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HomeMy WebLinkAboutResolution - 2000-R0131 - Contract - SPFB - BDF, 2000 Summer Food Service Program - 05_11_2000Resolution No. 2000-R 0131 May 11, 2000 Item No. 24 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK THAT the Mayor of the City of Lubbock BE and is hereby authorized and directed to execute for and on behalf of the City of Lubbock, by and between the City of Lubbock and South Plains Food Bank, a contract for the Breedlove Dehydrated Foods for the 2000 Summer Food Service Program for children funded by Texas Department of Human Services, and related documents. Said contract is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the City Council this 11thday of May 2000. ' ,� I /r1►a ATTEST: f Kaythi Damell City Secretary APPROVED AS TO CONTENT: Victor Kilman Purchasing Manager APPROVED AS TO FORM: William de Haas Competition and Contracts Manager/Attorney Ccdocs/South Plains Food Bank.Breedlove.res II. CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT (Continued) B. The Contractor accepts final administrative and financial responsibility for food service operations in each school, summeifceding site, and child and/or adult care facility, hereinafter referred to as a site, operated or sponsored by the Contractor. The responsibility includes any audit exceptions or payment deficiency in the program covered by this contract, and all subcontracts hereunder, which are found after monitoring or auditing by TDHS or USDA and will be responsible for the collections and payback of any amount paid in excess of the proper claim amount. C. The Contractor submits for TDHS approval only those applications for sites which have delegated the authority for the administration of food service operations to the Contractor or which have executed subagreements with the Contractor for the administration of food services operations. D. Contractors participating in the NSLP agree 1. that the official signing the Claim for Reimbursement will be responsible for reviewing and analyzing meal counts to ensure accuracy and compliance with federal regulations 2. to enter into an agreement to receive donated foods as required by federal regulations, and 3. to price lunch as a unit E. Contractors participating in the CACFP provide or accept responsibility for the provision of organized, non-residential child day care and will immediately report to The Texas Department of Protective and Regulatory Services (TDPRS) Licensing or Child Protective Services staff; any suspected violations of TDPRS Licensing standards or suspected abuse of children in sponsored centers or day homes. III. RECORD KEEPING A. The Contractor will keep financial and supporting documents, statistical records, and any other records pertinent to the services for which a claim was submitted in the manner and detail prescribed by TDHS. The records and documents will be kept for a minimum of 3 years and 90 days after the termination of the federal fiscal year for the relevant program. If any litigation, claim, or audit involving these records begins before such period expires, the Contractor will keep the records and documents for not less than 3 years and 90 days and until all litigation, claims or audit findings are resolved The case is considered resolved when there is a final order issued in litigation, or a written agreement is entered into between TDHS and the Contractor. The Contractor will keep records of non -expendable property acquired under the contract for 3 years and 90 days after final disposition of the property. B. The Contractor and its subcontractors will allow TDHS and USDA officials and other appropriate officials determined by TDHS to inspect facilities and records and to audit, examine, and copy records at any reasonable time. This includes access to all records of costs paid, even in part, by TDHS. IV. CIVIL RIGHTS POLICY COMPLIANCE A. The Contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (Public Law 88-352) and all requirements imposed by the regulations of the Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR Parts 42 and 50) and FNS directives or regulations issued pursuant to that act and the regulations. Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112), the Americans with Disabilities Act of 1990 (Public Law 101-336), Title IX of the Education Amendments of 1972 (7 CFR Part 15a), the Age Discrimination Act of 1975 (Public Law 94- 135), and all amendments to each, and all requirements imposed by the regulations issued pursuant to these acts. In addition the contractor agrees to comply with Title 40, Chapter 73, of the Texas Administrative Code. These provide in part that no person in the United States shall, on the ground of race, color, national origin, sex, age, disability, political beliefs, or religion be excluded from participation in, or denied any aid, care, service or other benefits provided by federal and/or state funding, or otherwise be subjected to discrimination. The contractor also agrees to comply with Health and Safety Code Section 85.113 (relating to workplace and confidentiality guidelines regarding AIDS and HIV). The contractor hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement. 1 IV. CIVIL RIGHTS POLICY COMPLIANCE (Continued) B. This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants and loans of federal funds, reimbursable expenditures, grant or donation of federal property and interest in property, the detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration; or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease or furnishing of services to the recipient, or any improvements made «rith federal financial assistance extended to the program applicant by the TDHS. This includes any federal agreement, arrangement, or other contract which has as one of its purposes the provision of cash assistance for the purchase of food, and cash assistance for purchase or rental of food service equipment or any other financial assistance extended in reliance on the representation and agreements made in this assurance. C. The Contractor agrees to compile data, maintain records, and submit reports as required, to permit effective enforcement of the above Acts and permit authorized TDHS, USDA and FCS personnel during normal working hours to review such records, books, and accounts as needed to ascertain compliance with the above Acts. If there are any violations of this assurance, TDHS, USDA and FCS have the right to seek judicial enforcement of this assurance. This assurance is binding on the Contractor, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from the department. The person whose signature appears on this contract is authorized to sign this assurance on the behalf of the Contractor. D. A religious or charitable organization is eligible to be a contractor on the same basis as any other private organization. The contractor retains its independence from State and local governments, including the contractor's control over the definition, development, practice, and expression of its charitable or religious beliefs. Except as provided by federal law, TDHS shall not interpret this contract to require a charitable or religious organization to alter its form of internal governance or remove religious art, icons, scripture, or other symbols. Furthermore, if a religious or charitable organization segregates the government funds provided under the contract, then only the financial assistance provided by these funds will be subject to audit. However, neither TDHS's selection of a charitable or faith -based contractor of services nor the expenditure of funds under this contract is an endorsement of the contractor's charitable or religious character, practices, or expression. The purpose of this contract is the provision of services; no State expenditures have as their objective the funding of sectarian worship, instructions, or proselytization. A charitable or faith -based provider of services under this contract shall reasonably apprise all assisted individuals of the following: "Neither THDS's selection of a charitable or faith -based provider of services nor the expenditure of funds under this contract is an endorsement of the provider's charitable or religious character, practices, or expression. No provider of services may discriminate against you on the basis of religion, a religious belief, of your refusal to participate in a religious practice. If you object to a particular provider because of its religious character, you may request assignment to a different provider. If you believe that your rights have been violated, please discuss the complaint with your provider or notify your local TDHS Special Nutrition Programs office. Section 104 of The Personal Responsibility and Work Opportunity Reconciliation Act of 1996.42 U.S.C. § 604a, sets forth certain additional rights and responsibilities for chantable and faith -based providers of services, certain additional rights of assisted individuals, and certain additional responsibilities of TDHS to these providers and assisted individuals. This contract is subject to those additional rights and responsibilities. 1y TDHS CLAIMS PAYMENT A. TDHS will, subject to the federal appropriation and availability to TDHS of sufficient funds for the applicable program, make program payment to the Contractor in accordance with the terms of this agreement. No reimbursement shall be made for performance under this agreement occurring prior to (a) the beginning effective date of this agreement or (b) a later date established by TDHS based on the date of receipt of a fully executed copy of this agreement. B. In accordance with Section 403.055(h) of the Government Code, the contractor agrees that any payments due to the contractor under this contract will be first applied to any debt and/or back taxes the contractor owes the State of Texas. Payments will be so applied until such debts and back taxes are paid in full. This clause does not apply if federal law requires payment to be made to the contractor for goods and services provided in support of any of the USDA child and adult nutrition programs, and may not apply if federal law conditions the receipt of the money for these goods or services to the state on the basis of payment being made to the contractor. VI. IMMIGRATION The Contractor agrees to comply with the requirements of the Immigration Reform and Control Act of 1986 regarding employment verification and retention of verification forms for any individuals hired after November 6, 1986, who will perform any labor or services under this contract. VII. CERTIFICATION A. Regarding Debarment, Suspension, Ineligibility, or Voluntary Exclusion For Covered Contracts - The contractor certifies, by execution of this agreement, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in this contract by any federal department or agency or by the State of Texas. By making this certification the contractor agrees to the following terms: 1. The above certification is a material representation of fact upon which reliance was based when this contract was entered into. If it is later determined that the contractor knowingly rendered an erroneous certification, in addition to other remedies available to the federal government, the Department of Health and Human Services, United State Department of Agriculture or other federal department of agency, or the Texas Department of Human Services may pursue available remedies, including suspension and/or debarment. 2. The contractor shall provide immediate written notice to the person to which this certification is submitted if at any time the contractor learns that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 3. The words "covered contract," "debarred," suspended," "ineligible," "participant," "person," "principal," "proposal," and voluntarily excluded," as used in this certification have meanings based upon materials in the Definitions and Coverage sections of federal rules implementing Executive Order 12549. Usage is defined in the attachment. 4. The contractor agrees by submitting this certification that, should the proposed covered contract be entered into, it shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, and/or the Texas Department of Human Services, as applicable. 5. The contractor further agrees by submitting this certification that it will include TDHS Form 2046 titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts" without modification, in all covered subcontracts and in all solicitation for all covered subcontracts. 6. A contractor may rely upon a certification of a subcontractor that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered contract, unless it knows that the certification is erroneous. A contractor must, at a minimum, obtain certificates from its covered subcontractor upon each subcontractor's initiation and upon each renewal. 