for and act on our organization?s behalf. - I understand that, as the permit holder. the governing body is ultimately responsible for maintaining compliance with the minimum standards and other child care licensing law. - I understand that all waivers and variances must be requested and signed by me or by the designee. - I understand that the governing body must notify Licensing anytime there is a change in the governing body*s designee. - I understand that Licensing provides the governing body and all controlling persons in the operation with documents showing the operation's compliance or de?ciencies and any remedial actions that Liceming takes against the operation. Authorized Signature Signature the Chief Executive Of?cer or Head of the Governing Body or Each Partner Signer?s Title: Date Signed Vice President. HIS 7 Part Certi?cation and Signature certify that provided' here contains no willful misrepresentation or falsi?cation and that it is true and complete to the best of my knowledge and belief I understand that any willful misrepresentation is cause for immediate denial of the application or later denial or revocation ol the license. The documentation to complete this application is attached (see the checklist provided below) i understand that this application will be retumed if the attached documentation is incomplete or does not conform to applicable laws. if a license is granted. there will be no racial discrimination in the admission or care of children. Sig Head of the Governing Body Date Signed 1i? RECEIVED Hill-P? N319 Form 2960 Page 5 I 04-2019-E Part IX - Certi?cation and Signature Floor plan of the and surrounding space to be used Proof of Iiabilily insurance (or documentation that you are 'th indoor dimensions and the purpose of all rooms . . . . . . . . . . . unable to obtain liability Insurance) and a copy of the notice 23:55:; specify where the children and to parents about whether you have liability insurance. Policies, procedures. and documentation. as required by either Child-Placing Agency Documentation Required at Certi?cate of Good Standing or Formation (if applicable) Application or General Residential Operations Documentation Required at Application Checklist (if applicable) Veri?cation of Fee Payment (if applicable) Request for Background Check(s) Form 2982. Personal History Statement (as needed) Form 2760? Controlling Person Child Care Licensing Driving directions to the operation: Please provide clear and concise directions for driving to your operation from the nearest Licensing of?ce. RECEIVED 2 Privacy Statement HHSC values your privacy. For more information, read the privacy policy online at: hitcs:iihhs.te LEW . NT ELEVATION DORMS 1 '1 0 SO. 1/ RIGHT ELEVATION SO. REAR ELEVATION so. 11 LEFT ELEVATION STANFORD HOUSE 30. 1/4" 33918 STANFORD MANZI INVESTMENTS LOS TX Wing DmOmchb ?hom?Om?n? RECEIVED nut-2 2 20m mun TEXAS zone MINI and Human Sanka Cam Request tor Background check use rm form no request checks required by Tums Cone (TAG) 5141635 Vou ran also submll Wound mucous mmugrr HHSC's website See mu um um luv insrrucuons based on operation type lor hackgmund check requesls rm Your opom'on is - Imnsea cniia oars comer your operation musl submit backgmund check request: via HHSC's. Quin scoot-ago program ham or anal-School Cale Emvidu page mgr-m ma mild can home regrslared home or mural car: provider our 095mb" listed family home emnlayei- yum opelahan may :ublml hankgroumi check requasl: vin Child cm band mid rare operation or 5mm operaliun. Framer page amail \he to fax "15 backgmund check Ion-n to 512-339-5571, 0! mall the background check [mm ID Emgmunfl Check UM. 0 Box 149030. Mai1 Code 121.1. Auslin TX 73114--9030, Dreams. Canola: me My rnlomianan hr nun person requimd lo nava a background mack Download addilionul lawns [mm the HHS lotus websne mm: kilo-rum- Nam! 0mm No Ami Cork! and Tatum)": No ens Home srronar -- wm(m Cay mil? Coo.) "yr Shh.l'F Codi) Comm] -- I warned (by are person Social Sammy am orer runs.) mm the irrlormauorr on Ihis no wmful and mm um I: and complain in me base 0! my knowledge, I undamand marl HHSC may ran-domes Ind.l1 any liner wet contained hall I oral Iny willful mlsrepmsamml'an or urn- provide mum inhalinth within me allied rims unrn a mum lor damn! umra lawns-Mn or revaluation of my Inaugural-airman. Sign"! mam WNW RECEIVED JULZZ Zfl'rfl Form FIQBZ Individual's Identifying Information \j Initial Renewal Fingerprint Check Required FBI Results in DPS First Name Middle Name Last Narna Claudia Janet Rivera List any other names the indivldual uses or has used in the past, including married and maldan names, below. ll ynu do not provide every name that the individual has used, you may receive inaccurate results. other First Names other Middle Names other Last Name: Claudia Janet Gonzalez Address (Street. City. State. ZIP Code) County Area Code and Telephone Nut Date or Gender: Cameron OMale (R)Femala List any other any in Texas where the person has been a resldant and any addresses. including county. where the person has lived outside at Texas In it>> previous five