The Lic 610E form is an important document for businesses in New York State. This form is used to apply for a Business Certificate and to register with the Tax Department. The Tax Department uses this information to determine a business's tax liability. Filing this form correctly is critical, so make sure you are familiar with the requirements. For more information, consult the instructions provided by the Tax Department.
Below are some specifics of lic 610e form. You can read it before typing in the gaps.
| Question | Answer |
|---|---|
| Form Name | Lic 610E Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | lic 610 rcfe, california lic 610e, lic610e, lic 610e form california |
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY |
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES |
EMERGENCY DISASTER PLAN FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
INSTRUCTIONS:
Post a copy in a prominent location in facility, near telephone.
Licensee is responsible for updating information annually. Return a copy to the licensing office.
NAME OF FACILITY
ADMINISTRATOR OF FACILITY
FACILITY ADDRESS (NUMBER, STREET, |
CITY, |
STATE, |
ZIP CODE) |
TELEPHONE NUMBER
( )
FAX NUMBER
( )
CELL PHONE NUMBER
( )
I.ASSIGNMENTS DURING AN EMERGENCY (USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED)
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NAME(S) OF STAFF |
TITLE |
ASSIGNMENT |
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1. |
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DIRECT EVACUATION AND PERSON COUNT |
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2. |
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HANDLE FIRST AID |
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3. |
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TELEPHONE EMERGENCY NUMBERS |
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4. |
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TRANSPORTATION |
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5. |
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NOTIFY FAMILY MEMBERS |
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6. |
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NOTIFY CCL AND OTHER AGENCIES |
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II.EMERGENCY NAMES AND TELEPHONE NUMBERS (IN ADDITION TO
FIRE/PARAMEDICS
POLICE OR SHERIFF
RED CROSS
OFFICE OF EMERGENCY SERVICES
PHYSICIAN(S)
POISON CONTROL
HOSPITAL(S)
AMBULANCE
DENTIST(S)
ADULT PROTECTIVE SERVICES
LONG TERM OMBUDSMAN
OTHER AGENCY/PERSON
COUNTY MENTAL HEALTH
III. FACILITY EXIT LOCATIONS (USING A COPY OF THE FACILITY SKETCH [LIC 999] INDICATE EXITS BY NUMBER)
1.
3.
2.
4.
IV. TEMPORARY RELOCATION SITE(S) (IF AVAILABLE, SUBMIT LETTER OF PERMISSION FROM RENTER/LEASEE/MANAGER/PROPERTY OWNER)
NAME |
ADDRESS |
TELEPHONE NUMBER |
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( |
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NAME |
ADDRESS |
TELEPHONE NUMBER |
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( |
) |
V.UTILITY
ELECTRICITY
WATER
GAS
VI. FIRST AID KIT (LOCATION)
VII. AED (IF AVAILABLE - LOCATION)
VIII. EQUIPMENT
SMOKE DETECTOR LOCATION
FIRE EXTINGUISHER LOCATION
TYPE OF FIRE ALARM SOUNDING DEVICE (IF REQUIRED)
LOCATION OF DEVICE
IX. AFFIRMATION STATEMENT
AS ADMINISTRATOR OF THIS FACILITY, I ASSUME RESPONSIBILITY FOR THIS PLAN FOR PROVIDING EMERGENCY SERVICES AS INDICATED BELOW. I SHALL INSTRUCT ALL CLIENTS/RESIDENTS, AGE AND ABILITIES PERMITTING, ANY STAFF AND/OR HOUSEHOLD MEMBERS AS NEEDED IN THEIR DUTIES AND RESPONSIBILITIES UNDER THIS PLAN.
SIGNATURE
DATE
LIC 610E (10/03) (PUBLIC)