7. Nothing contained in all the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this certification document. The knowledge and information of a contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. S. Except for contracts authorized under paragraph 4 of these terms, if a contractor in a covered contract knowingly enters into a covered subcontract with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the federal government, Department of Health and Human Services, United States Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Human Services may pursue available remedies, including suspension and/or debarment. VII. CERTIFICATION (Continued) B. Regarding Federal Lobbying - This certification applies only to this contract and is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than S 10,000 and not more than $100,000 for each such failure. The contractor certifies, to the best of his or her knowledge and belief; that: No federally appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection writh the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment; or modificatiorrof any federal -contract; grant, loan; or cooperative agreement. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer -or employee of Congress, or an employee of a member of Congress in connection with this federally funded contract, subcontract, subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. The contractor shall require that the language of this certification be included in the award documents for all covered subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all covered subrecipients shall certify and disclose accordingly. C. The contractor certifies that if it is a corporation, it is either a for -profit corporation that is not delinquent in its franchise tax payments to the State of Texas, or is a non-profit corporation or is otherwise not subject to payment of franchise taxes to the State of Texas. D. The contractor certifies that all information submitted pursuant to this agreement is true and correct. The contractor understands that the deliberate misrepresentation or withholding of information is a violation of this contract and may result in prosecution under applicable state and federal statutes. E. Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in this contract, bid, or application is not ineligible to receive the specified grant, loan, or payment and acknowledges that this contract may be terminated and payment may be withheld if this certification is inaccurate. VIII. EFFECTIVE DATE AND SIGNATURES The parties hereto in their capacities stated, affix their signatures and bind themselves for the faithful performance of the terms of this contract pursuant to participation in the following program or programs: National School Lunch Program School Breakfast Program Special Milk Program City of Lubbock Name of Contracting Organization (Please print or type) L L. Name of Official Signing Please print or type) ttest To: Kaythie Darnell Child and Adult Care Food Program Summer Food Service Program Signature of chairman of the board of directors or other official who has been authorized to sign contracts oh behalf of the contracting organization_ nJ=Q_ Title of'Official (Please print or type) TEXAS DEPARTMENT OF HUMAN SERVICES Effectiv fro D� until terminated. By: Date: Represe ve Approved for Form by OGC: Revised December, 1999 APPROVED AS TO FOR -1: illiam de Haas Competition and Contracts Manager APPROVED AS TO CONTENT: Tommy G zale Assistant City Manager TEXAS DEPARTMENT OF HUMAN SERVICES SPECIAL NUTRITION PROGRAMS AGREEMENT STATE OF TEXAS COUNTY OF TRAVIS § The Texas Department of Human Services, hereinafter referred to as TDHS, Kvi-i7 City of Lubbock hereinafter referred to as the. Contractor, der hereby make and enter into this contract, as required by the National School Lunch Act and the Child Nutrition Ad, as amended, and the follo%ving program regulations: the National School Lunch Program (NSLP), 7 Code of Federal Regulations (CFR) Part 210; the Special Milk Program (SNP), 7 CFR Part 215; the School Breakfast Program (SBP), 7 CFR Part 220; the Summer Food Service Program (SFSP), 7 CFR Part 225; and the Child and Adult Care Food Program (CACFP) 7 CFR Part 226. This agreement specifies the rights and responsibilities of TDHS and the Contractor pursuant to the Contractor's participation in one or more of the above named programs as stipulated herein. By signing this agreement, both parties are bound by its terms and conditions from its beginning effective date until terminated in accordance with this agreement. I. MUTUAL AGREEMENTS The Parties mutually agree: A. If the Contractor fails to provide services in accordance with the provisions of this contract, TDHS may, upon written notice of default to the Contractor, immediately terminate the whole or any part of this contract, including refusal to pay claims for reimbursement, and such termination shall not be an exclusive remedy but shall be in addition to any other rights and remedies provided by law or under this contract. B. If federal or state laws or other requirements are amended or judicially interpreted so that the continued fulfillment of this contract, on the part of either party, is substantially unreasonable or impossible, or if the parties are unable to agree upon any amendment which would therefore be needed to enable the substantial continuation of the services contemplated by this contract then, the parties shall be discharged from any further obligations created under the terms of this contract, except for the equitable settlement of the respective accrued interest or obligations, including audit findings, incurred up to the date of termination. C. This contract may be canceled by mutual consent. Ho%vever, if such mutual consent cannot be attained, then and in that event, either party to this contract may consider it to be canceled without cause by giving thirty (30) days notice in writing to the other party and this contract shall thereupon be canceled upon the expiration of such thirty (30) day period 'Nothing in this paragraph shall be construed to prohibit immediate cancellation pursuant to above paragraphs A and/or B. H. CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT A. The Contractor will comply with the applicable regulations for its designated program, as well as 7 CFR Parts 245 and 250, as amended, the Uniform Federal Assistance Regulation (7 CFR, 'Part 3015, as amended), Audits of State, Local Governments, and Non -Profit Organizations (7 CFR 3052, as amended)and state policies and procedures as issued and amended by TDHS. The Contractor further agrees to perform as described in its application (including its Policy statement and supporting documents, and approved amendments to the application) for participation in the designated program. II. CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT (Continued) B. The Contractor accepts final administrative and financial responsibility for food service operations in each school, summer feeding site, and child and/or adult care facility, hereinafter referred to as a site, operated or sponsored by the Contractor. The responsibility includes any audit exceptions or payment deficiency in the program covered by this contract, and all subcontracts hereunder, which are found after monitoring or auditing by TDHS or USDA and will be responsible for the collections and payback of any amount paid in excess of the proper claim amount. C. The Contractor submits for TDHS approval only those applications for sites which have delegated the authority for the administration of food service operations to the Contractor or which have executed subagreements with the Contractor for the administration of food services operations. D. Contractors participating in the NSLP agree 1. that the official signing the Claim for Reimbursement will be responsible for reviewing and analyzing meal counts to ensure accuracy and compliance with federal regulations 2. to enter into an agreement -to rcceive-donatc&fodds asrequired-by federal regulations, and 3. to price lunch as a unit E. Contractors participating in the CACFP provide or accept responsibility for the provision of organized, non-residential child day care and will immediately report to The Texas Department of Protective and Regulatory Services (TDPRS) Licensing or Child Protective Services staff, any suspected violations of TDPRS Licensing standards or suspected abuse of children in sponsored centers or day homes. III. RECORD KEEPING A. The Contractor will keep financial and supporting documents, statistical records, and any other records pertinent to the services for which a claim was submitted in the manner and detail prescribed by TDHS. The records and documents will be kept for a minimum of 3 years and 90 days after the termination of the federal fiscal year for the relevant program. If any litigation, claim, or audit involving these records begins before such period expires, the Contractor will keep the records and documents for not less than 3 years and 90 days and until all litigation, claims or audit findings are resolved. The case is considered resolved when there is a final order issued in litigation, or a written agreement is entered into between TDHS and the Contractor. The Contractor will keep records of non -expendable property acquired under the contract for 3 years and 90 days after final disposition of the property. B. The Contractor and its subcontractors will allow TDHS and USDA officials and other appropriate officials determined by TDHS to inspect facilities and records and to audit, examine, and copy records at any reasonable time. This includes access to all records of costs paid, even in part, by TDHS. IV. CIVIL RIGHTS POLICY COMPLIANCE A. The Contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (Public Law 88-352) and all requirements imposed by the regulations of the Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR Parts 42 and 50) and FNS directives or regulations issued pursuant to that act and the regulations. Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112), the Americans with Disabilities Act of 1990 (Public Law 101-336), Title IX of the Education Amendments of 1972 (7 CFR Part 15a), the Age Discrimination Act of 1975 (Public Law 94- 135), and all amendments to each, and all requirements imposed by the regulations issued pursuant to these acts. In addition the contractor agrees to comply with Title 40, Chapter 73, of the Texas Administrative Code. These provide in part that no person in the United States shall, on the ground of race, color, national origin, sex, age, disability, political beliefs, or religion be excluded from participation in, or denied any aid, care, service or other benefits provided by federal and/or state funding, or otherwise be subjected to discrimination. The contractor also agrees to comply with Health and Safety Code Section 85.113 (relating to workplace and confidentiality guidelines regarding AIDS and HIV). The contractor hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement. IV. CIVIL RIGHTS POLICY COMPLIANCE (Continued) This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants and loans of federal funds, reimbursable expenditures, grant or donation of federal property and interest in property, the detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease or furnishing of services to the recipient, or any improvements made with federal financial assistance extended to the program applicant by the TDHS. This includes any federal agreement, arrangement, or other contract which has as one of its purposes the provision of cash assistance for the purchase of food, and cash assistance for purchase or rental of food service equipment or any other financial assistance extended in reliance on the representation and agreements made in this assurance. C. The Contractor agrees to compile data, maintain records, and submit reports as required, to permit effective enforcement of the above Acts and permit authorized TDHS, USDA and FCS personnel during normal working hours to review such records, books, and accounts as needed to ascertain compliance with the above Acts. If there are any violations of this assurance, TDHS, USDA and FCS have the right to seek judicial enforcement of this assurance. This assurance is binding on the Contractor, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from the department. The person whose signature appears on this contract is authorized to sign this assurance on the behalf of the Contractor. D. A religious or charitable organization is eligible to be a contractor on the same basis as any other private organization. The contractor retains its independence from State and local governments, including the contractor's control over the definition, development, practice, and expression of its charitable or religious beliefs. Except as provided by federal law, TDHS shall not interpret this contract to require a charitable or religious organization to alter its form of internal governance or remove religious art, icons, scripture, or other symbols. Furthermore, if a religious or charitable organization segregates the government funds provided under the contract, then only the financial assistance provided by these funds will be subject to audit. However, neither TDHS's selection of a charitable or faith -based contractor of services nor the expenditure of funds under this contract is an endorsement of the contractor's charitable or religious character, practices, or expression. The purpose of this contract is the provision of services; no State expenditures have as their objective the funding of sectarian worship, instructions, or proselytization. A charitable or faith -based provider of services under this contract shall reasonably