years. Ethnicity (must accompany race): Race (C)Hispanic QAstan OBIaek (C)While ONnn--Hispanic oArneriean Indian/Alaskan Native SociaISeeuri No. Photo IDType: DrWerLtcense: Na_ Stale- canedian 5m: stare ID: Mltitary ID: Passport: Permanent Resident Card: Contact Information is required to schedule a fingerprint appointment You must select one of the (allowing choices and provide either an email address or phone number tor the Individual. Freterred method or contact tor scheduling fingerprint appointment: (C) Email calvarem smedical.com Ma code and Telephone No. Please enter the person's email address. Do NOT enter the operatlnn's email address. Provlding art entail address will allow notifications requiring action lronr this person to be received quickly, Rule at Operation: 0 Adaptive Parent 0 Contracted servlca Provider 0 Director 0 FosterParent Footer/Adoptivet'arenl 0 Household Member 0 FrequenllRegulaersltor (C) Licensed Administrator 0 Owner/PenultHoldar slanlErnployeu Unverified Respite Provider 0 volunteer .ioe Dulles/nits: Program Director-- Licensed Child Care Administrator: Responsible and accountable tor the daily operations and which include administration, financial reports development. data collection and ensuring/monitoran contract perturlnance in accordance with ORR pellcies and procedures. Cooperative Agreement, lioensing standards. and all other applitzble state and tederal law. rules. and guidelines. For foster/adopflve names only: between child/children to be placed and the luster/adoptive or prospective foster/adoptive parent(s): 0 Relative Fictive Kin Unrelated Will this person be supervised by a caregiver who is counted in the child-caregiver ratitfl. OVes (The supervising caregiver should be an employee or your operation or a caregiver in a luster and/or adoptive home who is otherwise able to have unsupervised access to children in your care, and who is not restricted trom supervising others.) What ege(s) at children will this person be caring for? Q) 17 months to matheryasrs 3years--4years sysars-- 13 years 0 14yaars -- r7yaars 0 Over 17 years 0 NIA Form 2971 Page 3 RECEIVED .mH 2 2019 TEXAS mm Ham Dunn 52MB Child can Request for Background check Use mas form to request background means mum by Texas Adminrsmuve Coda {119515510} You can also submit bourgroum meek room through webs-r: See the man new ror hm" based on opemhcn |ype ror background meek raquesls than. Your rs a lwsad mm mm ashlar, your openum must sunmr mgmunu check requesn vra mm program. hem or mar-smear Core Ema! P599- mum seemed min: < Fofln 2911 Plal 2 Inmates Identifying Initial Renewal [j Required El FBI Results in DPs cluennghouse First Name Middle Name Last Name Francisco Fabian Delgado Lisl any olher names lite irdivimal uses or has used In the past, including married and maiden names. below. ll you do not provide every name that the Individual has used, you may receive inaccurate results. (Miter First Names other Middle Names O|her Last Names Address iSlnai ii state. ZIP Code) County Area Code and Telephone No. Date or Emit Gender: (C)Male OFemals Cameron List any other dry in Texas where the person has been a rasldent and any addresses. Including oourtry, where the person has lived outside of Texas in the previous live years Ethnicity (must accompany race): Raoe (C)Hispa 'c OAslan OBlack @wrtite ONun-Hispanic OAmerioan Indian/Alaskan Native No. PhoioIDType: Merriam in. se- semen statelD: Military ID: Passport: Permanent Resident Cam: Cuniacl Information is required to schedule a fingerprint appointment. You must select one of the following choioes and pravlde either an email address or phone number tor the individual. Preiened method or contact tor scheduling fingerprinl appointment; (C) Email idel ado hsmedical.DDm 0 Area Code and'reiephrme No. Please enter the person's email address. Do NOT enter the operations email address. Providing an email address will allow notifications requiring action (mm this person to be received quickly. Role at Operation: 0 Adoptive Parent 0 Contracted Service valdor 0 Director 0 FosterPereni Foster/Adoptive Parent 0 Household Member 0 Frequent/Regularvtsilor LicensedAdmlnisiraior stair/Employee Unverified Respite Provider 0 Volunteer Job Dutiesrrtue: Assisianl Program Direch Assists the Program Diredor in the management ol the overall operation or the program in aocordanoe with ORR policies and procedures, Cooperative Agreement, licensing minimum standards. and all oiher applicable state and tedetai law, rules. and guidelines. For insierladopflve homes only: Relationship between child/children ID be piaoed and the luster/adoptive parenlls) Dr praspedive taster/adoptive parenlis): 0 Relative Flclive Kin unrelated Will this parsnn be supervised by a caregiver who is oounled in lite child-caregiver ratio OYes (The supervising caregiver should be an employee or your operation or a caregiver in a roster and/or adoptive home who Is otherwise sole to have unsupervised amass In children in your rare, and who is restricted irorn supervising others.) What 392(5) :11 children will person be Daring lor? (C) o-17months tamonths--Zyears ayears--Ayeers 5years~13years (lyears--I'lyeats 0 Over 17 years 0 REFCIVFD 1915 Form 2971 Page 3 I01-2019-E RECEIVED 2. 