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Resolution - 4176 - Agreement - South Plains Food Bank - Summer Food Service Program For Children - 06_10_1993
Resolution No. 4176 June 10, 1993 Item #33A 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 a Contract by and between the City of Lubbock and the Food Bank for the furnishing of meals and other food service in the furtherance of the Summer Food Service Program for children, such Contract being attached herewith, which shall be spread upon the minutes of the Council and as spread upon the minutes of this Council shall constitute and be a part of this Resolution as if fully copied herein in detail. Passed by the City Council this ATTEST: Betty o n n, y Secretary APPROVED A 0 CONTENT: 7 ee Osborn, Director of Parks and Recreation APPROVED AS TO FORM: ony i1williams, ss stan ty Attorney AJw:ja/F00DEANK.HES D1-Aganda/Jun® 9, 1993 AGREEMENT TO FURNISH FOOD SERVICE THIS AGREEMENT is made and entered into by and between City of Lubbock and South Plains Food Bank "�Qjjth glains Food Bank agrees to supply meals to city of Lubbock with and for the rates. Breakfast ..... $ each Lunches.....$ 1.55 each Snacks ........ $ each Suppers.....$ each It is further agreed that (school) South Plains Food Bank pursuant to the provisions of the Summer Food Service rogram Regulations, the attached copy of which is part of this agreement, will assure that said meals meet the minimum requirements as to nutritive value and content, and will maintain full and accurate records that the institution will need to meet its responsibility including the following: 1. Menu Records, including amount of food prepared. 2. Meals, including daily number of meals delivered by type. These records must be reported to city of Lubbock at the end of each month. South Plains Food Bank agrees also to retain records required under the preceding cause for a period of three (3) years and ninety (90) days after the end of the fiscal year to which they pertain (or longer, if an audit is in progress); and upon request, to make all accounts and records pertaining to the program available to representative of the U.S. Department of Agriculture and the General Accounting Office for audit or Texas Department of Human Services for an administrative review at a reasonable time and place. No payment will be made for meals that are spoiled or unwholesome at the time of delivery or do not meet program component and/or portion requirements. This agreement shall be effective as of (date) June 9, 1993 It may be terminated by notice in writing given by any party hereto to the other parties at least sixty (60) days prior to the date of termination. IN WITNESS WHEREOF, the parties hereto have exec;2LaX ent as of the dates indicated below: Agreed to this date Q 3 Sponsor offi i School offici Lfj itle z Location of foo preparation center(s): cAP cze-� South Plains Food Bank SECTION E—GENERAL CONDITIONS 1. Delivery Requirements A. The contractor will make deliveries to each site according to the Sponsor's order. 8. Meats will be delivered daily, unloaded, and placed in the designated site by the contractor's personnel at each of the loca. tions and times listed in Schedule A. C. The contractor is responsible for delivery of all meats and dairy products at the specified time. Adequate refrigeration or heat- ing win be provided during delivery of all food to ensure the wholesomeness of food at delivery according to state or local health codes. 0. The Sponsor may add or delete sties. This Is done by amendment of the Schedule A. The Sponsor will provide to the con- tractor a list of the food service sites approved by the state agency, along with the approved level for the maximum number of meals to be served in each site 17 CFR 225.8(b)61. The Sponsor will notify the contractor of all sites which have been approved, cancelled. or terminated subsequent to the aubh ission of the Mat approved site list and of any changes in the approved level of meal service for a site. This notification is provided within forty-eight hours or less if mutually agreed upon between the parties to this contraeL 2. Supervision and Inspection The contractor will provide supervision at all times and will maintain constant quality control inspections to check for portion size, appearance, and packaging in addition to the quality of products. 3. Recordkeeping A. The contractor must prepare delivery tickets In triplicate: one for the contractor, one for the site personnel, and one for the -Sponsor. Delivery tickets must be itemized to show the number of meals of each type delrvered to each site. The Sponsor's designee at each site will check adequacy of delivery and meats before signing the delivery ticket. Invoices are accepted by the Sponsor only if signed by the Sponsor's designee at the she. B. The contractor must maintain records supported by delivery tickets, invoices, receipts, purchase orders, production records for this contract or other evidence for inspection and reference to support payments and claims. C. The contractor's books and records pertaining to this contract must be available for three years and 90 days from the date of submission of the final claim for reimbursement, or until the final resolution of any audits, for inspection and audit by representatives of the TDHS, representatives of the. U.S. Department of Agriculture, the Sponsor and the U.S. General Accounting Office at any reasonable time and place. 