apprise all assisted individuals of the following: "Neither THDS's selection of a charitable or faith -based provider of services nor the expenditure of funds under this contract is an endorsement of the provider's charitable or religious character, practices, or expression. No provider of services may discriminate against you on the basis of religion, a religious belief, or your refusal to participate in a religious practice. Ifyou object to a particular provider because of its religious character, you may request assignment to a different provider. If you believe that your rights have been violated, please discuss the complaint with your provider or notify your local TDHS Special Nutrition Programs office. Section 104 of The Personal Responsibility and Work Opportunity Reconciliation Act of 1996.42 U.S.C. § 604a, sets forth certain additional rights and responsibilities for charitable and faith -based providers of services, certain additional rights of assisted individuals, and certain additional responsibilities of TDHS to these providers and assisted individuals. This contract is subject to those additional rights and responsibilities. V. TDHS CLAIMS PAYMENT A. TDHS will, subject to the federal appropriation and availability to TDHS of sufficient funds for the applicable program, make program payment to the Contractor in accordance with the terms of this agreement. No reimbursement shall be made for performance under this agreement occurring prior to (a) the beginning effective date of this agreement or (b) a later date established by TDHS based on the date of receipt of a fully executed copy of this agreement. B. In accordance with Section 403.055(h) of the Government Code, the contractor agrees that any payments due to the contractor under this contract will be first applied to any debt and/or back taxes the contactor owes the State of Texas. Payments will be so applied until such debts and back taxes are paid in full. This clause does not apply if federal law requires payment to be made to the contractor for goods and services provided in support of any of the USDA child and adult nutrition programs, and may not apply if federal law conditions the receipt of the money for these goods or services to the state on the basis of payment being made to the contractor. VI. IMMIGRATION The Contractor agrees to comply with the requirements of the Immigration Reform and Control Act of 1986 regarding employment verification and retention of verification forms for any individuals hired after November 6, 1986, who will perform any labor or services under this contract. VII. CERTIFICATION A. Regarding Debarment, Suspension, Ineligibility, or Voluntary Exclusion For Covered Contracts - The contractor certifies, by execution of this agreement, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from -participating -in this contract by any federal department or agency or by the State of Texas. By making this certification the contractor agrees to the following terns: 1. The above certification is a material representation of fact upon which reliance was based when this contract was entered into. If it is later determined that the contractor knowingly rendered an erroneous certification, in addition to other remedies available to the federal government, the Department of Health and Human Services, United State Department of Agriculture or other federal department of agency, or the Texas Department of Human Services may pursue available remedies, including suspension and/or debarment. 2. The contractor shall provide immediate written notice to the person to which this certification is submitted if at any time the contractor learns that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 3. The words "covered contract," "debarred," suspended," `ineligible," "participant," "person," "principal," "proposal," and voluntarily excluded," as used in this certification have meanings based upon materials in the Definitions and Coverage sections of federal rules implementing Executive Order 12549. Usage is defined in the attachment. 4. The contractor agrees by submitting this certification that, should the proposed covered contract be entered into, it shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, and/or the Texas Department of Human Services, as applicable. 5. The contractor further agrees by submitting this certification that it will include TDHS Form 2046 titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts" without modification, in all covered subcontracts and in all solicitation for all covered subcontracts. 6. A contractor may rely upon a certification of a subcontractor that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered contract, unless it knows that the certification is erroneous. A contractor must, at a minimum, obtain certificates from its covered subcontractor upon each subcontractor's initiation and upon each renewal. 7. Nothing contained in all the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this certification document. The knowledge and information of a contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. S. Except for contracts authorized under paragraph 4 of these terms, if a contractor in a covered contract knowingly enters into a covered subcontract with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the federal government, Department of Health and Human Services, United States Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Human Services may pursue available remedies, including suspension and/or debarment. .. i VII. CERTIFICATION (Continued) B. Regarding Federal Lobbying - This certification applies only to this contract and is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than S 10,000 and not more than $100,000 for each such failure. The contractor certifies, to the best of his or her knowledge and belief, that: No federally appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an offices or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the malting of any federal loan, the enteringinto of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federally funded contract, subcontract, subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. The contractor shall require that the language of this certification be included in the award documents for all covered subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all covered subrecipients shall certify and disclose accordingly. C. The contractor certifies that if it is a corporation, it is either a for -profit corporation that is not delinquent in its franchise tax payments to the State of Texas, or is a non-profit corporation or is otherwise not subject to payment of franchise tares to the State of Texas. D. The contractor certifies that all information submitted pursuant to this agreement is true and correct. The contractor understands that the deliberate misrepresentation or withholding of information is a violation of this contract and may result in prosecution under applicable state and federal statutes. E. Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in this contract, bid, or application is not ineligible to receive the specifier) grant, loan, or payment and acknowledges that this contract may be terminated and payment may be withheld if this certification is inaccurate. EFFECTIVE DATE AND SIGNATURES The parties hereto in their capacities stated, affix their signatures and bind themselves for the faithful performance of the terms of this contract pursuant to participation in the following program or programs: National School Lunch Program School Breakfast Program Special Milk Program City Cif Liihhnnk Name of Contracting Organize ' (Please t e) t;qindy)Si4tn Name of Official Signing (Please print or type) I Attest To:j�l.l^Q Gtlma Kaythie Darnell Child and Adult Care Food Program Summer Food Service Program Signature of chairman of the board of directors or other official who has been authorized to sign contracts on behalf of the contracting organization: Mayor - Tide of Official (Please print or type) TEXAS DEPARTMENT OF HUMAN SERVICES Effective,fro — OOC7 until terminated By: Date: 5-1111070 �rr-s, Approved for Form by OGC: Revised December, 1999 APPROVED AS3? FORI: : illiam de fraas Competition and Contracts Manager APPROVED AS TO CONTENT: Q1zzn4,4 &4A&6e- Tommy Gon alez Assistant City Manager Texas Department of Human Services SUMMER FOOD SERVICE PROGRAM APPLICATION FOR PARTICIPATION Give as much Information as possible. Attach additional sheets If needed; Identity each attachment with the name of the contracting organization." SECTION 1-SPONSOR INFORMATION —SO^ ed For Breakfast n A.M. Form 1506fJanu 2000 FOR OHS STAFF ONLY 7!��-2—/CUT o FY f) C 0 nch ❑ P.M. Supp. ❑ Supper n All ContractingLCanizaGk6\e 10 No. J 17S�00o's 6W (exas eleph( ) - II 7S-.4 8 Hotli SU o��J —O6%O Mailing A ss (Street or P.O. Box, City, State, ZIP) o Qox rJc�o b 0Ck i q L+5 Street Address (if different) E-mail Address bbs ,1 • t . bf)c •�4x. Name of Administrator Title N e o1.8FSP Contact Pe Telephone of Contact Person (include Area e) O ��5 80 7 -a67g f A. Contractor Classification (Check all that apply): Residential/Nonresidential es, nit of Government -Contractor certifies that all food ❑ National Youth Sports Program ❑Summer Camp rvice sites are operated directly by the contractor. Continuous Calendar ❑ School Food Authority ❑ School Year ❑ Private Non-profit B. Is your program a year-round program?.............................................................................. ❑ Yes ® No C. Type of Contractor. " Public Entity Is your agency considered to be state ownedloperated? .......................................................... _ . ❑ Yes E4No Do you deposit your program reimbursement directly into the State Treasury? ........... ........................ ❑ N/A ❑ Yes [D No Do you deposit your program reimbursement into a local bank? ...:. , . .... ❑ N/A ® Yes ❑ No If yes, is it direct deposit?....................................................................................... []Yes " No ❑ Private Nonprofit Organization -Tax-exempt status established. Attach letter of determination (IRS 501-30) of tax-exempt status from IRS. Do you deposit your program reimbursement into a local bank?......... ❑ N/A [I Yes ❑ No ....................................... If yes, is it direct deposit?....................................................................................... ❑ Yes ❑ No D. Does the organization provide an ongoing year-round service to the community that is to be served by the Summer Food Service Program(SFSP)?....................................................................... lzlyes [I No if no, which of the following circumstances applies? ❑ Residential Camp ❑ Failure to operate would deny program to a poor area ❑ Serves Migrant Children ❑ Failure to operate would deny a significant number of children access to program E. Does the organization expend $300,000 or more in federal funds yearly? .......................................... 1.9 Yes ❑ No Attach a copy of the audit covering last year's program operation or documentation that an audit conforming with SFSP policy will be conducted, including the date it will be conducted. Form 1506 Page 2 SECTION Il—BUDGET A. Estimate all SFSP costs which will be claimed for reimbursement for the program vear: 1. ESTIMATED OPERATIONAL COSTS PROGRAM YEAR COSTS Program Labor tt 1 41 Fringe Benefits Food -isq, I a Non-food Supplies boo Utilities Rent Equipment Use Fee Rental of Equipment Rate per mile Transportation Other (specify): Other (specify): Other (specify): TOTAL 1: I� 3 2. ESTIMATED ADMINISTRATIVE COSTS PROGRAM YEAR COSTS Administrative Labor (Management, Monitor, Clerical) /� 10 �6 Fringe Benefits IF-Sg Rental of Office Space Utilities Office Supplies b b Office Building Maintenance Equipment Use Fee Audit Fees Legal Fees Rate per mile Transportation 3 i X Shoo 1 3 5 a Other (specify): a Other (specify): TOTAL 2: B. Indicate projected income to the food service from all sources other than SFSP reimbursement. Identify exactly the costs this income will cover. (Do not include state or federal funds.1 Source of Income Amount will be used for. Source of In meR Amount Will be used for. SECTION III —MANAGEMENT PLAN A. List administrative level personnel who will be responsible for management and monitoring of the SFSP. (Do not include site cnnervisors_ cooks_ ianitors or other personnel involved in on -site food service.) TITLE OF POSITION NUMBER IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES -�nc�oor cc $ 1 r CAR C. Lkb�ocFS SFSP ac f- Form 15o6 Page 3 B. Are children charged separately for meals? .............................................. ...... .............. ❑ es ® No If yes, complete Form 1506, Attachment A (page 2), and submit with this application. C. Do you want to receive advance payments? For Operational Costs? ❑Yes El No For Administrative Costs? ❑Yes ®No D. If meal service is self -preparation, do you want to receive commodities? .............................................. []Yes ZNo If yes, Form 1608, Application and Agreement for Commodities, must be completed and returned with your SFSP application. SECTION IV —PROGRAM OPERATION A.1. Beginning and Ending Dates of Meal Service A.2. Number of Sites FROM: TO: B. Ust dates and topics of 5r5P twinq: • � Sri .. • I ► ��� J 1 W � . 