2m Form 2750 TEXAS Mill-i- 5' Controlling -- Care Licensing complele rile iaquiied rnionnaiion ior eaen wnhulling person vvirir your npelalicn Tnis includes all people in lire opereiion. as slaled under Title in Team Corie ?745 901 lar lire definilion oi cunlmiling person Nola The rules may lransier in me 26 al a ialer dale Operation lnlomiauun Operaarrn Marne CHs Sianiard House Shaker 096mm No 'Aiu Cod: and Telephone No Aoaress nl operation (sueei Ci Slale and ZIP caoei Cnuni and Slummn Tile iniomreiion an liris iorrn comains no Tire rnlonnarian given is and complete in lire oesi oi my knowledge. I understand iirai any wilirul mierepreseniarien or leiiure lo pmvide rdenmyina inlormallan wnirln the required lime frames is a cause fol remedial acriun regarding my applicaiion or permil i I Dal A alepIicanr. nee, or Head at me Gaveming Body Enedrve Date offnle. Poe'nion or Rellfinnship: Applicant r-v - Firar Name: Middle Marne usr Name Sum curucria Janel Rivera names (mauled. maiden. Gk) Fits Name: Mm! Name. Last Nam: Suffix Claudia Jarrer ennzaiez Dam oi Driver License No., Driver Llama -- Texas liiai'vidufl'l mares: (sneer. C'ny. Stain and Zip Code)' Area Code am Terepnurre No: 2794 Piraesso Ln. Texas 75520 -- Tine. Pm'nim or Reiarlansnip: 2| Licensee El Governing Body Member 3 Mary Caregiver in cniia Care Home 2] Diredor ciriel Execuiive omuer Spouse oi Primary Caregiver l] Boarfl Member 1: Owner Adult Living in cniia Care Harrie Other. "person is win a planing ageney. indicare iliire person is assoclaied lire main in branch Dime: 0 Main 0 Branch ii branch. wnai numben RECEWED JULZZ 101 HHSC Uu Only Narn- or [amino moormm'ng mum More snanna (m5) 5mm sneer: AARS Sialul: 0 Claim! 0 Match Form 21m Page 1 1054015: Applicant Name: Middle Name: Last Name: Sulfix: Francisco Fabian Delgado Diher names used (married. maieen, Mo.) Flrsi Name: Name: Lasl Name: Suffix: Driver Lleanse slnle: Soclal Sewnry Nn.: Date a! Elfin: Driver License No; Ame Colin and Telephone No.: Licensed Mmlnisiralor Governing Body Member Primary Caregiver in Child Care Home Direcior Chiel Execulive Ofl'loer souuse oi Primary Careg'wer jaoard Member Owner Mull Living in Care Home Olher: Assisiaanmgram Dlreclor Eflecllva Dale ol Title. or Relaflonih ll person is associarea wilh a child plecinp agency. lndicale ll lhe person is associalad wilh me main or branch ufl'lce: 0 Main 0 Branch ll branch, whal number: Inform-Hon Name: Name: Last Name: Suffix: Melissa Denloe Aguilar Omar name: used (married. malaen. 9ch Firsl Name: Middle Name: Lasl Name: 5qu; Melissa Denice DeLeon Scclal Seeunry No Dal: of fin Driver ND Ind Musl'a Address (Shael Olly Slale and ZIP Code), Area Code and Telephone No Dr Relarionshl :1 Licensed Administralor Governing Bady Member Primary Caregiver in Child Care Home 3 Direaer Chlei Execullve orncer Spouse el Primary Caregiver Board Member 3 Owner 1: Adull Living In Care Home Olhel" RGV Prugram Coordinator Dale orTmer Position or 06/10/201 5 li person is associated wilh a child plaeing apeney, indicale ii the person is assoclaled wilh lhe main or branch once: 0 Maln 0 Branch ll branch. whal number: RECEIVED lull Infarmatian Form nan Page 3 Ins-lame Firsi Name: Middla Narns: Last Mama: suffix: Keilh Allen Rigdan used (married. maiden. sic.) Firsi Nama: Middle Name: Lasi Name: Sulfix: Date at El Driver License 513 Area Code and Tsispnona No.. Title. Position or Licensed Adminislralur Director Board Member I 05/10/2018 Governing Body Member Chiel Executive Officer Owner other: Vice-Presidenifiulnaniiarian Immigraliun Services Eflecllva Da|e Mme. Pasiliun Dr Primary Caregiver in Child Care Home Spouse ai Primary Caregiver Adull Living in Child Care Home 0 Main 0 Branch Ii person is associaied wirn a child placing agency. indicate ii the person is associaled mm the main or branch office: ii branch. what number: 11319 Faun I'll TEXAS rum 2m: Mam Ilitnun Services Residential Child Care Llcensing Governing Body/Administrator or Executive Director Designation Use this ionn to designate an olficlal represenlatlve (designs) In speak and an on your organization's behall Also use this rurm lo designate an or execullve director Directions To complete lunnl uul Salmon A la name 3 designs andlor Sectiun in designate an admlnislralor or axecuilve dlrector The Certification and Signature secllan must be cempieted lo verily inionnalien In Sectlan A and/or Section For more ll'llofl'l'lfillon. suntan your representallve Section Oniclal Reprenunlatlve Operation Name Opemllon Number Telephone Number cl-Is Stanton: House Sheller (956) 233mm Gnveming Body or Organizailm Name Telephone Number Comprehensive Health Services LLC (321} 565-8500 Nani- aI I:th Examine Wear hr Head anuvemlng Body Nunber Keith Rigdnn (321) Bea-8500 Send nnmna mnespomeme the CEO or Head chwemIng Body? 6) Yes No Name or Deaignee aI summing Early ralmnuna Nunber Melissa Aguilar (956) 233-051: Operallan sues: Address City County ZIP Code Los Fresnns Camemn - cmarning