4. Method of Payment The contractor will submit itemized invoices to the Sponsor biweekly or monthly as specified. Each Invoice must include a detailed account of the number of meals delivered at each site during the preceding two weeks or month. The Sponsor deter• mines the average number of meals dervered each day for the applicable period. Payment will be made at the unit price for that range. Each payment period is calculated and paid for independent of other payment periods. The contractor is not paid unless the required delivery receipts have been signed by the Sponsor's -designee at the site. The contractor will be paid by the Sponsor for all meals delivered according to the contract and the SFSP regulations. How• ever, neither the U.S. Department of Agriculture nor the TDHS assumes any liability for payment of differences between the number of meals delivered by the contractor and the number of meals served by the Sponsor that are eligible for reim- bursement. 6. Inspection of Facility A. The Sponsor, OHS, and the U.S. Department of Agriculture (USDA) have the right to inspect the contractor's preparation faciliities before award of a camas and during the contract period without prior notice. These entithies have the right to be present during preparation and delivery of meals. l8. The contractor's facilities are subject to periodic inspections by the TONS, USDA, state and local health departments, or any other agency designated to inspect meal quality for the state. Inspections are accomplished in accordance with USDA regulations. C. The contractor must provide for periodic inspection of meals which it prepares by the local health department or an indepen- dent agency to determine bacteria levels. The bacteria levels must conform to the local health authority's bacteria levei standards applied to other establishments in the locality. Form G. Performance and 864 RequirAment 7. Availability of funds The Sponsor has the option to cancel this contract if the federal govemmcnt withdraws funds for the Summer Food Service Program. It is further understood that if the contract is cancelled, the Sponsor is responsible for meals that have already been assembled and delivered according to this contract. S. Number of Meals and Delivery Times The contractor must provide exactly the number of meals ordered. Meals will be counted at aA sites before they are accepted. Damaged or incomplete meals will not be included in determining the number of delivered meals. 9. Emergencies In emergencies, the contractor must immediately notify the Sponsor by telephone or telegraph of the following; 11) the impossi- bfTfty of on•time delivery; (2) the circumstance precluding delivery; and 13) a statement of whether or not succeeding deliveries will be affected. The contractor will not be paid for deliveries made later than • 30 mi nutes hours after the specified meal time. Emergencies Mthe site which preclude use of meals are the Sponsor's concern. The Sponsor may cancel orders if the contrac- tor is given at least 48 hours notice. This time frame may be shortened if mutually agreed upon between the parties to this con- tract. Adjustments for emergencies affecting the contractor's abirity to deliver meals, or the Sponsor's ability to use meals, for periods longer than 24 hours must be mutually worked out between the contractor -and the Sponsor. *Sponsor shalt sat tiff" In accordance with suit 89ency Instructions. 10. Termination A. The Sponsor has the right to terminate this contract if the contractor fails to comply with any of the contract requirements. The Sponsor must notify the contractor and surety company, if applicable, of specific instances of noncowrianee in writing. tf the contractor has been notified of noncompliance with the terms of the contract and has not taken krdrmedrate corrective action, the Sponsor has the right, upon written notice. to irmmedrately terminate the contract The contractor or sxxety com- pany, If applicable, will be Gable for any damages incurred by the Sponsor. The Sponsor will process a reprocurerrrent action on a competitive basis to obtain a fair and reasonable price If the contractor was not required to be bonded in accordance with 7 CFR 22S.16Q) and 225.161k). 8. The Sponsor may. by written notice to the contractor, terminate the contractor's right to proceed under this contract if the Sponsor finds that the contractor gave or offered gratuities in the form of entertainment, gifts or otherwise to any officer or employee of the Sponsor to secure a contract or favorable treatment in the awarding or amendumg of the contract. This is providing that facts exist which support" -Sponscr`sfr 4iing-arid-ar"varlable for review by any-competern t ooM- C. If this contract Is terminated as provided In paragraph (8). the Sponsor is entitled M to pursue the same remedies against the contractor as it could pursue in a breach of the contract by the contractor, and Ili) to a penalty in addition to any other dam- ages in an amount not less than three or more than 10 tunes the costs incurred by the contractor in providing any gratuities to any officer or employee. O. The rights and remedies of the Sponsor as provided In this clause are not exclusive and are supplemental to any other rights and remedies provided by law or this contract 11. Subcontracts and Assignments The contractor may not subcontract for the total meal, with or without milk, or for the assembly of the meal. The contractor may not assign his contract or any interest in the contract vvidvm the advance written consent of the Sponsor. In the evert of any assignment, the contractor remains liable to the Sponsor as principal for the perfor manse of go the oblige. doffs under this contract. Day 1st Day 2nd Day 3rd Day 4th Day 5th Day bth Day 7th SUMMER LUNCH PROGRAM Bologna Sandwich Lettuce/tomato Apple Chocolate Milk Peanut Butter/Jelly Sandwich Cheese Stick Celery Sticks Slice Squash Raisins Chocolate Milk Ham & Cheese Sandwich Pork'n Beans Pretzels Apple Chocolate Milk Bologna Cheese Sandwich Potato Salad Grapes Chocolate Milk Turkey Sandwich Celery Sticks Sliced Cantaloupe Chocolate Milk Salami & Cheese Sandwich Lettuce/Tomato/Pickle Chips