1 � .1;11 '.A . :`� �;., 'Em M-WAIK119,771111 M-14. ra W,..M'' C. Is the organization currently contracting with a year-round food service management company? ...................... ❑Yes [ZNo If yes, submit a copy of your procurement procedures, bid, contract, and all amendments; skip Item D. If no, complete Item D. D. Is the organization planning to contract with a food service management company? .................................. Z Yes ❑ No f yes, and the contract will exceed $10,00% attach a copy of the invitation to bid. Also give: Date of Bid Publication Place of Publication Date of Bid Opening Time of Bid Opening tf-K- co I ftT q 8 -oo Is bid expected to be $100,000 or more? B yes, give place of bid opening: Yes No Also, attach a copy of a minimum 11-day-cycle menu lgcluding all specific menus to be used. E. Attach a copy of the letterphich has been (or will be) sent by the organization to the Health Department not6ingtthem of intent to operate a Food Service Program at the site(s) indicated on the attached Site Information sheet (Form 1507). F. Are you implementing the option to allow off -site consumption of food? .............. ❑ All Sites ❑ Some Sites (Z] No Sites SECTION V—ASSURANCES A. Free Meal Policy Statement 1.The contracting organization assures the Texas Department of Human Services (DHS) that all children at the sites described on the Site(s) information Sheets for the Summer Food Service Program, will be offered the same meals with no physical segregation of, or other discrimination against, any child because of race, color, disability, age, sex, national origin, religion, or political beliefs. No separate charge will be made for any meal except in accordance with attachment A of this application. 2.The contracting organization assures DHS that, if it is sponsoring camps or other enrollment programs: • The contracting organization has or will obtain family size and income data about all children whose meals will be reported as free or reduced -price; and • The children claimed as free or reduced -price meet the current family size and income standards set by the United States Department of Agriculture, DHS Form 4504, Standards for Determining Free and Reduced -Price Eligibility. 3.If the contracting organization is sponsoring a camp or other enrollment program that charges separately for meals, the contracting organization has read Attachment A to this application, 'Additional Assurances for Camps and Other Enrollment Programs that Charge Separately for Meals", and assures DHS that all requirements have been or will be met. Form 1506 Page 4 B. Public Release I. The contracting organization will make efforts to ensure that the local news media will make a public announcement of the program and will supply them with a news release: If the contracting organization is sponsoring a camp or other enrollment program, this release must contain, at a minimum; a list of all approved sites, a list of the current standards for determining free and reduced price eligibility, and the following statement: "The (Name of the contracting organization) announces the sponsorship of the Summer Food Service Program. Income eligibility will be based on family size and income using the Standards for Determining Free and Reduced -Price Eligibility, provided by the United States Department of Agriculture. Meals will be provided at the site(s) listed. People who are eligible to participate in the program must not be discriminated against because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who believes that they have been discriminated against should write Immediately to: Director, Civil Rights Division, MC W-206, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington, D.C. 20250. NOTE: Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services." For all other programs the announcement must contain, at a minimum, a list of all approved sites and the following statement: "The (Name of the contracting organization) announces the sponsorship of the Summer Food Service Program. Meals will be provided at the site(s) listed. People who are eligible to participate in the program must not be discriminated against because of race, color, national origin, sex,. age, disability,, religion, or political belief. Anyone who believes that they have been discriminated against should write Immediately to: Director, Civil Rights Division, MC W-206, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington, D.C. 20250. NOTE: Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services." 2. This public release was or will be published in the following new NAME OF MEDIA OUTLET DATE OF RELEASE k�a� {'nai .-) s media outlet(s): NAME OF MEDIA OUTLET DATE OF RELEASE 3. Attach.a copy of the contracting organization's public release statement as submitted to the news media and any other materials used to publicize the program's availability and nondiscrimination requirements. SECTION VI-- WAIVER REQUESTS (Check all for which you are applying, submit appropriate waiver request form and documentation. ❑ Waiver to operate more than 25 sites (Nonprofit organizations only.) ❑ Waiver of the time restrictions for meal service at migrant sites. ❑ Waiver of the 15 consecutive school day requirement for year-round school program sites. SECTION VII— CERTIFICATION (see Form 1506, Attachment B) I certify that the Information on this application is true and correct to the best of my knowledge. I certify that reimbursement will be claimed only for approved meals served to eligible children during the hours they are in attendance at approved sites. I know that deliberate misrepresentation or withholding of Information may result In prosecution under applicable state and federal statutes. or pnnt) 'A0 VI, , , HOO A5 FOR DHS USE ONLY APPROVED ❑ DENIED (reason): Date 9A11rjP,,...ffl rimW�!�_ v"• , CITY of LUBBOCK SUMMER LUNCH PROGP A-N1 MENU Resolution No. 2000—R 0131 May 11, 2000 Item No. 24 Day 1 Poor Boy Sandwich 1 oz bologna 1 oz cheese 1/2oz. salami Bread, 2 slices Lertucc.'tomato 1/4 cup Apple Iwhole(l/2 c) Cookie Milk 1 cup Day 2 Peanut Butter/Jelly Sandwich 1 oz. Peanut Butter/Jelly Bread 2 slices Cheese Stick 1 oz. American Cheese Celery Sticks 114 cup ?apple 1 whole(1l2 c) Milk 1 cup Day 3 Ham & Cheese Sandwich 1 oz. Turkey Ham 1 oz. American Cheese Bread, 2 slices Orange Juice 4 oz. 100% juice Mixed Fruit 318 cup Cookie 2 each :Milk 1 cup Day 4 Pastrami/S«zss Sand%ich 1 oz. Turkey Pastraani 1 oz. Swiss Cheese Bread, 2 slices Potato Salad 1/4 cup Orange 1 whole Cookie 1 each Mille 1 cup Day S Turkey Sandwich 3 oz.=2 oz. bleat required Bread, 2 slices Lettuce & Tomato 1/4 cup Jello w/ Peaches 1/2 cup Peaches Milk 1 cup Day 6 Ham & Cheese Sandwich 1 1/2 oz. Ham Lettuce/Tomato/Pickle Chips i Peaches Cookies Milk Day 7 Bologna & Cheese Sandwich Apple Juice Pineapple Chunks Brownie Milk Day 8 Submarine Sandwich Lettuce/Totnato Orange, whole Cheese Corn Bag Milk Day 9 Peanut Butter/Jelly Sandwich Cheese Stick Carrot Sticks Apple Grape Juice Milk Day 10 Turkey Sandwich Letruce/Totnato Applesauce Orange Juice Milk Day 11 Ham & Cheese Sand«zch Potato Salad Fruit Cocktail Pickle Spear Milk 1/2 oz. Cheese Bread, 2 slices 1/4 cup 1/2 cup 2 each 1 cup 1 1/2 oz. Bologna 1/2 oz. Cheese Bread, 2 slices 4 oz. 100% Juice 318 cup 1 each 1 cup 1 1/2 oz. Bologna 1/2 oz. Cheese Hot Dog Bun 1/4 cup 1 each (1/2 cup) 1 each 1 cup 1 oz. Peanut Butter/Jelly Bread, 2 slices 1 oz. American Cheese 1/4 cup 1 whole (1/2 cup) 1/4 cup 1 cup 3 oz--2 oz. Meat required Bread, 2 slices 1/4 cup 1/4 cup 1/4 cup 1 cup 1 112 oz. Ham 1/2 oz. Cheese Bread, 2 slices 114 cup 3/8 cup 1/8 cup 1 cup Resolution No. 2000-R 0131 May 11, 2000 Item No. 24 CITY OF LUBBOCK MEMO TO: Martha Ellerbrook, Supervising Sanitarian FROM: Angie Hobbs, Indoor Supervisor DATE: 4/6/00 RE: Summer Lunch Program The City of Lubbock will once again be participating in the Summer Lunch Program for Children. The program will begin on Tuesday, May 30th and will end on Friday, August 11, 2000. Following you will find the meal service times, sites and addresses: 10:50am Rawling Community Center - 40th & Ave. B 12:15pm Simmons Community Center - 23rd & Oak 12:35pm Hodges Community Center- 42nd & Ave. U 12:50pm Trejo Supercenter - 3200 Amherst (Tuesday's lunch will be served at the Rodgers Park Pavilion) In addition to these sites, LISD will be participating in our program also from June I' through June 29`h. Below you will find the meal service times, sites and addresses: 11:30am Wolffarth Elementary - 3202 Erskine McWhorter - 2711 1" Jackson - 201 Vernon Ramirez - 702 Ave T Dupre - 2008 Ave T Bean - 3001 Ave N Brown - 2315 36" , New Release FOR ]IMMEDIATE RELEASE: Contact: Angie Hobbs, 775-2678 The City of Lubbock is pleased to announce the Summer Food Program for Children, sponsored by the Texas Department of Human Services. This program is provided through the City of Lubbock Parks and Recreation Department, under the direction of Civic Services. The program will provide a nourishing noon meal to youngsters age one through eighteen. Meals will be served Monday through Friday, beginning May 30th and ending August 11, at four locations at the following locations and times. Mae Simmons Community Center - 23rd & Oak- Meal Service, 12:15am Copper Rawlings Community Center - 40th & Ave. B -Meal Service, 10:50 am Hodges Community Center — 42nd& Ave U. - Meal Service, 12:35pm Maggie Trejo Supercenter - 3200 Amherst - Meal Service, 12:50pm Beginning June 5 and ending June 29`h, meals will be served Monday through Friday, at 11:30am at the following locations: Wolffarth Elementary - 3202 Erskine McWhorter Elementary - 2711 1st Jackson Elmentary - 201 Vernon Ramirez Elementary - 702 Ave T Dupree Elementary - 2008 Ave T Bean Elementary - 3001 Ave N Brown Elementary - 2315 36th Children who are eligible to participate in this program must not be discriminated against on the basis of race, color, national origin, age, religion, sex, disability, or political beliefs. Anyone who believes he or she has been discriminated against, should write to: Director, Civil Rights Division, MC W-206, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington, D.C. 20250. NOTE: Discrimination complains based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services." Resolution No. 2000-R 01 PERCENTAGES OF STUDENTS ON FREE OR REDUCED -PRICE LUNCH AS OF FALL PEIMS SNAPSHOT, OCTOBER 29, 1999 FREE % RED. PRICE% TOTAL FIR % ARNETT 83.7% 9.9% BALLENGER 81.3% 17.9% 99.2% BAYLESS 51.9% 13.8% 65.7% 89.0% 7.3% EWA BOWIE 25.4% 15.5% 40.9% BOZEMAN 93.9% 2.9% 96.8% 67.2% 17.6%i°c WE 78.9% 11.9% 1 90".8° . GUADALUPE 73.5% 9.8% 83.3% HARDWICK 26.4% 13.2% 39.6% y� 89.4% 7.3% �'t-`f,�o?� HAYNES 18.8% 8.2% 27.0% HODGES 74.9% 13.8% 88.7% HONEY 6.6% 3.7% 10.3% MW 88.2% 5.5% 0 3.7 7) ILES 78.2% 10.6% 88.8% LE 88.5% 6.3% 1[CTORTF 78.6% 14.3%8T9 MAEDGEN 41.4% 13.3% 54.7% MARTIN 82.4% 16.4% 98.8% MURFEE 10.8% 2.9% 13.7% OVERTON 47.9% 24.7% 72.6% PARKWAY 91.5% 5.4% 96.9% PARSONS 31.8% 14.1 % 45.9% POSEY 92.8% 4.5% 97.3% IgRE=2 83.7% 8.3% Como RUSH 32.3% 11.0% 43.3% SMITH 5.1% 2.2% 7.3% STEWART 36.0% 13.0% 49.0% STUBBS 58.2% 16.4% 74.6% TUBBS 65.6% 14.1 % 79.7% WATERS 15.8% 11.5% 27.3% WESTER 52.6% 12.4% 65.0% WHEATLEY 88.4% 6.9% 95.3% WHEELOCK 53.5% 16.6% 70.1 % WHITESIDE 5.3% 4.7% 10.0% WILLIAMS 21.7% 11.3% 33.0% WILSON 24.4% 9.9% 34.3% AMAMZF,A_�,� � 78.1 % 13.5% 9 6 WRIGHT 63.5% 16.1% 79.6% Resolution No. 2000-R 0131 I i00L DISTRICT ENCOMPASSES NCRTH DISTRICT LINE r$ 3L:lE=iEL0 STRE:T 5 SQUARE MILES.- Ursul,ne St , , i 'ROXIMATE VALUE OF ` r� - ERNE-� I0PROPERTIES I sy WEANEa a' .�� a` `" O L i �Yci Pc ` )7 MILLION. wO3.87 ACRES.I ErSfttne Si 1 Addoff —_ ToA� E'SKin e Q ®I5CHCCL PLANT pJ.., CIRECC'VAZ_.S M' _fit, TU885N �N/GUAOAL'J E TRa J ELE!A. I _ewH.0AC't RTER ELE%c r ! 5 ^ 'L M.liY aELE. i EI.JEa?SCN '!?CT-E., ;E'.t_ 41h =t. ! I E NZIE JR. ril � RA w li / aaGc�. PCSEV .tAR'tN C'<NT'ca v I BrppdwpV HAROWICK RUSH I ! ELF?, HE40 ELEM. ELEM. AOMINIST ATIVE START / L'J880CK OFFICES I d H hwpv 119m 51. 19th St p r 9tn �r I ■OUPRE E'_Eu PgCJECT INTERCEPT c+E� 'NILSCN ELEM .I N10,'ENTER LCHGPMAN A LISD - T! . WILSON OVERTON I ( !LES SLATON dEAN iL_M cLc;a. �• .I NEa? JH. ; ,f BOWIE I JR.Ht� ME! VA.HUTCHINSCN zemMCORON, 1 JR.HIELEMoAFFM"34th SI.00 SR. HI MApTIN ATC i I 'LAM. I 3.:th C_t I FFA. FARM I STUBBS ELEM. BROWN ELEM.' ALLENGER ^!STg19UT'CN CENTER �✓ 'BAI'YION WHEELOCX ELEM ttal HEAD START, ,.__ „ voc I ` SSIN I ■ a ■HARWELL ELEM. MAEOGEN ELEM. ;WEST ELEM. �W T� MONTEREY + a I 50th 55ELEM. $R. HI a I 50rh Sr. c' ` 66rh St. WILLIAMS ELEM. EVANS JR.HI �HAYNES ELEM PARSONS ELEM. No ATKIN$ ELEM. �JR.HI BAYLESS LEM. E TRANSPORTATION i � 6olh S MURFE- FIELD Y�� I,.--.._.r__.�_�... fM.loe ` \ a WHITESIOE a ,; d WATERS a 'MOEGLLEE n '2 ELEM, g a' a ELEM. N FIELD c c a' IRONS : c ® o TRACT Y o JR. HI __Jp0 1 T J tZ 82nd St 'n o 5 ro- 82nd S MAP INFORMATION AS CF JUNE. 1998 HONEY ELEM. TRACT d SMITH ELEM. a 98th St. 981h St. a i I I J 11 1 1 1 5 Resolution No. 2000-R 0131 t 4 I r. lam P9 i I Arr, M.� Fill, P 1j IVA IIJ M111! oI i al, Altl —is L �Fllf I IN I J Air F I Aw 4; it r- It r l!io"_ 1-r 1 rx — liill� I I - 1 1.1 1 1-1-1 1 I'I I.i I 1 1 6"1 L 141! YI eQ-A 1 -- �s; -s 31. ;1. 