any womanlzanan'a Street Andres on, County ZIP Code 8600 Aalronaul Cape Canaveral Brevam 32920-4306 CEO or Head soars Street Address City: Cuunty Code 8500 Astronaut Cape Canaveral Brevam 32920-4305 Designsa Addresa Cay Cnunty. ZIP Coda Lu: Preanaa Cameron - Section at Executive Director Mama alAdminislraInr or Exaeulive Dinner Mallisa Agullar. Certification and Signature lFleurnplaring Section A oI Inia term. I hereby designate Ina person rwted as Ins ofliclal represenrallve (designee) to speak tar and act on our organization's behalf, I that all correspond-nae and copies campliance ducument: he sent to the designers. I undersland trial I: the permlt holder. the governing body is ultimately tor maintaining compliance wiill the child care "Causing law and minimum standards I understand "15! all waivers and variance: must be requested and signed lay me or by llie designee. I understand [ital any lime (have is a change in lite Olin opemliwn. lite gnverning body is iur Licensing. I understand that Licensing will naliiy lhe gmming body and all persons of mpllanne documents and remedial amion against the uperalion. By completing Section a! lorm. I hereby designala the person "Died as the administrator or execulive director 01 my Slam" Olchlof Exocufiv- omur. um.- ewunlng Body, em Pan-m. or nulanao nar. Signed wnlum lqu 2 lull 1334348 750711 mom 05.15? Ver. 9 . (Ravens/e) Texas Franchise Tax Report - Page 1 'Tcode 13250 ANNUAL I Taxpayer number I Report year Due date 15210446280 2018 05/15/2018 Taxpayer name Secretary of State tile numbe- COMPREHENS IVE HEALTH SERVI CES INC . Mailing address 8 8 1 0 ASTRONAUT BLVDCity State Country ZIP code pius 4 Check box it the '5 caps camva?Check box If this Is a combined report Check box If Total Revenue ls edhsled for .D Tiered Partnership Election, see Instructions ID Is this and a cor sticn liebll com association Itmilsd artnershi or ?nancial institution? Yes NO if not twelve months. see instructions for annualized revenue Accounting year Accounting year at SIC code NAIOS code muste?l 010117 enddatg I 123117 I REVENUE [Whole dottars only) 1. Gross receipts or sales 1.I Dividends 2" 3. Interest 3.. 4. Rants (can be negative amount) 4.I 5. Royalties 5.. B. Gainsllosses (can be negative amount) 8.. 7. Other income {can be negative amount) 7.. 8. Total gross revenue (Add items 1 thru 7) 8.. 9. Exclusions from gross revenue {see 9.I 10. TOTAL REVENUE {item a minus item 9 if 1o.' less than zero. enter 0) COST OF GOODS SOLD (Whole dollars only) 11. Cost of goods sold 11.I 12. Indirect or administrative overhead costs 12.I (Limited to 13. Other (see instructions) 13.I J4. TOTAL COST OF 80008 SOLD {Add items 11? thru 13) 14.I COMPENSATION {Whole doifars onfy) 15. Wages and cash compensation 15.I 16. Employee benefits 16.I 17. Other (see instructions) 17,- 18. TOTAL COMPENSATION (Add items 15 thru 17) 1B.I RECEIVED 2019 VEIDE El PM Date Texas Comptroller Official Use Only 4: Page 1 of 2 2019 1334345 mm mm as use-e Texas Franchise Tax Report - Page 2 - Var 9 .0 {Rave-tern} IToode 13251 ANNUAL I Taxpayer number I Report year Due date Taxpayer name 15210446280 2018 05/15/2018 comm MARGIN (Whole dollars only) 19. 70% revenue (item 10 . 70) 19. I 20. Revenue less COGS ?tem 1'0 - item 14) 20. I 21. Revenue less compensation ?tem 10 - item 18} 21. I 22. Revenue less $1 million (item 10 - $1,000,000} 22. I 23. MARGIN {see instnictionsi 23. I APPORTIONMENT FACTOR 24 Cross receipts in Texas Mhole dollars onlyzi 24. I 25. Gross receipts everywhere dollars only) 25. I 28. APPORTIONMENT FACTOR {Divide item 24 by item 25. round to 4 decimal places) TAXABLE MARGIN (Whole dollars only) 27. Apportioned margin (Multiply item 23 by item 26) I 28. Allowable deductions (see instructions) 28. I ARGIN ?tem 27 minus item 28) 29. I TAX DUE 30. Tax rate (see instructions for determining the appropriate tax rate) 30. I It itm29 ttitrtiit so 11 31.I TAX ADJUSTMENTS (Dollars and cents) (Do not include poor payments} 32. Tax credits: ?tem 23 from Form 05-160 32. I 33. Tax due before discount ?tern 31 minus item 32) 33. I 34. Di soon i I art zone and zoom 34. I TOTAL TAX DUE {Dollars and cents) 35. TOTAL TAX DUE (item 33 minus item 34) 35. I Do not include payment it item 35 is less than $1,000 or if annualized total revenue is less than the no tax due threshold (see instructions). lithe entity makes a tiered partnership election. ANY amount in item 35 is due. Complete Form 05-170 it making a payment. Print or type name Area code and phone number JAMES VAN DUSEN (321) 783?2720 I declare that the irilormatlon in this document and any attachments Is true and correct to the best at my knowledge and bellel. Ma" original t0: Texas Comptroller at Public Accounts . 9.0. Box 149348 ril?e-N a? 3? 3018 Austin. rucllons each report year are cnline at comptroller. lexas It you have any questions. call 1- 800 252-1381. Texas Comptroller Official Use Only In. veroe 1?15 1019 Page 2 of 2 TX 05-102 (Ssdiun A Continuation) com HENSIVE HEALTH SERVICES INC. 15210446280 m. m. W. Mumm vs: ES 1: mm F0 TREASURER i WNAPLES 5.7m. FL upwaum m. m. cm, um Jonas VICE PRES. -- c. COCOA BEACH Sm. FL arcaa32922 Nm 7 I'm- me Irm uni-[m I: v55 ,wzu mas SR VICE PRES . -- cn MELBOURNE 5m. FL "53442940 m- m, Mum" "ms SR VICE PRES. m: mm VA "5.40105 NW. N. mm, mm", Lil um! :Dan DIRECTOR a. WINTER PARK Sm. FL EPW327851 mn- nu. 