Peaches Chocolate Milk Bologna & Cheese Sandwich Orange Macaroni Salad Chocolate Milk 1 oz. bologna 1 oz. cheese 2 Slices of bread 1/4 Cup 1 whole (1/2 C.) 1 Cup l oz. Peanut Butter/Jelly Bread 2 Slices 1 oz. Amer. Cheese 1/4 Cup 1 Slice 1/2 Cup 1 Cup 1 oz. Turkey Ham l oz. Amer. Cheese Bread, 2 Slices 1/4 Cup 1 Bag 1 Whole (1/2 Cup) 1 Cup 1 oz. Bologna 1 oz. America Cheese Bread, 2 Slices 1/4 Cup 1/2 Cup 1 Cup 3 oz. = 2 oz. Meat Required Bread, 2 Slices 1/2 Cup 1/2 Cup 1 Cup 1 1/2 oz. Salami 1/2 oz. Swiss Cheese Bread, 2 Slices 1/4 Cup 1/2 Cup 1 Cup 1 1/2 oz. Bologna 1/2 oz. Cheese Bread, 2 Slices 1 Whole 1/4 Cup 1 Cup SUMMER LUNCH PROGRAM PAGE (2) Day 1 Cold Fried Chicken Drumstick 1.5 oz. (3.25 oz - 8th Uncooked Drumstick 1.5 oz Cooked) Roll 1 oz. Cheesewedge 1 oz. Potato Salad 1/4 Cup Peach 1 Whole Chocolate Milk 1 Cup Day Peanut Butter/Jelly Sandwich 1 oz. Peanut Butter/Jelly 9th Bread, 2 Slices Cheese Stick 1 oz. Amer. Cheese Carrot Sticks 1/4 Cup Apple 1/2 Cup Chocolate Milk 1 Cup Day Turkey Sandwich 3 oz. = 2 oz. Meat Required loth Bread 2 Slices Lettuce/Tomato 1/4 Cup Applesauce 1/4 Cup Chocolate Milk 1 Cup Day Ham & Cheese Sandwich 1 1/2 oz. Ham llth 1/2 oz. Cheese 2 Slices Bread Potato Salad 1/4 Cup Mixed Fruit 3/8 Cup Pickle Spear 1/8 Cup Chocolate Milk 1 Cup ** ALTERNATE Hot Dog or Hamburger Frank or Charpattie Bun Mustard PC Chips 1 Bag Pintos Beans 1/2 Cup Lettuce/Tomato 1/4 Cup Brownie/Cake/Cookie 1 ea. Chocolate Milk 1 Cup Average times 10% *All sandwiches include 2 oz. enriched White Bread, of 2 oz. enriched Hot Dog Bun. *This menu may included: Chips, Crackers, Dessert, fresh Vegetables and fresh fruits. ATTACHMENT 2 Page 1 of 5 l 1. Is this grant: 2. Is a match required? GRANT PROPOSAL EVALUATION FORM Page 1 New Continuing x_ Number of Years 4 Yes No X If yes: Percentage Amount Is it: In -kind OR Cash Source 3. Is indirect cost allowed? If yes: 4. Are audit costs reimbursed? If yes: Yes X Percentage .1600 Yes X Percentage No m S. What are the audit requirements for this grant? Audit costs are reimbursed by the grant, if enought administrative reimbursements are secured. 6. Can this grant be renewed? Yes X No If yes, how many times? It is not anticipated that the funds from What are the terms of renewal? TDHS will eliminated. 7. Does the grant require the City to gradually assume the cost of the program? Yes No X If yes, what is the timetable? 8. Piease address whether other agencies are currently administering similar programs and whether any other agencies are available to administer this program. A similar program is not being offered in Lubbock- It does_ not appear that any agency is interested in providing this program. We assume most facilities do not have the scope, facilities, or public service direction (with the exception of LISD) to provide this program. A�)F-1 Page 2 of 5 GRANT PROPOSAL EVALUATION FORM Page 2 9. For the 'Current Year', please identify how expenditures are to be made in the following categories and how the program will be funded. If the grant Is for an on -going program, please project revenue and expenditures for future years. If the grant Is for one year, show any on -going costs to the city, such as the cost of maintenance on equipment purchased by the grant. CURRENT F U T U R E Y E A R S YEAR 1913 19,E4 19-25 19,U 19,91 EXPENDITURES Personnel 34,474 34,474 34,474 34,474 34,474 Admin. �u RlS es, Site Supervisors s PP 2,995 2,995 2,995 2,995 2,995 Maintenance 0 0 0 0 0 Other 94,1�6 Food Caterer, Contractual Program Monitor, 94 126 Audii 94,126 94,126 94,126 Capital TOTAL EXPENDITURES 131,595 131,595 131,595 131,595 131,595 REVENUE Federal Grant State Grant 130,680 130,680 130,680 130,680 130,680 Local Match Other TOTAL REVENUE 130,680 130,680 130,680 130,680 130,680 10. Please list any new positions to be added: 11. Please list any capital items to be purchased: 12. Please discuss how this program will Impact current employee allocation and utilization and whether It will have a long-term financial or manpower Impact. Attach additional pages If needed. The Summer Lunch Program will fund 1.71 man years of labor that would not normally been employed for this fifty-four (54 day program). Over a five (5) year period this produces 8.6 man years of employment if the scope of the program remains the same for its duration. A25-2 Page 3 of 5 GRANT PROPOSAL EVALUATION FORM Page 3 13. In narrative form, please provide a brief description of the program, Including the need which will be addressed, the goals and objectives of the program, the target population to be served, and any other significant aspects of the application. Attach additional pages if needed. SEE ATTACHED SHEET H APPR AL GRANT PROPOSAL EVALUATION FORM This project will provide a nutritious noon meal, for youths one to eighteen years of age. The program will operate June 1 through August 13, 1993 at 16 sites, Monday through Friday. The program will provide an alternative meal opportunity for low income and latch key children in identified City neighborhoods. It is anticipated that an average of 1100 meals will be served daily. The program will also foster involvement of these children in not only the lunch program, but other supervised, positive activities provided through the Parks and Recreation Department. In the 1992 Summer Food Service Program more than 850 children per day were served nutritious lunches at four community centers and eight playgrounds in low income areas. Due to the success of this program in the past three years, the number of sites 1s being increased to 16 sites this year. we anticipate an .increase of 250 meals this year, therefore serving an average of 1100 meals per day. Based on 1100 meals per day. Expenditures are averaged much higher than anticipated. This grant reimburses the "highest" reimbursement amount. For