1; 1; 1; 1; WA Iti i ir dt i it 1% it itm I 1 11 !1 7 0.1i a k_1 i ALI -1L 71. IN 7�77­7— lk4 Fi 4p r 1� r---�'.esolution No. 2000— R0131 Texas Department Form 1507!January 2CC0 of Human Semces SUMMER FOOD SERVICE PROGRAM FOR OHS USE ONLY SITE INFORMATION T( Name t Food Service Site Tele none No. (Inc. AiC) E - Address of Site (Street, City, State,ZIP) �u N Lo Tic oS Period of Operation of Food Service (moldaytyr.—mo.ldayryr.) Number of Op- May June Jury Aug. Sept. From: -$Ur1'e 5 a2= through: 7 ne a 1 erating Days: � d ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children 1. Indicate Type of Site: ❑ (serving one to thret meals) ❑(serving one to three meals) ❑Nonresidential Camp m Other Site (serving one to three meals) (serving one or two meals) 2. List ALL counties served by this site: L L L1 �- 3. A. Is your site open?............................................................................ ©Yes �No S. Is your site enrolled?.......................................................................... L Yes No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Section 2).......................................... q ( . 3 % D. If open sites, submit documentation supporting this percentage figure (such as census data, school data). For open sites using school data. list the schools used to document site eligibility; attach formula used by school dirt. to establish percentage of free & reduced price children. E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP Handbook, Section 2.) If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free and reduced -price meals for the site? .................................... 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ [—]Yes [D-No 5. If yes, give name of contracting organization: lonitoring Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within: k. First week of Operation B. First Four weeks of Operation C. Additional Reviews T4•�� S Z"k��9� .SOW (4,He s -- 5L.,ve 2_?Vocl fuwG ,, z 7 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF EUGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch �r•3� 2'. 7v Pjkt. Supplement i Supper % -Tr" IntoRnaoon 1S Wn57Rereg oy Nna rrnen aemng uie appprrovcu rncm a & vw corm. %QrJr nacu:uvun, accaon eq 7. Do you plan to feed children undertone: (1) year )d? ........... .................. ..:- ❑Yes ,� No _.". 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) Ilf-Preparation VendeQlsing School Using Food Service Management Company Using Private Non -Profit n On Site 7 Central Kitchen n Food Authority excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep Form 1507 Page 2 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cateteda-style Children are Seated Children Line Up ❑ Meal Service sand are Given Meals ❑ and Pick Up Meals ❑ Other. B. If using cafeteria -style meal service and I sponsor is a school food authority, will the site be implementing offer vs. serve? .. ❑ Yes 21 No 10. JST Sire persunnul m+v mn uc a ivvivCu w any ezient M the meat ser nce. (arar ManCDOOK, -section Y): TrrLE OF POSMON ( NO. IN POSMON I SPECIFIC FOOD SERVICE PROGRAM OUTIES 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2) Indoor Meal Meal Service El Service ❑ Will Be Cancelled ❑ Other: 12. Is this site implementing the option to allow off -site consumption of food? .................................................... []Yes IoNo 13. Are meals delivered to the site? ..................... ............................................. es ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ............................... []Yes r5.7', No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. . 0AA c� S+C-eI vim. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored In Refrigerator Thrown Away Returned to Vendor and Served the Next Day ❑at the Site [I for Disposal ❑Other. I CERTIFY that the Information on this form Is true and correct to the best of my knowledge. I certify that this site has been visited and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation withholding of Information may result in prosecution under applicable state and federal statutes. Name of Contracting Organization Eeinart idai of Contractna Organization Date Name of _'al (please type or 1lI�e7�i;�� t ,2J V, 021�2 l�Irrl��lr�i��lr � FOR gApproved ❑Denied, reason: DHS USE Tina ONLY 2r Signature-DHS Representa e D B Resolution No.2000—R 0131 Texas Department of Human Services Name SUMMER FOOD SERVICE PROGRAM SITE INFORMATION For.. 15071Januar FCR OHS US-. ONLY TX 2 -- Cp i ❑ R I Teie^none No. tint. AX) 76 6 Address of Site (bcreet. %_+ry. QUM, Girl — a s c� 64 7k Period of Operation of Food Service (moJdayryr.-mo4daytyr.) Number of Op- May June Jury Auq. (Sapt. From: Sun S through: S� t �% &0 crating Days: Q 0 y v ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children 1. Indicate Type of Site: ❑ (serving one to three meals) ❑(serving one to three meals) ❑Nonresidential Camp Other Site (serving one to three meals) © (serving one or two meals) 2. List ALL counties served by this site: L �,l � 6 CCJ< 3. A. is your site open?........................................................................... . FjYes� No S. Is your site enrolled?.......................................................................... .� � Yes ER No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Section 2).......................................... D. If open sites, submit documentation supporting this percentage figure (such as census data, school data). For open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced price children. N ¢\ E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program -refer to SFSP Handbook, Section 2.) If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free and reduced -price meals for the site? ..................................... °a 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ [I Yes l`J No If yes, give name of contracting organization: N F�- 5. Monitoring Plan (SFSP Handbook, Section 4)- Enter date of monitoring review to be conducted within: A. First week of Operation I B. First Four weeks of Operation C. Additional Reviews 3w�_S - �3 s Qo�l _ J ,_ . S - -,Tuy,03,W a w�� 5 - s u.►.Q_ ;L9 , 2 n 0y 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO B£ SERVED MEAL SERVICE TIME BEGINNING ENDING Brealdast A.M. Supplement Lunch 1 z, P P.M. Supplement I Supper I -TNS informauon LS conSiceree oy uno wnen aewnq Qic appivyc „ -- aa, ..w M-1. cr 7. Do you _plan.ta feed children undertone it ). year old? ....................................._ ... ... � ❑Yes � o N S. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) Of -Preparation I Vendetsing School Using Food Service Management Company Using Private Non -Profit r-1 nn cirri n Central Kitchen I -I Fnnd Authority IK (excludes all -year contracts with on -site oreol 7 Organization that is Self -Prep I'll —- Form 1507 Page 2 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ®and are Given Meals ❑ and Pick Up Meals ❑ Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve?..[] Yes ®No 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook.1Secton 2): TITLE OF POSITION NO. IN POSITION I SPECIFIC FOOD SERVICE PROGRAM DUTIES i 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2) Indoor Meal Meal Service IRService ❑Will Be Cancelled ❑Other: 12. Is this site implementing the option to allow off -site consumption of food? .................................................... ❑ Yes ZNo 13. Are meals delivered to the site?...................................................................................... Ryes ❑ N IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ............................... ❑ Yes %Z No If no, describe arrangements within standards presc:ibed by local health authorities for delivery and holding of meals until time of service. — "%v 16. If there is an excess of meals delivered, meals will be (SFSP Handbook. Section 2) Stored In Refrigerator Thrown Away Returned to Vendor ,Eand Served the Next Day ❑ at the Site ❑ for Disposal ❑ Other. I CERTIFY that the Information on this form Is true and correct to the best of my knowledge. l certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. �3-oa I C; 44 Date Name of Of k;ial (please type or pnnp me FOR Approved ❑Denied, reason: OHS uSE `% Title ONLY -f/t, _ �� Signature —OHS Represe uva Dafte —,,,Resolution NO. 2000—R 0131 Texas Department of Human Services SUMMER FOOD SERVICE PROGRAM Form 1507IJaruary , ci FOR OHS USE ONLY SITE INFORMATION TX �Z - �i ! I Cf R Ui Name of Semce Site lWo. (inc.A4C)tJ (Food � Ifc7 l S Address of Site ( treet. City, State, ZIP) Tx ► 1 i Pencil of Operation of Food Semce (moddayryr.—mo /dayfyq Number of Op- May June Jury Aug. Sept . From: Zt through: ' 0 grating Days: l � (� ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children ❑ ❑ 1. Indicate Type of Site: (serving one to three meals) (serving one to three meals) Nonresidential Camo Other Site ❑ (serving one to three meals) (serving one or two meals) 2. List ALL counties served by this site: LA OU K 3. A. is your site open?............................................................................ CI Yes E No B. Is your site enrolled?.......................................................................... L,..I Yes El ,No C. Site Eligibility: Enter the percentage of children eligible for free and/or q'0 reduced price meals for the site (SFSP Handbook, Section 2).......................................... 'a D. It open sites, submit documentation supporting ;his percentage figure (such as census data, school data). For open sites using school data. list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced price children. E. For enrolled sites, Farms 1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP Handbook, Section 2.) If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free and reduced -price meals for the site? .................................... 0110 4. Did the site participate in the previous years'.SFSP? (SFSP Handbook, Section 2) ............................ []Yes Z No If yes, give name of contracting organization: fV P� S. Acnitering Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within: A. First Week of Cperauon B. First Four weexs of Operation C. Additional Reviews 3 .+ 4 , Zoo e I Sc .� 5 — Itt Z31 Z000� 7t t tee. 5 — JU,>da J 1 Zoo 0 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF MEAL SERVICE TIME ELIGIBLE CHILDREN TO BE SERVED BEGINNING ENDING Breakfast A.M. Supplement Lunch g 5 I Z d p P.M. Supplement Supper i `This informatton 4s constaere(3 oy uri, wnen setung the approved menu sei-0 level. tQrar narnaaooR. JecUon e) 7. Do you plan to,feed�chitdren under one -*(I) year old? ......... .. ..! ............................................ ❑ Yesz No 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) iif-Preparation vendetsing School Using Food Service Management Company Using Private Non -Profit 7 On Site 7 Central Kitchen n Food Authority ((excludes all -year contracts with on -site preol n Organization that is Self -Prep �, �-`• Form 1507 Page 2 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service sand are Given Meals ❑ and Pick Up Meals ❑ Other. B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve?..[] Yes ZNo 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook. Section 2): WLE OF POSMON NO. IN POSMON 1 SPECIFIC F000 SERVICE PROGRAM OUTI£S 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2) Indoor Meal Meal Service Service ❑Will Be Cancelled ❑Other. 12. is this site implementing the option to allow off -site consumption of food? .................................................... ❑Yes TZ No 13. Are meals delivered to the site? ................................................... � ❑ ................................. Yes No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ............................... [:]Yes � No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. m prti lz' t-0 '11 too A Q .l 1 y_An � _ Q , Lt,1 o,v n) (an c , h �K `1,,v 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stoned In Refrigerator Thrown Away Returned to Vendor and Served the Next Day El at the Site ❑for Disposal " ❑Other: I CERTIFY that the Information on this form fs true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. i know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. / Name of Contracting Organization Signatu idol of Contracting Organization ate Name of Official (please type or print) Title FOR ppmved ❑ Denied, reason: OHS USE ONLY _C SiQnature-DHS Reores five Date N Texas Department of Human Services SUMMER FOOD SERVICE PROGRAM SITE INFORMATION "rm 15071January CO FOR OHS USE ONLY TX elepnone No. up _ / Ui aaa V. Q.- %w 4 v ,. _—, .... , ` ' q0 f"I-il V �i�kv&hi Tom- y/3 Period of Operation of Food Service (moJdaym. aday r.) Number of Op- May June Jury From:;nlb e) through: 8 /�d O crating Days: o� ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children 1. Indicate Type of Site: ❑ (serving one to three meals) ❑ (serving one to three meals) Nonresidential Camp Other Site ❑ (serving one to three meals) (serving one or two meals) 2. List ALL counties served by this site: L 4 bh O Cx 3. A. Is your site open?............................................................................ Eyes C No B. Is your site enrolled?.......................................................................... ❑ Yes �Z N 0 C. Site Eligibility: Enter the percentage of children eligible for free and/or S L, n reduced price meals for the site (SFSP Handbook, Section 2).......................................... 