'Dnmu Tum unmm asm .1 1mm CHIEF MED OFICR 1 a mnoma FL Mame Nan: mm aw. Yum "mm DH vEs Oaxan .m IRECTOR a c, COCOA BEACH sm- FL mum-32 9 3 1 w. 'mwu v55 m: 5 my, SECRETARY RESTON M. VA m. m- am vEs Elam". cm Sm. zwcom m. m. w. Mum," 1: ms mam." Ema. m. rm- W, Mum." v55 Wm I c" m. 72>> on, mm mm RECEIVED 2 13'3u4s m'om mm n: Texas Franchise Tax Public Inlonnation Hapm I 9 . 0 Murmur", 70 ha lile by leilad thl'lny Cumulus (LLB). lellad (LP), Pmlanmnl! mac/mans (F41 financial Instilurl'ona I funds 1 3 1 9 6 I Taxpayu I R-pon yea: Vnu luv- umln mm mm. cum. 552 am an. Emu-mm l. m. 15210446280 2015 mm. cumm-u-wmaz-ml mum:st an I cm" Him-mnnmamhulamru a. 32920 leul-um) um: cumvmuln 1292 unmet. dkacluv. "lumbar, umnu and minimal |n1mm@5 @Wsu mm Plan" am: 09me 17"!an rut-51 llgnad In (Ix 1511(14'575013 SECTION A Name M19 Ind mlilmn "m 0" dim" number glneral of mammal. Tw- '7 [fl .5 GARY G. PALMER PRESIDENT Mmcanal u, 'mcm 1192: ml mum: 7" vs: JUDY C. HALL DIRECTOR "mm" Miflr nun: any COCOA men Sm: FL lama 32931 Num- m- 7" 5 7 [El was JAMES MONCRIEF DIRECTOR Wm" . man" my was 5. mos . Simon 5 Enter lureacn cwnuvallnn LP PA 0: lnslilullnn. lawman anuly wnsan Ifl um may male. unnsasnanmhc "my qudlnmeb-mm mum uc' mu..an sEc'nuu Emu In! each :mnnvaliuu. LLB. LP at Manual lnsn'mflan My mal awn: Ill at In umml or move ln ml; enliw. slur-wame m, a: mama me on I: conundran SYSTEM omcugg mm 5; mg a; 25cm DALLAS TX "m 15sz maumumlm. m: u. .1 mm hummu- m- . mm- mam mm" an": mm mum-In: bul myInM-flpn .a ham. .. .1 n. .m . nayal an", mm. Inn-noma- . muuql much: unity mm by: .v "um Wham uc sign m. hm TREASURER Texas Comet-ill." ot'i'fll' um um ml:qu $019 um ~--ms.uum.m. (321) 783-2720 TEXAS mt; Nulfll Ind Humn Senna; Verification of Insurance Use an Inan In indluile whellm ynumpemlmn nas nanny Insurinnu as manned hy Human Remus Code 542 M9 Wrens In mam: a mgimmu am can name, Islea Iamuly home. small mud care opmnan we 0' 5W9- opemnn Inlay do noI reqmra IranIIny lnsumme nlncuonn. The pannil halmr emulates We In Its enume and send: In Care Lmensmg as part cl an :pplnunan Iva Manse Glneral lufcrmatlon Opemnm Nam: Numhel CHS Slanfum Hum snenar Operanan Mums; Duel your upIrinun have II-mlny Insurance In the amount M5300 000 bleach assurance aI Mal-Wu: mung mm In am? Vs (Ilyes' mam a copy at m: nenmmle aluminum) [1 ygs' Emu 11-msz No. Thu gponuan don Ml nun Ilmmy ollmurlnc by smion 41.04! Mum-n Rnnum Codl (av m- lollowinn rum": 0 Funawu'al reasons. Dmvioe explanwon. Owens: nuIavulabIe hum In unnerwnw. Immde 0 Thu limnzhulls nvmeumum May have been exhumed Date the policy wIIl be mam: Nafiflutlon o! Luck of Insurance Par-ms luv: been, ur will be. unified by (mean all apply) l: mumpampnleun yam (mach a my) Node: pom: In - pine: (attach a copy) AqunamI: an Inn (mm a away) Posted on Wilson's website Diner (ipeaiy): Camila-non and Shanamre . Designee a Dim! RECEIVED .IUILZZ 1M9 DATE CERTIFICATE OF LIABILITY INSURANCE 05121112019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING AUTHORIZED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER. IMPORTANT: If the certi?cate holder is an ADDITIONAL INSURED. the policy?es) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED. subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certi?cate does not confer rights to the certi?cate holder In lieu of such endorsemenus). PRODUCER CONTACT Marsh USA Inc FA): Sit 900 I?m? as . . Richmond. VA 23219 mess. Attn. 212-948-1307 INSURERS) AFFORDING COVERAGE MIC I1 18-19 INSURER A Beazley :nsurance Company INSURED . - 1 Comprehensive Health sm- Inc . Starr 8. Liab?uly Company 33315 10701 PaIkridge INSURER Commerce and Industry lnsuranoe Company Reston. VA 20191 INSURER D: INSURER "awn COVERAGES CERTIFICATE NUMBER: ?00048947410? REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE 1?31 lg?gtm?xr, ?mg I CLAIMS-MADE OCCUR PREMISES {Ea oocurmmei 300-000 MED EXP {Any one person] 8 PERSONAL a. ADV INJURY 101000-000 gm AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE 10.000000 POLICY 313281: LOG PRODUCTS - COMPIOP AGE 5 10.000.000 OTHER. 5 51 LE LIMIT 3 LIABILITY 1110112018 1110112019 3 2300.000 ~11 ANY AUTO BODILY INJURY {Per person) OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY {Per accident) 5 NON-OWNED PROPERTY DAMAGE 1? AUTOS ONLY AUTOS ONLY 5 UMBRELLA LIAB OCCUR a I 111012019 EACH OCCURRENCE 15.W.UIIU EXCESS AGGREGATE 15.000000 DED I I RETENTIONSO 1110 19 WORKERS COMPENSATION 112018 11101120 PER OTH- AND LIABILITY I, I STATUTE I ER 1.111.110 {Mandatory In NH) See 2nd Page ior Add? WC Policies EL DISEASE - EA EMPLOYEE 1.000.000 11 E03. desaibe under 1 000 000 OP OPERATIONS below EL. DISEASE - POLICY LIMIT 3 1 1 RE Los Fresnos Shelter 32120 FM 1847 Los Fresnos. TX T8566 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 101. Additional Remark! Schedule. may he If marl space It required) ll 5 CERTIFICATE HOLDER CANCELLATION 11 l: l. :1 I: Comprehensive Health Services. 