this reason, I over estimated the site supervisory needs (expenses) in case we add personnel. This grant will reimburse all direct expenses associated with the program, Page 4 of 5 GRANT PROPOSAL EVALUATION FORM INSTRUCTIONS Page I Basic Information Department/Contact - Identify the department and contact person for this grant application. App. Due Date - Enter the date that the application is due back to the granting agency. Contract Amount - Enter the amount you are applying for from the granting agency. This number should not include any match. Grant Title - Enter the name of the grant program as you want it to appear on the computer system. Grant Agency - Enter the name of the entity offering the grant. Contract Period - Enter the effective dates for the grant. Federal CFDA # - Enter the number assigned to the grant in the Catalog of Federal Domestic Assistance, if applicable. Pass -Through Grantors # - If the city will receive this grant as a third party, (e.g. the state receives funds from the federal government and passes them on to cities), enter the number assigned to the pass -through agency, if applicable (e.g. the state, in this case). Questions 1. Identify whether this grant is for a new program or activity or whether it is a continuing program. If it is a continuing program, please indicate how many years the City has received the grant. 2. Identify whether a match is required and if so, what the percentage and dollar amounts are, whether it is in -kind or cash, and where the match will come from (i.e. in -kind office space and utilities). 3. Identify whether Indirect Costs are an allowable grant expense and if so, in what percentage. 4. Identify whether Audit Costs are an allowable grant expense and if so, in what percentage. 5. Identify any audit requirements of the granting agency. 6. Identify whether this grant can be renewed for future years and if there are any terms for renewal. I. Identify whether the grant will require an increasing matching percentage from the City from year to year. If so, identify what the match percentage will be for each year of the project. 8. Identify any other agencies that are currently operating similar programs. Identify whether any agencies are available to administer this program and if not, why not. A25-4 Page 5 of 5 GRANT PROPOSAL EVALUATION FORM INSTRUCTIONS Page 2 9. Outline the grant budget, including revenues and expenditures, for the current year and projections for future years. 10. If any new positions are to be added, please list by title. 11. If any capital items are to be purchased, please list. 12. Please discuss how this program will affect the work hours and productivity of City employees and the affect it will have on scheduled operational activities. Also, discuss the long-term impact of the program on the community and the City organization. Approval After all required signatures have been obtained, submit the original of this form to the City Secretary's office. In addition, if the grant is required to go to Council, 18 copies need to be brought to the City Manager's Office to be placed in the agenda backup material. A25-5 Texas Department Form 1604, Attachment C of Human Services February 1991 SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CRIMINAL PROVISIONS AND PENALTIES 1. Whoever, in connection with any application, procurement, record keeping entry, claim for reimbursement, or other document or statement made in connection with the program, knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or whoever in connection with the program knowingly makes an opportunity for any person to defraud the United States or does or omits to do any act with Intent to enable any person to defraud the United States, shall be fined not more than $10,000 or imprisoned not morel then five years. 2. Whoever being a partner, of ricer, director, or managing agent connected in any capacity with any partner- ship, association, cooperation, business, or organization, either public or private, embezzles, misapplies, steals, or obtains by fraud, false statement or forgery, any benefits provided by the program, or any money, funds, assets, or property derived from benefits provided by this program, shall be fines not more than $10,000 or imprisoned for not more than five years or both. If the benefits, money, funds, assets, or property Involved Is not over S200, then the penalty shall be a fine of not more than $1,000 or imprisonment for not more than one year, or both. 3. If two or more persons conspire or collude to accomplish any act made unlawful under this subsection, and one or more such person commit any act to effect the object of conspiracy or collusion, each shall be fined not more than $10,000 or imprisoned for not more than five years, or both. TERMINATION PROCEDURES The following list of deficiencies are grounds for termination. Grounds for termination, however, are not limited to this list: 1. Non-compliance with applicable bid procedures and contract requirements of Federal Child Nutrition regulations. 2. The submission of false information to the Texas Department of Human Services (DHS). 