7, cs 'o D. If open sites, submit documentation supporting this percentage figure (such as census data, school data). For open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced price children. wyty�'L� E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP Handbook, Section 2-) If the enrolled site used school data, list the school used to document the site: IVT� F. What is the percentage of free and reduced -price meals for the site? .................................... 1 *9_ "o 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ ®Yes ❑ No 5. If yes, give name of contracting organization: donitoring Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within: a First week of operation B. First Four eeks of O ton C. Additid al Reviews 3 Gb rS D �O 3 () v1' f7 D V 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement �P Lunch 0 !z *-IS Pry P.M. Supplement Supper `This intormation is considered ay um wnen semng me approved meaj service revel. (arbr nana000K, ,becrion l) 7. Do you plan to feed children under one (1f year old? ................ ............................... ............... []Yes 1MNo 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) Self-Preparabon Vendeglsing School Using Food Service Management Company Using Private Non -Profit ❑ On Site ❑ Central Kitchen I ❑ Food Authority (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep Form Iso7 Page 2 9. A. Indicate the systemto be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up []Meal Service ❑ and are Given Meals Lq and Pick Up Meals ❑ Other: S. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve? .. ❑ Yes ,® No 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook Section 2): OF POSrriON NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES �pTiTLE o< 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2) Indoor Meal Meal Service Service []Will Be Cancelled —]Other: 12. Is this site implementing the option to allow off -site consumption of food? ................................................... ❑ Yes ®No 13. Are meals delivered to the site? ............ .................:........................... s ❑ o Ye N IF YES, COMPLETE ITEMS 14, 15, 8, 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ............................... � Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day Zit the Site ❑for Disposal ❑Other. 1 CERTIFY that the Information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. 1 know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of Contracting Organization zA/ :�A4I3 t Signaturo,qffidat.of Cbntracting Organization Date Name of Official (pi&qp we or p// /rint) Title FOR Approved ❑Denied, reason: Ofis USE l r1V TNe ONLY Aw47 ignature—DMS Repres ntative Dath Texas Cepartment of Human Services f� SUMMER FOOD SERVICE PROGRAM SITE INFORMATION Resolution No. 2000—R 0131 Form 1507/January FOR DHS USE ONLY TX 15--/Cof I CAR Name of Foos Jarvtce aue ✓QC�60 � E__k � 1pV1�u-i-I _I '(4 o 6 eanone o 24 4 Address O1 Uerno Penad or Cperauan or rota aerv,w c- tmo4oayryr.-mo.(oayryr.) May June Jury Aug. Sept. �Number of p- / O Q From: cJu_,,P. 5 through: 3-LL y �9, joc6 erating Days: Y ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children 1. Indicate Type of Site: ❑ (serving one to three meals) ❑ (serving one to three meals) Nonresidential Camp Other Site ❑ (serving one to three meals) ❑{ er+ing one or two meals) 2. List ALL Counties served by this site: LLt Wx_k 3. A. Is your site open?.......................................................................... OYes L.40 B. Is your site enrolled?.......................................................................... ;_�Yes E No C. Site Eligibility: Enter the percentage of children eligible for free and/or 44 n reduced price meals for the site (SFSP Handbook, Section 2).......................................... 7 15 0. If open sites, submit documentation supporting this percentage figure (such as census data, school data). For open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced price children. E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP Handbook, Section 2.) i If the enrolled site used school data, list the school used to document the site: - F. What is the percentage of free and reduced -price meals for the site? ..................................... _ "a 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ []Yes ,® No If yes, give name of contracting organization: N Pr 5. 7onitoring Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within: 4. First week of operation B. First Four Weeks of Operation C. Additional Reviews 5 - ?'w^e 9 f ?moo o I J w+.a_ S - J'w+,_ 23, ? 2 9 204 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN To BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch P.&I. Supplement I Supper r -ants altormaaon s wns.cerea vy una wnen semng the apprvrvu a. x,-,..o .ora.. %arar nanuwun. Jccuvn ct 7. Do yotl Plan. to feed,children under one (1� year �Id? ... _ ..... ....'..... _ ...... 1 .......... []Yes RNo 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) Self -Preparation Vendetsing School Using Food Service Management Company Using Private Non -Profit —1 n fn Site M Central Kitchen rl Food Authoritv (excludes all-vear contracts with on -site oreol n Organization that is Self -Prep Form 1507 Page 2 9. A. Indicate the systerrtto be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Sec on 2) Cafeteria -style Children are Seated Children Line Up [--]Meal Service 51 and are Given Meals ❑ and Pick Up Meals ❑ Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve? .. [:]Yes � No 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2): Tr LE OF POSITION I NO. IN POSITION I SPECIFIC FOOO SERVICE PROGRAM DUTIES 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2) Indoor Meal Meal Service ®.Service [:]Will Be Cancelled []Other: 12. Is this site implementing the option to allow off -site consumption of food? .... ....................................... . ........ []Yes &0 13. Are meals delivered to the site?...................................................................................... SYes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. 1F NO, FORM 1S COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ............................... ❑ Yes R[No If no, describe arrange) Imen(ts within standards prescribed by local health authorities for delivery and holding of meals until time of service. m,oMhn t 1i' ll 1 C AA (t rAnAi� 11 n ALA QMCY r �ifM�i/�/ lM ( 00 � k 'Jfu 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor and Served the Next Day ❑at the Site ❑for Disposal []Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of Information may result In prosecution under applicable state and federal statutes. Name of ontracting Organization Sigma Taal o ontrac.ing Organization Date Name o! Official (please type or pnnq i we FOR Approved ❑ Denied, reason: OHS USE Title ONLY Oa Signature -OHS R resentative Texas Department r1�, Form 1507/january 2000 of Human Services SUMMER FOOD SERVICE PROGRAM FOR DHS USE ONLY SiTE INFORMATION .X ❑R �U Name of Food Service Site r Telephone No. (ins A/C) Addre� f?S ^ ti et, City, State, ZIP) Period of Operation of Food Service (mo4day/yr.-m 4daytyr•) Number of Op- May �AmeJuly �Au . A Sept From: r, 130&0 through: $ (l QQ erating Days: fir) ATTACH A MAP WITH THE SITE SE ViC'E AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children 1. Indicate Type of Site: ❑ (serving one to three meals) ❑ (serving one to three meals) Nonresidential Camp Other Site ❑ (serving one to three meals) (serving one or two meals) 2. List ALL counties served by this site: Lu-6 0(_,k 3. A. Is your site open?............................................................................ 171 Yes ❑ No B. Is your site enrolled?.......................................................................... ❑ Yes ®No C. Site Eligibility: Enter the percentage of children eligible for free and/or C? . reduced price meals for the site (SFSP Handbook, Section 2).......................................... �' D. If open sites, submit documentation supporting this percentage figure (such as census data, school data). For open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free A reduced price children. E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program -refer to SFSP Handbook, Section 2.) If the enrolled site used school data, list the school used to document the site: _ N a F. What Is the percentage of free and reduced -price meals for the site? .................................... A) (:k- % 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ ®Yes ❑No If yes, give name of contracting organization: 0-1kA 30 5. Monitoring Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four weeks of operation 1 C. Additional Reviews S A o q>0 - 64 o S 3o o o-(0 23 0 5130100 - RA In r. - i r 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Brealdast _ A.M. Supplement Lunch SO Coto P P.M. Supplement Supper 'This IMormation is considered Dy Ilrt-b when setting ine approves meal service level. (-brae rianawcir, -becuon x) 7. Do you plan to feed children under one (I)- y�ar old? ......... ............................ . ....................... Dyes No ......- 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) Self -Preparation Vendetsing School Using Food Service Management Company Using Private Non -Profit ❑ On Site ❑ Central Kitchen ❑ Food Authority ,(excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep Forth 1507 Page 2 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals � and Pick Up Meals ❑ Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve?.. ❑ Yes []No 10. List site personnel who will be involved to anv extent in the meal service. (SFSP Handbook. Section 2)- TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES 6w'. ' r 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2) Indoor Meal Meal Service Service ❑Will Be Cancelled ❑Other: 12. Is this site implementing the option to allow off -site consumption of food? .................................................... []Yes ® No 13. Are meals delivered to the site? ............. .. .......................................... ............... ® Yes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM iS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Adminlstrative Site Personnel Will Communicate FD Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ............................... ®Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor ❑and Served the Next Day ®at the Site ❑tor Disposal QOther: i CERTIFY that the Information on this form is true and correct to the best of my knowledge. i certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. y Name of Contracting Organization Sig re-0fraial of Contracting Organization Date Name of icial (please type or pnn. i jue_! FOR��pproved ❑Denied, reason: DHS USE TNe ONLY yl2�16V Signature—DHS a enWve Oafe (00,11 (3esolution No. 2000-RO131 Texas Department Form 1S071January 2^00 of Human Services SUMMER FOOD SERVICE PROGRAM FOR OHS USE ONLY SITE INFORMATION TX Z— O0 ❑R Name of Food Service Site I Teiepncre No. (mc..VC) Address of Site (Street, City, State, ZIP 9-711 Period of Cperawn of Food Service (moddayryr.-m 4daylyr.) Number of 0 May June Jury Au/`Scot. From: _'AIL IL 5 through: Ickmp ;9, 2e6q crating Days Y O � /oJ � O �V � r-) ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED. Residential Camp Site Serving Primarily Migrant Children 1. Indicate Type of Site: ❑ (serving one to three meats) ❑ (serving one to three meals) ❑Nonresidential Camp Other Site (serving one to three meals) jj LXj (serving one or two meals) 2. 11st ALL counties served by this site: l 3. A. is your site open?............................................................................ ®Yes - No 8. Is your site enrolled?........................................................................ . .� .Yes I- I No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Section 2).......................................... D. If open sites, submit documentation supporting this percentage figure (such as census data, schcci data). For open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced price children. .1mmkort-f- r- E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program -refer to SFSP Handbook, Section 2.) If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free and reduced -price meals for the site? ... ............................... . 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ []Yes Le�ijNo If yes, give name of contracting organization: N 5. Monitoring Plan (5F5Y Handbook, Section 4)— Enter date of monitonng review to be conducted within: A. First week of operation fj. First Four Weeks of Operation I C. Addition! Reviews SuJ4, 5- -:yLVCj_q, Z00(I TGxv' 5 -< ►ate al.2aZMU'A D. S- 7&- zoo 0 6. Meat Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement I Lunch 114 0 AAA ! �' • 3 /y1 P.M. Supplement ` Supper 'This information m consraerea oy uns wnen semng me approveu moo ao ,iw wrvg. %error n4nuuvur<, aecuon e) 7. Do you plan,to feed children%nder:one.(1) year old? ............ .... .. ..... []Yes ®No S. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) Self -Preparation vende�lsing School Using Food Service Management Company Using Private Non -Profit I-'1 n., ca. n r'.ntrel vitrh.n M I:nnA Mithnrity lexcludes all-vear rnntrarta with e%n.cit• nren) I 1 Organization that ie 4elf.pren Form 1507 Page 2 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑Meal Service and are Given Meals Eland Pick Up Meals I] Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve? .. ❑ Yes No 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2): TTn_E OF POSITION NO. IN POSITION, SPECIFIC FOOD SERVICE PROGRAM DUTIES { { 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook. Section 2) Indoor Meal Meal Service Service ❑ Will Be Cancelled ❑ Other: 12. is this site implementing the option to allow off -site consumption of food? ............................................. . ...... ❑ Yes No 13. Are meals delivered to the site? .......................... . ...... . ... . ............... ........ 29Yes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ............................... ❑Yes No If no, describe arrangements within standards presc: ibed by local health authorities for delivery and holding of meals until time of service. 'i r-r Ar,� 0 Q A 4 o, n r) C o.c r r c M 0. KI-rr v 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Retumed to Vendor and Served the Next Day [I at the Site ❑for Disposal ❑Other. I CERTIFY that the Information on this form Is true and correct to the best of my knowledge. I certify that this site has been visited and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of Information may result In prosecution under applicable state and federal statutes. Name or Contracting Organization type or pnnt) .� I ntfe r I _ FOR k2pproved ❑Dented, reason: DHS USE o 2 % Tide �zSiravwe-'.S 'e resentative Dq1e Texas Department Form 15071Jan of Human Services SUMMER FOOD SERVICE PROGRAM FOR OHS USE ONLY SITE INFORMATION TX ❑R Name of Food Service Site T i pnf a No. (inc. A/C) uEl Address of Site (Street a 1,3 ft. State, ZIP) I01 Period of Operation of Food Service (moJdaytyr.-mo (laytyr.) Number of 0 May June Jury Aug. Sept UI From: cJ D D O through: �% p crating Days. a. V � V z V q ATTACH A MAR WITH THE SITE SERV'IC9 AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children 1. Indicate Type of Site: ❑ (serving one to three meals) ❑ (serving one to three meals) Nonresidential Camp Other Site ❑ (serving one to three meals) %(servingg one or two meals) 2. List ALL counties served by this site: LL( �&X 3. A. Is your site open?............................................................................ ® Yes ❑ No B. Is your site enrolled? ................................................... ................... ❑ Yes � No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Section 2).......................................... D. If open sites, submit documentation supporting this percentage figure (such as census data, school data). For open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced price children. &t W01 E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program -refer to SFSP Handbook, Section 2.) If the enrolled site used school data, list the school used to document the site: IV I- F. What is the percentage of free and reduced -price meals for the site? ..................................... lul 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ Yes ❑ No If yes, give name of contracting organization: (_-i 5. Monitorinq Plan (SFSP Handbook, Section 4)- Enter date of monitoring review to be conducted within: A First Week of Operation B. Fitsi F ur weeks of Opera n C. Additional Reviews 0— O D --f/i 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TOO SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch �`1 1b : O RM •�-: P.M. Supplement Supper ; 'This infomtation is consicerea Dy vnzi wnen semng me approved mea, aervice ievei. tw-br nan0000K, aecoon zl 7. Do you plan to -feed children under one. (1) Year old?............. ::...... .\:.:.............. ❑ Yes,® No 6. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) Self -Preparation vendeqJsing School Using Food Service Management Company Using Private Non -Profit ❑ On Site ❑ Central Kitchen ❑ Food Authority] (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep Form 1507 Page 2 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up Meal Service ❑ and are Given Meals Nand Pick Up Meals ❑Other: ❑ B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve?.. []Yes `O 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook. Section 2): TM_E OF POSMON SPECIFIC ... SERVICE PROGRAM DUTIES Ell 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2) Indoor Meal Meal Service Service ❑Wilt Be Cancelled []Other: 12. Is this site implementing the option to allow off -site consumption of food? .... .............................. _ ... I. ....... ❑ Yes 0 No 13. Are meals delivered to the site?...................................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of Communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ............................... 1,aV Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day L,0 at the Site ❑ for Disposal ❑ Other. 1 CERTIFY that the Information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of Information may result In prosecution under applicable state and federal statutes. Name of Contracti q Organiz lion .i JVL o C'� L4 nEure of icial or Contracting Organization Date Name of Micial (please type or pnnt)i me _ FOR pproved ❑Denied, reason: DHS USE „ � Z..�� Trt}e ONLY [` Sionahue-DH oresen ' e ate �e Resolution No. 2000-R 0131 Texas Department Form 15071,1aruary 2CCa of Human Services SUMMER FOOD SERVICE PROGRAM FOR OHS USE ONLY SITE INFORMATION TX Name of Food Service Site Taiepnon No. "rc. AJC) 1 Cze iPe ( 90 7C�6 -1833 Address of Site (Street. City, State, ZIP) v Period of Operation of Food Service (mo./da ryr.-moadayryr.)wNumber 0} Op- May June Jury Aug. Sept. From: SlS through: Tu" lmdl orating Days: 4 d C/ Q ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children 1. Indicate Type of Site: ❑ (serving one to three meals) ❑ (serving one to three meals) Nonresidential Camp Other Site ❑ (serving one to three meals) ® (serving one or two meals) 2. List ALL counties served by this site: L'l_V40L 3. A. Is your site open?............................................................................ r—� Yes x r No B. Is your site enrolled? ....................................................................... r ?Yes FS] No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Section 2).......................................... D. If open sites, submit documentation supporting this percentage figure (such as census data, school data). For open sites using school data, list the schools used to document site eligibility: attach formula used by school dist. to establish percentage of free & reduced price &ildren. — R&M-1, ft�_- E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Progr;m—refer to SFSP Handbook, Section 2.) r If the enrolled site used school data, fist the school used to document the site: F. What is the percentage of free and reduced -price meals for the site? ...................................... 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ []Yes No If yes, give name of contracting organization: Al 5. nonitonng Tian (Jror nd11U1JCOK, JeCUon 4)- Cnter Qdte ui ntuniturmy review to Oe conqumeu witnrri. A. Frst week of Operation B. First Four weeks of Operation C. Additional Reviews << .,•.a. 31'1_11� 9� 2oorn I s S - Tw-p-Z3 f u 5 — � _ �- ) 200 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch �D Q111 lo AeK 2 0 6-4 P.M. S:yclement I Supper ( ' -This Rlformanon is consleerec uy uflJ wnen setting the approveu mrai yc,viw rove. v)rar nnnuwuN Jecaon e) 7. Do you plan to teed children underone (1) year old? ... .... .. e r......�:........ .� �,. ,. ❑Y s M No 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) Seif-Preparawn VendelJsing School {c Using Food Service Management Company Using Private Non -Profit f1 nn Site (1 central Kitchen 7 Food Authoritv t/V (excludes all -year contracts with on -site areal n Organization that is Self -Prep Fon-:tsc; page 2 9. A. Indicate the system -to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) . Cafeteria -style Children are Seated Children Line Up []Meal Service � and are Given Meals ❑ and Pick Up Meals ❑ Other: B. if using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve? .. ❑ Yes RN 0 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook. Section 2): TITLE OF POSITION NO. IN POSITION SPECIFIC F000 SERVICE PROGRAM DUTIES � I � 11. Indicate what provisions will be made for meal service during periods of increment weather. (SFSP Handbook, Section 2) Indoor Meal Meal Service Service ❑Will Be Cancelled []Other: 12. Is this site implementing the option to allow off -site consumption of food? .................................................... Fly., ZNo 13. Are meals delivered to the site? ... _ ... Yes ❑ No ............................... IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT 60TTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook. Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Wlli Contact Vendor ❑ Direc'Jy With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ............................... []Yes , No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. . I _ k �l�riT:��7fiRT�r.71 �>GTi7R\l�i7r�^iS �7w�IiI�ATil1\ �� 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor nd Served the Next Day ❑ at the Site ❑ for Disposal ❑ Other. I CERTIFY that the Information on this form Is true and correct to the best of my knowledge. i certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. 1 w �a+.� /Jwncracuig veyani au�n -1�-0o C1r oc naiur i al of Con actlng Organization Date Nano of Official (ptease type or print) Title----,, p FOR pproved ❑ Dented, reason: DHS USE Title ONLY Z p� Signature —OHS Representative Dale Texas Department of Human services SUMMER FOOD SERVICE PROGRAM SITE INFORMATION 11W Jo,-- 5,r�A"ns C0v% I Form 15071January 2oo0 FOR DHS USE ONLY TOR `❑u Telephone No. (inc. A/C) eDG - )(-7 - a-2cb Period of Opetation of Food Service (moJdaytyr.-=4daytyr.) umber of Op- May June Jury Aug. �j Sept From: $ 30 through: // O crating Days: �a"l 020 1 ATTACH A MAP wrTH THE SITE SE VICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children 1. Indicate Type of Site: ❑ (serving one to three meals) ❑ (serving one to three meals) Nonresidential Camp Other Site ❑ (serving one to three meals) ❑ (serving one or two meals) 2. List ALL counties served by this site: uj j:n XJC 3. A. Is your site open?............................................................................ ®Yes ❑ No B. Is your site enrolled?.......................................................................... ❑ Yes Ar:2Mj No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Section 2).......................................... /o D. If open sites, submit documentation supporting this percentage figure (such as census data, school data). For open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced price children. T DES E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP Handbook, Section 2) If the enrolled site used school data, list the school used to document the site: Nyt F. What is the percentage of free and reduced -price meals for the site? .................................... ram°/a 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ 1zYes ❑ No ./ e 1i/11 If yes, give name of contracting organization: 5. Monitorina Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four weeks of Operation C. Additional R 5 000- a oo �3aUo -�a S120e o 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Brealdast A.M. Supplement Lunch �Od ��• c'J 1�''` -`lr� Pitl P.M. Supplement Supper -"us vttonrawn is cormaerea cy Lim wren semng ine approvea meal service ievei. tar-w- nana000K, aecoon zt 7. Do you plan to feed children under one (1) year old? .................................. . ...........................1. ❑Yes ® No 8. Aethod of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) Self -Preparation Verdetising School Using Food Service Management Company Using Private Non -Profit ❑ On Site ❑ Central Kitchen ❑ Food Authority (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep Form 1507 Page 2 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: B. If using cafeteria -style meal service and If sponsor is a school food authority, will the site be implementing offer vs. serve? .. ❑ Yes ,� No 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2): V C TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2) 1711 Indoor Meal Meal Service LlYService Will Be Cancelled ❑Other: 12. Is this site implementing the option to allow off -site consumption of food? ...................................... . ......... ❑ Yes 19� No 13. Are meals delivered to the site?...................................................................................... llnlYes [:]No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel WIII Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) .......................... . .... ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor Eland Served the Next Day Mat the Site ❑for Disposal ❑Other. CERTIFY that the Information on this form Is true and correct to the best of my knowledge. I certify that this site has been visited and that It has the capability and facilities for the meal service planned for the number of children anticipated. 