'nc 10701Parltridge #200 Heston. VA 20191-4359 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Timothy .1. Brandt 019 ACORD 25 (2016i03) 1958-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 0N102581481 Loc Nashville I COR. ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Hausa INSURED Mash USA Inc. Comprehensive Health Services. Inc. 10101 Parkridge Poucv NUMBER Reston. VA 20191 CARRIER CODE areecme DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM [5 A SCHEDULE T0 ACDRD FORM, FORM NUMBER: 25 FORM TITLE: Certi?cate of Liability Insurance Additional Workers Compensalion Pornies Starr ndernnily Llabilily Company A. AL. AR. 1111.011. 00. GA. 1.10 MN NV. OR. SC Policy Dates 1110112018 - 1110112019 Limits. Per Statute 51.000000 - Employers Liability Each Accident 51.000000 - Employers Uabilily Disease - Policy Limit 51.000000 - Employers Llabilin Disease - Each Employee Starr Inderrmily a. uabilily Company K. FL) Policy Dates: 1110112010 - 1110112019 Limits: PerLalute 51.000.000 - Employers Each Awident 51.000.000 - Employers IJability Disease - Polty Urnit 51.000.000 - Emplonrs Liability Disease - Each Employee ACORD 101 (2000101) 2000 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A EVIDENCE OF PROPERTY INSURANCE TNIS EVIDENCE DE PROPERTV INSURANCE IS ISSUED As A MATIER or oNLv AND CDNFERs ND RISNTS uPoN TNE ADDITIONAL INTEREST NAMED EVIDENCE DOES AEFIRIAATTVELV on NECATTVELV AMEND, EXTEND DRALTER TNE CDNERAGE AFFORDED Bv TNE TNIS EVIDENCE or INSURANCE DDES Nor A BETWEEN TNE ISSUINC INSURERIS). REPRESENTATIVE DR PRDDUCER, AND THE INVERESL AMY cumm muw": lh- Imus mm um mews>>: Sumo sun-am. VA 71219 Air mam-Annuan Baum m.>>qu "mum--Ina gun-L cons: AMY mum mu Nuulil mm mm ('amusm Hum Sluts. In: I mm. I. m'i" mm." magnum, m. Romy-DR mm: mm. PROPERTV INFORMATION TNE POLICIES or INSURANCE LISTED RAVE BEEN ISSUED TO THE INSURED NAMED ABDVE FOR THE Poucv PERIOD INDICATED. REDUIREMENT, TERM DR CCNDITIDN DE ANY OR OTHER WIYH RESPECY To WHICH TRIS EVIDENCE OF PRDRERTV INSURANCE BE IssuED OR PERTAIN, YHE mum: AFEDRDED By THE DESCRIBED HEREIN IS To ALL TRE TERMS, EXCLUSIONS AND CONDITIONS or sucn POLICIES quTs RAVE BEEN REDUCED BY PAID CLAIMS COVERAGE INEORNIATIDN pans INSURED IBASII: <>: mum Imam 2mm. Imoam 15m mud Imam zsmu 3| FUNKY hm I'd mm REMARKS SECIBI CDndIIlonl] SNUULD ANV or TNE ABDVE DESCRIBED BE CANCELLED BEFORE THE EXPIRATION DATE TREREDE. NOTICE WILL BE DELIVERED IN ACCORDANCE WITII THE PDLICV PROVISIONS, ADDITIDNAL INTEREST NAIKAPE mum mom-mm I IENIIEHS Loss nuns LOSS PAst warsz . amm WhipIns. firmly .I. BramII Mt. 5M 11(2n1un1) mum CORPORATION. AII "gm: mum. ACORD niml and logo in milks 0 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE 0512102019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATWELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING AUTHORIZED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER. IMPORTANT: If the certi?cate holder is an ADDITIONAL INSURED. the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy. certain policies may require an endorsement A statement on this certi?cate does not confer rights to the certi?cate holder in lieu of such endorsementIs). PRODUCER CONTACT Marsh USA Inc. 33:10.2 FAX 9011 SAP as I 9 . Richmond,? 23219 W- 212-948-1307 INSURERS) AFFORDING COVERAGE NAIC INSURER A Beazley Insurance Company '"Sgg?gmhensm Ham Inc msuaea a Starr lndenm?y I. Liability Company 38318 10701 Parkridge INSURER and Indush'y Mariana Smog-II Reston, VA 20191 INSURER o: INSURER INSURER COVERAGES CERTIFICATE NUMBER: ATL-004890005-05 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER 103033500. LIMITS A COMMERCIAL GENERAL 111002018 111002010 EACH OCCURRENCE 5 10,000,000 CLAIMS-MADE OCCUR PREMISES IE: occurrence} 3 3001000 MED EXP {Any one person) PERSONAL 5 AW INJURY 10.000000 ?m AGGREGATE UMrr APPLIES PER. GENERAL AGGREGATE POLICY 53% LOC PRODUCTS - COMPIOP AGG 3 10.000000 OTHER: 3 11 1 1 SINGLE LIMIT LIAEILITY 1?0 120 3 111002019 3 2000.000 ANY AUTO BODILY INJURY (Per person} BODILY INJURY [Per accident} 5 HIRED NON-OWNED DAMAGE 3 AUTOS ONLY AUTOS ONLY {Per g?mli UMERELLA me i. OCCUR 110112010 111019019 EACI-I OCCURRENCE 5 15-000 ?00 EXCESS U03 CLAIMS-MADE AGGREGATE "00 DED I I 112010 0 WORKERS COMPENSATION 1110 1110112019 PER TH- LIABILITY AZ TX NC I STATUTE I 5? m. I In new ACCIDENT 1.000.000 [Mandatory In NH) See Page IOF Md" WC E.L. DISEASE - EA EMPLOYEE 5 1-39-1000 g?es. describe under 1 000 SC PTION OF OPERATIONS below EI. DISEASE - POLICY LIMIT 5 - - DESCRIPTION OP OPERATIONS I LOCATIONS I VEHICLES 1131. Additional Remarks Schedule. may be attached II more space ls required) RE: 299 Heywood. San Ben'to. TX T8536 ??35029 JUL 22 219 CERTIFICATE HOLDER CANCELLATION Comprehensive Health Semces, In: 10?01 Partridge Blvd. #200 Reston VA 20191-4359 SHOULD ANY OF THE ABOVE DESCRIBED POLIC THE EXPIRATION DATE THEREOF, NOTICE ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE oI' Marsh USA Inc. Timothy J. Brandt 5M ACORD 25 (2018.013) 1938-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN1025814B1 Loc Nashville A . AICORD ADDITIONAL REMARKS SCHEDULE ?19? 