3. Program violations at a significant proportion of the sponsors' sites. Such violations include but are not limited to the following: A. Non-compliance with the meal service time restrictions. B. Failure to maintain accurate records. C. Failures to adjust meal orders to conform to the variations in the number of participating chiidrem. D. The simultaneous service of more than one meal to any child. E. Service of a significant number of meals which do not Include required quantities of all meat components. F. The claiming of program payments for meals not served to participating children. G. Excessive instances of off -site meal consumption. H. Continued use of food service management companies that are In violation of health codes. Texas Department Form 4506 Of Human S ekes July 1990 CERTIFICATE OF AUTHORITY This is to certify that Name of Authorized Ottsaal (please type or pnnt) Title Paula Simpson Special Programs Supervisor Signature —Authorized Official Is designated as the authorized representative of Name of Contracting Organization City of Lubbock Address (Street, city, state, zip) P.O. Box 2000 - Lubbock Texas 79457 The representativ ! nated above is authorized on behalf of the contracting organization to make written agree- ments with th exas Depaqment of Human Services to operate a food program, to sign documents or reports about the agreeme t, and to preAt ci burseme n appropriate, to the department. 06/10/93 Signatur iaaf of Cont ing Agenq Date Name of Offiaai (please type or print) r" David Langston I Mayor FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: Agreement No. Received 6y Date TX- Texas Department of Human Services Form asw My 1"o CERTIFICATE OF AUTHORITY This is to certify that Name of Authorized Official (please type or print) Title Susan Bailey I Recreation Outreach Signature —Authorized Official Is designated as the authorized representative of Name of Contracting Organization City of Lubbock Address (Street, City, State, ZIP) P.O. Box 2000 - Lubbock, Texas 79457 The representatl Hated above is authorized on behalf of the contracting organization to make written agree- ments with the T xaXpresen uman Services to operate a food program, to sign documents or reports about the agreement, nd f e mbu ement, when appropriate, to the department. 06/10/93 icial of Contra i Agency Date Name of Official (please type or print) rate David Langston I Mayor FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: Agreement No. Received 6y Date TX- Tex" Department of Human Servfoes Form 45M July 1 M CERTIFICATE OF AUTHORITY This Is to certify that Jame of Authorized Official (ptease type or pnnt) Title Lee Osborn I Director, Parks & Recreation Dept. Signature —Authorized Official Is designated as the authorized representative of game of Contracting Organization City of Lubbock lddress (Street. City, State, ZIP) P.O. Box 2000 - Lubbock, Texas 79457 The represerttati Hated above Is authorized on behalf of the contracting organization to make written agree- ments with th exas Dep me t of rvices to operate a food program, to sign documents or reports about the agreeme t, and to pre clali s for re ursement en appropriate, to the department. 06/10/93 Signatur icial of Cont ct g Agency Date game of Official (please type or print) rrtte David Langston I Mayor FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: ilgres - nt No. Received ey Date TX- SUMMER FOOD SERVICE PROGRAM AGREEMENT STATE OF TEXAS § COUNTY OF TRAVIS § The Texas Department of Human Services, hereinafter referred to as DHS, City of Lubbock Parks & Recreation Department P.O. Box 2000 916 Texas Avenue Lubbock, Texas 79401 hereinafter referred to as the contractor, do hereby make and enter into this contract, as required by the National School Lunch Act (Section 13) and the Summer Food Service Program, hereafter referred to as the SFSP, Federal Regulations (7 Code of Federal Regulations [CFR], Part 225). I. MUTUAL AGREEMENTS The Parties mutually agree: A If the contractor fans to provide services in accordance with the provisions of this contract, the Department may, upon written notice of default to the contractor, immediately terminate the whole or any part of this contract and refuse to pay claims for reimbursement Such termination and/or refusal to pay claims for reimbursement shall not be exclusive remedy but shall be in addition to any other rights and remedies provided by law or under this contract B. If federal and 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 However, U 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. II. CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT A The contractor will comply with the SFSP Federal Regulations (7 CFR, Part 225, as amended), Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), and state policies and procedures as issued and amended by DHS. The contractor further agrees to perform as described in its application (including supporting documents and approved amendments to the application) for participation in the SFSP- B. The contractor accepts final administrative and financial responsibility for food service operations at each site sponsored by the contractor. This responsibility includes the performance of the conditions of settlement of any audit exceptions or payment deficiency in the program and the collection and repayment of any amount paid in excess of the proper claim amount which are found after monitoring or auditing by DHS or the United States Department of Agriculture (USDA). This responsibility applies to this contract, -and all subcontracts hereunder. C. The contractor will apply to DHS for approval of changes to its original application and for prior authorization for field trips if meals served on the field trips will be claimed for reimbursement Requests for changes and field trip authorization must be received by DHS at least five (5) calendar days before the requested effective date for the change or the field trip. Contractors will notify DHS within five (5) days of the termination of an approved food service site. SFSP RECORD KEEPING A. The contractor will keep financial and supporting documents, statistical records, and any other records pertaining to the services for which a claim is submitted. The records and documents will be kept for at least three (3) years and ninety (90) days after the termination of the contract period. If any litigation, claim, or audit involving these records begins before the stipulated time period expires, the contractor will keep the