1 know that deliberate misrepresentation or withholding of Information may result in prosecution under applicable state and federal statutes. Name of Contracting Organization 13 p p C,hL� oC nature-Oft;cial of Contracting Organization Date OF Name of official (please type or print) - Title FOR KApproved []Denied, reason: DNS USE Title ONLY W2110 Signature-0HS Aepres tative Da /01,11'esolutiou No. 2000—R 0131 Texas Cepa.-tment Form 1907!Januar, 2100 of Human Services SUMMER FOOD SERVICE PROGRAM FOR OHS USE ONLY SITE INFORMATION TX 5- DST 1 CD Name of Foos Service Site 41�546- No. tinc. AjC)1 1 Address of Site (Street, City, State, ZIP) P 0o`� �_: �s_ K►',o e L.> 66ock 1—K -?9 y f 5 Period of Cperaoon or rooa bervtce (moJaaytyr.-=o dayfyr.) Number of Op- May June jury Au Sepr. From: 7c,,., S through: �-( , 7 ?9, �i) erating Days: (� Q C) ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children 1. Indicate Type of Site: ❑ (serving one to three meals) ❑ (serving one to three meals) Nonresidential Camp Pserving ther Site (serving one to three meals) one or two meals'I 2. List ALL counties served by this site: 3. A. Is your site open?............................................................................ Yes No E. Is your site enrolled?.......................................................................... -i Yes No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Section 2).......................................... D. If open sites, submit documentation supporting this percentage figure (such as census data, schecl data). For open sites using school data, list the schools used to document site eligibility; attach formula used by school disc. to estabiish percentage of free & reduced price children. USG! 4A%=� - E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP Handbook, Section 2.) If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free and reduced -price meals for the site? .................................... %0 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ ❑Yes YNo If yes, give name of contracting organization: N 5. Monitoring Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Aecidonal Reviews 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch + f 0 •3b [f'^ ' 3!' f i1h P.M. Supplement � i Supper `This information is consmerea oy urrs wnen setting ute appruveu maw x,— rove. tarar- nanocooK, aecvon 41 7. DO you plan to feed children under one (1) year old? ................................. ._ .......,__-,.... ............. []Yes No S. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) Seif-Preparadon V'endej)sing School Using Food Service Management Company Using Private Non -Profit f-1 n. c;f. rl r entral Kifr•hrn I rl Fnnrf 4nthority (excludes all-vear contracts with nn-site oreol Organization that is Self -Prep I �. Form 1507 Page 2 9. A. Indicate the systelnto be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑Meal Service and are Given Meals ❑ and Pick Up Meals ❑Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve?.. ❑ Yes []No 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook. Section 2): TITLE OF POSITION I NO. IN POSITION I SPECIFIC FOOD SERVICE PROGRAM DUTIES L l61) N� r{ { I I 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2) Indoor Meal Meal Service Service ❑Will Be Cancelled ❑Other: 12 Is this site implementing the option to allow oft -site consumption of food? ......................................... . .......... ❑ Yes �No 13. Are meals delivered to the site? .. ............gYes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) ite Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ...:........................... ❑ Yes �No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. ff1�1 S w : i i %�, 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) SZdServed red In Refrigerator Thrown Away Returned to Vendor the Next Day ❑at the Site ❑for Disposal []Other: I CERTIFY that the Information on this form is true and correct to the best of my knowledge. 1 certify that this site has been visited and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of ContraC,ing Organization// Si re—Oftiaat bf ontracting Organization Date Name of Oft(please type or pnnt) ,/ / / t lue./ o % - l _ /�irf hbS _'A 'n„r vim. n�r SSG► /U� Y a�7 FOR ❑ Denied, reason: OHSkfApproved USE Title ONLY 710 D Sinnature—DHS Rearesentative D to Resolution No. 2000-R 0131 Texas Department of Human Services SPECIAL NUTRITION PROGRAMS SINGLE AUDIT IDENTIFICATION DATA (For Contract Year 2000 Form 1569 September 1997 Contractor C(e Ukb�� I ContactPe� rt �� 1 Address (Street qry.o. Box. City. State. ZIP) Teleone ��/- ) l � � —� � � Payee ID No. CanL•ad No. Contractor Fiscal Year End (mm/dOyyyy) Type of Contract Ise-atyamo ❑ For Profit ❑ Nan -Profit )SIGovemmenIA Check the appropriate box(es) to Indicate the type(s) of program(s) in which you currently participate or for which you are applying: COMMODITY ASSISTANCE PROGRAMS AGREEMENT NOS. ❑ A — National School Lunch ❑ B — Charitable Institutions ❑ C — Area Agency on Aging ❑ G —Summer Camps ❑ H — Summer Food Service ❑ J —Jails ❑ I - TEXCAP CASH REIMBURSEMENT PROGRAMS TX NOS. ❑ AD — Adult Day Care T_;_ BL— National School Lunch/Breakfast TX - CC — CACFP Center TX_ ❑ DH - CACFP Day Home TX- SF- Summer Food TX_ ❑ SM -Special Milk TX- TE - TEXCAP TX_ Give the source and amount of any federal funds that your agency expends other than from those programs Listed above: SOURCE AMOUNT t 5 (0cn C`o t L4,01,'i e uc /o -e A� �� k G`rbLdt`E� �3 e- ❑ SINGLE AUDIT EXEMPTION-1 certify that I am not required to submit an audit under the Single Audit Act for the following reason(s): 111 am a for -profit organization. ❑ I expend less than $300,000 annually in total federal funding. SINGLE AUDIT ASSURANCE —I understand that if I meet the requirements of the Single Audit AM I will agree to submit an audit as a condition of eligibility to participate in the Special Nutrition Programs, and that failure to do so as required could result in adverse action, including the withholding of my claim for reimbursement payments and tremination of my contract. I also understand that N I am a private non-profit organization subject to the requirements of the Single Audit Act and have a financial audit performed annually, 1 must also obtain a single audit on an annual basis. 3—/9-00 Date , . i / L Le Resolution No. 2000-RO131 Office of Accounting P.O. Box 2000 • 1625 13th Street Lubbock, Texas 79457 (806) 775-2156 • Fax (806) 775-3273 April 26, 2000 Texas Department of Human Services Special Nutrition Programs, Operation Division 2109 Avenue Q Lubbock, TX 79405 To whom it may concern, We are in the process of compiling information for the single audit report, which is performed in accordance with the Single Audit Act of 1984 and OMB Circular A-133. We anticipate that this will be completed and published by June 30, 2000. If you have any questions, please feel free to contact me at (806) 775-2148. Sincerely, Dena Moms Grant Accountant Texas Department of Human Services Form 4Sos March 199E SPECIAL NUTRITION PROGRAM CERTIFICATE OF AUTHORITY This is to certify that the following person(s): Name of Authorized Representative (please type or print) Title 4Ja. ILI bh6bs Sk r ; rQ r X ?A9 tur"uthorized PwomerCryve Name f Authorized Repre ative(please type print) Title r x J"�fj %.10 J— ' S'ntatu oriz Representative Is(are) designated as an Authorized Representative of Name of Contra=ng prganizatlon a Ck Address (Sires City. State. ZIP) The representative(s) designated above, and myself, are authorized on behalf of the contracting organization to make written agreements with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to the department. Name of off=w of Contracting Agency (please type or print) Title uu=f.a s: X Signatum-official of dn6 Agency es o: KaythieDi)arnell DELETED AUTHORIZED REPRESENTATIVES:- A contracting organization may not have more than three (3) Authorized Representatives, Including the Official of the Contracting Agency. If you are replacing or deleting an Authorized Representative, list the name(s) of the Individual(s) to be removed as Authorized Representative(s) below: Name of Deleted Representative 7 e of UeletedRepresentative I Name of Deletedpresentative -.0% ►ln 0 0%L1 V -vrl una vac will Agreement No. Race y Date R Tx- 00 Z- o� Texas Department Form 4526 ofliuman Services SPECIAL NUTRITION PROGRAMS May 1996 PRE -AWARD COMPLIANCE REVIEW To comply with the Civil Rights Act of 1964 and the Rehabilitation Act of 1973 (Section 504), the applicant must complete and return his questionnaire. Department staff cannot take action on the application until this questionnaire Is returned. Name of Applying Organization Agreement No. Q - 0 Please answer the following questions. Give as much information as possible. Attach additional sheets, if needed; please identify each attachment with the name of the applying organization. A. CIVIL RIGHTS ACT OF 1964 1. Submit copies of public release statement and any other materials used to publicize the program's availability and non-discrimination requirements. 2 a. Estimate by racial/ethnic group the number of recipients that will participate In the program at each facility. If the program consists of several camp sessons, specify the projected number of children by facility and date of session: (Name of school, camp, fark site, church, Yospltal.. nursing home, recreational center, child care center, ate.) A1 INDrA AN �r'� HASKAN � PACIFIC. ISLANDER BLACK HISPANIC WHITE 1� o b 3S A0S �6 6 5 55 koc, S3 b. Describe how this projection was made (i.e.: based on comparative enrollment In facilities, observation of recipients, recipient's surnames, etc.): 3. Does the applying organization have specific membership requirements?................................................... []Yes 010 It yes, describe those requirements: -Form 4526 Page 2 4. What efforts will be made by applying organization to contact minority and grass roots organizations about the opportunity to participate in the program? 5. What other steps will be taken by the applying organization to ensure that minorities have an equal opportunity to participate in the program? N0'kOx!t'�T, %U Tkm«Q S. Is the applying organization currently receiving financial assistance from agencies other than the United States Department of Agriculture?...................................................... 52Yes [:]No If yes, give details: 7. Has any federal agency notified the applying organization of noncompliance with the Civil Rights Act of 1964?............. ❑Yes &No If yes, give details including dates, names, and results: Form 4526 Page 3 B. REHABILITATION ACT OF 1973 (SECTION 504) 1. Are there any policies, practices, or architectural barriers that limit or deny persons with disabilities participation or employment in the program? .................................................. ❑ Yes M No If yes, explain: 2 Are there policies or practices that result in different treatment of participants, applicants, or employees with disabilities?.... ❑Yes No If yes, explain: 3. If the applying organization employs 15 or more people, has the agency �p►� designated a coordinator to carry out Sect. 504 requirements? ................................................ ❑ NA ` ICJ Yes []No f yes, give the name of the coordinator and title: /y► Name 0} COOtdlflai6f Are w c 70t)"'.V 1 Pe. r,.Q ill 4. If the applying organization employs 15 or more people, has the agency established � No grievance procedures that Incorporate appropriate due process standards .................................: ❑NA Yes If'NA' or •No,' continue with Item 5 at the top of the next page. If yes, do these procedures provide for the prompt and equitable resolution of complaints that allege an action prohibited by Section 504 of the Rehabilitation Act of 1973?....................................... Z Yes ❑ No If yes, has the applyng organization Informed the public of the right to file a complaint and of the filing procedure? .......... [!Yes ❑ No If yes, briefly describe how: '<f All d SO y nrr(�l4: r-) i S p (AA i 5lIvA i /1 C,j F Fenn 4523 Page 4 5. Has the applying organization taken steps to notify employees, participants, and applicants that the agency does not discriminate against persons with disabilities? ..................................... M Yes ❑ No If yes, do the people notified include those with impaired vision or hearing and members of unions or professional organizations holding collective bargaining or professional agreements? ........................ Ryes ❑ No If yes, describe how notification Is made: 0�11 Ao _('.CUB +-1' �j D u W :. a 4-: n.n C Q A.-\ � D ,n Q On (: rr. k, 6. Do all of the applying organization's forms, publications, and reruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the agency does not discriminate against persons with disabilities? ................................................ LaYes ❑ No If no, indicate steps being taken to comply with this requirement: 7. Does the applying organization have a procedure to ensure that the remedial or corrective action has been or will be taken 9 noncompliance has occurred?... ,,,,,,,,,,,,,,,,,,....,,,,,,,,. [XYes ❑ No If yes, explain: t ` 1 i -j : k\ 19-� 1r Q ,b1 •mod Pf� L1 e� �1-t►� l er rune pna (zed of AppVng Organization Date