2 ?f AGENCY NAMED INSURED Marsh USA Inc Comprehensive Health Services. lnc. 10701 Partridge Blvd. Pouc'r NUMBER Reston. VA 20191 CARRIER cone EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM. FORM NUMBER: 25 FORM TITLE: Certi?cate Of Liability Insurance Addilional Workers Compensation Policies Limits: Per Statute 51.000000 - Employers Llabiliry Each Amident 31.000000 - Employers Llabilrty Disease - Policy Limit S1.000.000 - Employers Lei-11y Disease - Each Employee Stan Indemnity 0 Liability Company mar?m Policy Dates: 111002018 - 11.002019 Units: Per Statute 31000000 - Employers Uabilily Each Accident 31.000000 - Employers lJabiIily Disease - Policy Limit 51000000- Employers Liability Disease - End: Employee Stan' lnderrm' 5 Liability Company PolOR. 30. Policy . 10 11.01l2019 ACORD 101 (2000.011) 2000 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD EVIDENCE OF PROPERTY INSURANCE mam TNIS EVIDENCE OF PROPERW INSURANCE IS ISSUED A3 A MATTER OF INFORMATION ONLV AND CONFERS ND RIGHYS TNE ADDITIONAL INTEREST NAMED BELOW, THIS EVIDENCE DDES Nor APFITNATIVELV DR NECATIVELV AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED PDLIEIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT A CONTRACT DEMEEN TNE INSURERISI. REPRESENTATIVE 0R PRODUCER, AND THE INTEREST. mm mm Dawn" NunusAv-a Nan-1mm IND-mum, mun- Cm: 105! WNA 23m Ann 212mm Wfllulm mm mm fawn-NM mam Elms. MC Emazmgw Erin'qu ms mmnou m: mu Asmarle mum mu: PROPERTV INFORMATION THE POLICIES OF INSURANCE LISTED BELOW NAVE REEN ISSUED TDTNE INSURED NAMED ABOVE FOR TNE PERIOD NOTWITHSTANDINC REQUIREMENT TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT RESPECT To WNICN THIS EVIDENCE OF PROPERTY INSURANCE MAV BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED EV TNE POLICIES DESCRIBED HEREIN IS SUEIECT To ALL THE AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN BEEN REDUCED Ev PAID CLAIMS. COVERAGE INPORNATIDN mum RED laws I IIROAD I lsscuu AmmwleuAANCE mm In my mm in! mums IEIMM 50011 CANCELLATION SHOULD ANV 0F TNE ADDVE DESCRIIED BE CANCELLED IEFORE TNE EXPIRATION DATE TNEREOF, NOVICE WILL DE DELIVERED IN ACCORDANCE INITN TNE mucV PROVISIONS. ADDITIONAL INTEREST mm mum: LDESPAVEE . mamas: I TIva 4- Brandi 12.47.;- ACORD 27 (Emma) 0 ACORD All IIanld. TN. ACORD nun. Ind nummd mm: MACORD IIEZZ 2N9 I ACORD CERTIFICATE OF LIABILITY INSURANCE DATE 052812019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING AUTHORIZED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is en ADDITIONAL INSURED. the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED. subject to the terms and conditions of the policy. certain policies may require an endorsement. A statement on this certi?cate does not confer rights to the certi?cate holder in lieu of such endorsemenus). PRODUCER Marsh USA Inc PHONE FAX [slain-lg CenSUIeF-?re I .1 900 gig-u. em: we. Hg): 1 TY . u? Richmond,vA 23219 M53 AtIn: 212-949-130? AFFORDWG COVERAGE INSURER A Beanie)I Insurance ii'lompanYI maggr?grehensiva Health Services Inc INSURER Starr Indemnity 8. Liability Company 33313 10701 Partridge INSURER Commerce and Induslry IW Comparny Reslon. VA 20191 INSURER o: INSUREIE INSURER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. A ma ormsunANcE poucv 5333' LIMITS A COMMERCIAL GENERAL LIABILITY 1110112018 1110112019 EACH OCCURRENCE 5 10,000,000 CLAIMS-MADE OCCUR memses [Ea ?$5ng 5 300-009 MED EXP {Any one person] PERSONALSADVINJURY 3 10,000,000 ?191. AGGREGATE LIMIT APPUES GENERAL AGGREGATE i POLICY Egg Loc PRODUCTS - COMPIOP AGG 10.000000 OTHER: COMBINED SINGLE LIMIT 3 LIABILITY 1110112015 1110112019 2.000.000 ANY AUTO BODILY INJURY {Per person} OWNED SCHEDULED . . AUTOS ONLY - AUTOS BODILY INJURY (Per accident. 5 HI )1 NONOIYNED DAMAGE AUTOS ONLY AUTOS ONLY MI) 5 me OCCUR 11002013 11010019 m? OCCURRENCE 15.000000 excess AGGREGATE 5 15,000,000 DED I I RETENTION 50 111011201 WORKERS COMPENSATION 8 1110112019 PER TH- AND LIABILITY AZ Tx NC I STATUTE I 5" IA I Y) EL EAICH 1 000.000 [Mendatery In 580 20d 9399 ?Add" WC P059135 EL DISEASE - EA EMPLOYEE 1 000.000 II gee. describe under 1 000 000 SCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 5 . DESCRIPTION or- ILOCATIONS I VEHICLES (ACORD 101. Remarks Schedule. may be attached II more space Is required! RE. Case Norma Linda 30199 Highway 100 Les Fresnos. TX T9506 CERTIFICATE HOLDER CANCELLATION CompIehensive Health Services Inc 10?01Par1Iridga #200 Reston.VA 20191-4359 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Timothy .1 Brandi Mi Ema??db ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 1988-2016 ACORD CORPORATTON. All rights reserved. RECEIVED IBIS AGENCY CUSTOMER ID: CN102581481 LOC 15: Nashville I CORD ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. Comprehensive Health Services. Inc. roror Parkridge em. POLICY NUMBER Reston. VA 20191 CARRIER NAIC cooE EFFECTIVE DATE: ADDITIONAL REMARKS nus REMARKS FORM :5 A SCHEDULE T0 ACORD FORM. FORM NUMBER: 25 FORM TITLE: Certi?cate of Liabil?y Insurance Additional Workers Comm Policies Starr Indemnity 