records and documents for not less than three (3) years and ninety (90) days after the termination of the contract period and until all litigation, claims or audit findings are resolved. The case is considered resolved when a final order is issued in litigation or a written agreement is signed by DHS and the contractor. Extensions are considered as separate contract periods. B. The contractor and its subcontractors wfll allow DHS and USDA officials and other appropriate officials determined by DHS 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 DHS. °VL CERTIFICATION 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, 19K who will perform any labor or services under this contract 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. VII. EFFECTIVE DATE AND SIGNATURES For the faithful performance of the terms of this contract, the parties hereto in their capacities stated, affix their signatures and bind themselves. City of Lubbock Name of the Contracting Organization (Please Print or Type) Original signature of the authorized representative of the contracting organization Paula Simpson Name Special Programs Supervisor Title Please print or type, in the spaces provided above, the name and title of the authorized representative signing this agreement on behalf of the contracting organization. :.. TEXAS DEPARTMENT OF H MAlV SERVICES Effective Dates: through BY Date: Revised January 1992 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, Parts 15, 15a and 15b) Department of Justice (28 CFR, Parts 42 and 50) and USDA and DHS directives or regulations issued pursuant to that Act or 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), 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 persons in the Untied States shall, on the grounds 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 under any program or activity for which the contractor receives federal financial assistance from DHS and USDA: and hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement. B. The contractor agrees to comply with Texas Revised Civil Statutes Article 4419b-4, Sections 5.03 and 5.04 (relating to workplace and confidentiality guidelines regarding AIDS and HIV). C- This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants and loans of federal fund, reimbursable expenditures, grant or donation of federal property or interest in such 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 contractor by DHS. This includes any federal agreement, arrangement, or other contract which has as one of its purposes the provision of assistance such as food, cash assistance for the purchase of food, rental of food service equipment or any other financial assistance extended in reliance on the representation and agreements made in this assurance. D. 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 DHS or USDA The person whose signature appears on this contract is authorized to make this assurance on behalf of the contractor. ky DHS CLAIMS PAYMENT DHS will, subject to the federal appropriation and availability to DHS of sufficient funds for the SFSP, make program payments to the contractor in accordance with the terms of this contract No reimbursement shall be made for performance under this contract occurring prior to (a) the beginning effective date of this contract or (b) a later date established by DHS based on the date of receipt of a fully executed copy of this contract. TEXAS CORPORATE FRANCHISE TAX CERTIFICATION PURPOSE: By state law (Texas Business Corporation Act, Article 2.45),-state agencies may not contract with for profit corporations that are delinquent in making state franchise tax payments. The following certification provides a means for establishing whether a corporation is current in its state franchtse tax Payments. INSTRUCTIONS: The certification must be signed by the individual authorized on Form 2031, Corporate Board of Directors Resolution, to sign the contract for the corporation. (For USDA -funded contracts, use Form 4508, Certification of Authority, to determine who must sign.) The cerWication must be newly completed by all corporations and Ned with each offer or contract renewal package submitted. Indicate the certification that applies to your corporation. ❑ A. The corporation Is a for -profit corporation and certifies that It is not delinquent In Its franchise tax payments to the Stale of Texas. ❑ B. The corporation Is a non-profit corporation or is otherwise not subject to payment of franchise taxes to the State of Texas. The undersigned authorized representative of the corporation certifies by signature that the above statements are true and correct and that he understands making a false certification is a material breach of contract and Is grounds for contract cancellation. ►lama of Corpar W lFi"S+"W DMO hwm of Corm AWwraim City of Lubbock I Paula Simpson h 11 l & -1 s,graar.'ir on Special Programs Supervisor Texas Oepattmettt of Hyman Services SUMMER FOOD SERVICE PROGRAM APPLICATION FOR PARTICIPATION NOTE: Give as much Information as possible. Attach additional sheets If needed; please Identify each attachment with the name of the contracting organization. SECTION I —SPONSOR INFORMATION Form ISOWl-92 FOR DNS STAFF ONLY TX No. Eff. Data Approved For ��N ❑ Breakfast ❑ A.M. Supp. ❑ Lunch ❑ P.M. Supp. ❑ Supper ❑ All Contracting Organization Name Vendor 10 No. Telephone No. (nclrrde A!C) 8 Mailing Address (Street or Plo. Box. City, State, Zfl P.O. Box 2000 Street Address At dinerenp 916 Texas Avenue, Lubbock, Tx 79401 Name of Administrator ide Paula Simpson TSpecial A. Contractor Classification: ❑ National Youth Sports Program ❑ Residentlal/Nonresidential Summer Camp ❑ School Food Authority ❑ Private Non-profit ® Unit of Government —Contractor certifies that all food service sites are operated directly by the contractor. B.Is your