5 Liability Company Fancy ALon. SC. Policy Detox 11101t2018-11101f2019 Units: Per Statute 51.000.000 Employers Liabi?ty Each Accident 51 $110,000 - Ern?oyers Liability Disease - Poiicy Umit 51.000.000 - Employers Liabiirty Disease - Each Employee Starr Indemnity in ?ability Company AK. PoiicyDates: 11 8- 111019019 Limits: Per Statute 81 000.000 - Employers Each Accident 51 000.000 - Employers Liability Disease - Policy Limit $1000.000- Employers Liability Disease - Each Employee ACORD 101 (2008I01) 2000 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A . EVIDENCE OF PROPERTY INSURANCE emu THIS EVIDENCE OF InsquNcE Is ISSUED A: A NATIER OF INFORMATION ONLV AND CONFENS ND UPON ADDITIONAL INTERESY NAMED EVIDENCE DOES Nat AFEIRNATIVELV on NEGATIVELV AMEND, EXTEND on ALTER COVERAGE AFFORDED Dy POLICIES EVIDENCE OF INIUNANCE DOE: A DETWEEN TNE DR DRDDIICER, AND THE ADDITIONAL INTENESI. mm" mm: cut-m mum: Inn-mum. mum-Imam an was>> wunx: mm. man-a mun-u mme mm." mm"? INFORMATION POLICIES OF INSURANCE LISTED BELOW HAVE BEEN To THE INSURED NAMED ABOVE FOR THE PERIOD INDICATED NOTWITNSTANDING ANV REQUIREMENT. IERN on CDNDITION DF Am CONTRACT OR OTHER WITH RESPECT To TNIS EVIDENCE or INSURANCE MAV DE ISSUED DR MAV PERTAINI TNE INSURANCE AFFORDED at THE POLICIES DESCRIBED HEREIN IS SUBJECT to ALL THE TERMS, EXCLUSIONS AND cuNDmoNs OF SUCH POLICIES LIMITS HAVE BEEN REDUCED av PAID CLAIMS COVERAGE DEAILS I SFEEIM. caveman-mm rum Allovqu Imma: mum-IE matm Pnysu hm ll I:mam "Iguana Pam Imam Elwyn25m EDndeIIsl CANCELLATION as THE ADDVE DESCRIBED PDLIEIES BE CANCELLED DEFOIIE ttIE EXPIRATION DATE THEREOF, NotIcE WILL BE DELIVERED IN ACCORDANCE PROVISIONS. ADDITIONAL INTEREST mums mm: mm "mum um mm VA anquSS .umuumssamm: minimum. 11mon J. Bram" AODRD 21mm") 0 Ina-2m ACDRD CORPORATION. AII mu. mm ACORD RECEIVED 20l9 TEXAS Form :lm mull-n- Residential Chiid care License Fee Schedule "Mm" Slale Law requires lhe Texas Haallh and Human Services Commission (HHSC) to cellocl lees lorlssulng licensee. registrations and listings and luv background cheats. HHSC lhe checks il receive: in lhe stale's garleml revenue lund. Directions: Please send only one check or order lor lhe entire amount (Includan background cheek lees). no not send cash. Make cheek or money order payaeie lo: Texas Health and Human Services liieil rhi- oompiued ion and your check or money order be: Texas Health and Human Services Acwunls Receivable v.0. Box I49n55 Austin. TX 78714-9055 Keep a eopy olyour canoeled chuck nr money order tor your records. Ne mulpt be This rornr and your paymenl will be murned in you if: the loan is blank ur imamnlela. you do nel send Illa comet lee enrounl. oryou send :2le Fl! 40 Texas Adminismilive Code 5745.509 establishes lhe (allowing [an schedule: Appliealion Foe: A nonrolundabie lee ior an Initial applicallon tor a license in operate a child care updralion or child-piecing agency. rhe lee is paid when the application is submibed. Initial Fee: A $35 lee hr 3 child are nusralioll (Miler Khan a child-placing agency). A 550 lee fora agency. This fee Is paid when lhe applicalion ls Inhlal Renewu 2 A $35 lee lol 5 child care opaiallnn. A $50 fee for a agency. The lee ls paid when license is renewed. Full Fee and Annual In: A $35 lee in! a child care DDerallori plus $1 ler each child lhe operalion is licensed lo serve (lather lhari a child-placing agency): a $100 lae for a child-placing agency. This lea is paid beloru lhe lull license is Issued and allha anniversary dale oi issuance, Background Check Fee: A 52 lee per person. paid each lirne Criminal History and Central beekground shed is requesied. The law requires inal it an upelaliun rails to pay lhe annual license lee when due. lhe iieerrse will be suspended lhe tee is paid. This means children rnual not be In care al the operation llan lhe suspension is lillad. lfyou da riot pay lhe lee within six Myour lioensa being suspended. your license will be aulomatlcally revoked. Operation lnlorlnalion El Please check il this Is a change eieddrese, Operation Nsrne: leperation Number (on your pennil): Telephone No CHSI Hausa Shaller rsliorl Address Slreoi Slate end ZIPC County: Cameron Email-Address: Jul-22 lel mapuilaroz@chsmedleel.oom Fees Service Code Operation (check one) Fee Type (check all that apply) Amount 529200952 (C) General Residential Operation Applicaliorl Child To The Order Of Mame: Comprehensive Health Services, LLC 8600 Astronaut Blvd. Cape Canaveral, FL 32920 321-183-2720 One Hundred Seventy Three And 001100 Dollars TEXAS HEALTH AND HUMAN SERVICES COMMISS ACCOUNTS RECEIVABLE PO BOX 149055 AUSTIN. TX 78714-9055 UNITED STATES OF AMERICA Suntruat Bank sunrnusr BANK 000562197 DATE CONTROL NO. AMOUNT 07/09/2019 000552197 $173.00 AFTER 90 WOODSEELHTM Comprehensive Health Services, LLC EDELBLELEW 562197 voucher No. vendor ID Invoice Number Invoice Date Discount Taken Net Amount Paid 2730664 6109703 LICENSEFE59019 01/09/2019 $.00 $173.00 Subtotals $.00 $173.00 Totals $.00 $173.00 Check Notes 2730664 Application Fee: $30 (Sanford House) Initial License Fee: $35 Non-Expiring License Fe RECEIVED JUN-22 2019