program a year-round program? ............................... ............................... ❑ Yes M No C. Type of Contractor. ® Public Entity (explain): City Government is your agency considered to be state ownedloperated?.............................................. ❑ Yes 1XI No Do you deposit your program reimbursement directly into the State Treasury? .................... ❑ NIA ❑ Yes IKI No Do you deposit your program reimbursement directly into a local bank? .......................... ❑ NIA 1EYes ❑ No ❑ Private Nonprofit Organization —Tax-exempt status established. Attach letter of determination ORS 501-30) of tax-exempt status from IRS 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)?.................................................. El Yes ❑ No If no, which of the following circumstances applies? ❑ Residential camp ❑ Serves migrant children ❑ Failure to operate would deny program to a poor area ❑ Failure to operate would deny a significant number of children access to- program E.I. Does the organization receive $100,000 or more in federal funds yearly? .................................. ® Yes ❑ No 2. Does the organization receive more than $25,000 but less than $100,000 in federal funds yearly? .............. ❑ Yes ® No 3. 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 15C Page SECTION II —Budget A. Estimate all SFSP costs which will be claimed for reimbursement for the month with the most operating days: 1. ESTIMATED OPERATIONAL COSTS MONTHLY COSTS Program Labor $ 9,801 Fringe Benefits 1,296 Food 35,090 Non-food Supplies 0 Utilities 0 Rent 0 Equipment Use Fee Rental of Equipment Rate per mile Transportation Other (specify): Other (specify): Other (specify): TOTAL 1: 47,540 1. ESTIMATED ADMINISTRATIVE COSTS MONTHLY COSTS Administrative Labor (management, monitor, clerical) $ 2,677 Fringe Benefits 504 Rental of Office Space 0 Utilities 0 Office Supplies 265 Office Building Maintenance Equipment Use Fee Audit fees Legal Fees Rate per mile Transportation Other (specify): Other (specify): TOTAL 2: 4,610 B. Indicate projected income to the food service from all sources other than SFSP reimbursement. Identify exactly the costs this incom will cover Source of Income Amount wm be used for: a Source of Irx:orne Amount V111 be used for: a SECTION lii—MANAGEMENT PLAN A. List administrative level personnel who will be responsible for management and monitoring of the SFSP. (Do not include she supe visors. Cooks. janitors or other Dersonnel involved in on -she food service.) TITLE OF POSITION NUMBER IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES 1. Special Programs Supv. 1 Director of City of Lubbock SFSP 2. Outreach Coordinator (FT)i 1 Asst. Director of City of Lubbock SFSP 3. Recreation Supt. FT 1 Developing Budget and Grant Application 4. Monitor 1 Personnel Personnel. Training, Manage Food Service Form 1506 Page 3 B. Are children charged separately for meals? .. ... ............................ ................... ❑ Yes ® No If yes, see Form 1508, Attachment B. C.Do you want to receive advance payments?......... ........................................... ❑ Yes ® No Ifyes, 1.For Operational Costs? .. ............................................................... ❑ Yes ® No 2. For Administrative Costs?................................................................... ❑ Yes ® No D. If meals service is self -preparation, do you want to receive. commodities? .................................... ❑ Yes ® No If yes, Form 1608. Application and Agreement for Comrnodities must be completed. SECTION IV —PROGRAM OPERATION A.1. Beginning and Ending Dates of Meal Service: From June 15 _ , 1993 through August 13, 199J 2. Number of sites: ............................................................................15 B. List dates and topics of SFSP trainino: DATES TOPICS Explanation of Pro ram, Site Management, Record Keeping Meal Requirements/Inventory Nondiscrimination C. Is the organization planning to contract with a food service management company for the preparation of unitized meals?....................................................................... ® Yes ❑ No r yes, anO the contract will exceed $10,000, attach a Copy of the Invitation to bid. Also give: Date of SW Pub "Son Place of Publication Date of Bid opening lime of Bid Opening 5/2 & 5 9 93 4:00 p.m. Is bid expected to be $100,000 or more? �I( yes. give place of bid 099drK . ❑ Yes ® No Also, attach a copy of an 11-day-cycle menu including all specific menus to be used. D. Is organization contracting with a year-round food service rrranagement company? ............................ ❑ Yes ® No If yes, submit a copy of your procurement procedures, bid, contract, and all amendments. E. Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department notifying them of intent to operate a Food Service Program at the she(s) indicated on the attached Site Information sheet (Form 1507). SECTION Y—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 B 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 childre n 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. Form 15C Page 3. If the contracting organization is sponsoring a camp or other enrollment program that charges separately for meals, the contractin, organization has read Attachment B to this application, "Additional Assurances For Camps And Other Enrollment Programs That Charg Separately For Meals", and assures the DHS that all requirements have been or will be met B. Public Release (SFSP Handbook, Chapter II, page 22) 1. The contracting organization will make efforts to ensure that the local news media will make a public announcement of the prograr 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 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 wwisalt)n) announces the sponsorship of the Summer Food Service Prograrr income eligibility will be based on family size and Income using the Standards for Determining Free and Reduced -Price Eligibil ty, provided by the United States Department of Agriculture. Meals will be provided at the alte(s) listed. People who are eligibi to participate In the program must not be discriminated against because of race, color, national origin, sex, age, disability, religior or political belief. Anyone who believes that they have been discriminated against should write Immediately to: Director, Clv Rights Division, MC E-609, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714.9030 or the Secretar of Agriculture, Washington, D.C. 20250. NOTE: Discrimination complaints based on religion or political beliefs must be referre 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 agains because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who believes that they have bee discriminated against should write Immediately to: Director, Civil Rights Division, MC E-609, Texas Department of Human Sen Ices, P.O. Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington, D.C. 20250. NOTE: Discrimina tion complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Depart ment of Human Services." 2. This public release was or will be pubftshed in the following news media outlet(s): NAME OF MEDIA OUTLET DATE OF RELEASE Parks and RecreationSummer Leisure Guide May 16th 199 Avalanche -Journal Week of May 94th, Week of Southwest Digest NAME OF MEDIA OUTLET DATE OF RELEASE E1 Editor Week of Week of Television Ma Ath 3. Attach a copy of the contracting organization's public release statement as submitted to the news media and any other materials use to publicize the program's availability and nondiscrimination requirements. SECTION VI --CERTIFICATION (see Form 1506, Attachment C) I certify that the Information on this application Is true and correct to the best of my knowledge. I certify that reimbursement wi be claimed only for approved meats served to eligible children during the hours they are In attendance at approved sites. I kno% that deliberate misrepresentation or withholding of Information may result In prosecution under applicable state and federal statute! signature—Orricial of contracting Organization owe Name (please " or prino FOR DHS USE ONLY ❑ APPROVED ❑ DENIED If denied, reason: Title Approved for Food Distribution Date ❑ Yes ❑ Ng 0 if yes, give date Form 1608 sent to FDD: f Title Signature—DHS Representative Date Texas DepanmSnt Form 1506/Allachment A of Hurnm servkes SUMMER FOOD SERVICE"°PROGRAM FOR CHILDREN earl k" 1990 CIVIL RIGHTS QUESTIONNAIRE I. CIVIL RIGHTS ACT OF 1964 A. 1. Estimate, by raciaVethnic group, the number of children that will participate in the program at each site. If the program consists of several camp sessions, specify the projected number of children by site and date of session: SITE (nart» of all@. School, camp, Ste.) AMERICAN INDIAN ALASiCAN NATIVE ASIAw ►ACInC IStANDER BLACK HISPANIC WHITE Skyview 3 Castle Garden 17 - 8 349 1,165 543 Atzlan 1 - 1 92 236 282 2. Describe how this projection was made (i.e.. based on comparative enrollment in sites, observation of students, student surnames, etc. Total racial/ethnic groups in census neighborhoods in 1990. B. Does the organization have specific membership requirements which result in the denial of program benefits to specific groups?............................................................... ❑ Yes 10 No If yes, describe those requirements: C. What efforts will be made by the organization to contact minority and grass roots organizations about the opportunity to participate in the program? The organization will be publicized widely through minority schools webkly, ethnic newspapers, and through the minority centers. D. What other outreach stops will be taken by the organization to ensure that minorities in the area from which it draws its attendance will have an equal opportunity to participate in the program? The program will be announced at neighborhood meetings:_ E. Has any federal agency notified the organization of non-compliance with the Civil Rights act of 19647 .............. ❑ Yes 'rAv7I No If yes, give details including dates, names, and results: 11. REHABILITATION ACT OF 1973 (Section 504) A. Does the contracting organization have any policies, pradices, or architectural barriers that limit, deny, or discourage participation in the program or employment by the contracting organization because of disability? ........ El Yes ❑ No if yes. explain: Some park/playground sites are not handicap accessible At these sites, staff will assist handicap participants. form 1506 / Attachment A Page 2 B. Are there any policies or practices that result in unequal treatment in the delivery of benefits or services to participants, applicants, or employees according to disability? ................................. ❑ Yes L No If Yes, explain: C. Does the contracting organization employ 15 or more people? ......................................... ®Yes ❑ No If yes: 1. Enter the name and title of the coordinator who will work with DHS to ensure that Section 504 requirements are met. Name Title 2. Has the organization established grievance procedures that incorporate appropriate due process standards? ..... .. ......................................................... ® Yes ❑ No If yes, do these procedures provide for the prompt and equitable resolution of complaints n that allege an action prohibited by Section 504 of the Rehabilitation Act of 1973? ................. Oyes ❑ No 3. Has the contracting organization informed the public of the right to file a complaint and of the filing procedure?.......... ... ..... ....... 10 Yes ❑ No If yes, briefly describe how the public was informed: The section 504 information is Published in the Parks & Recreation Leisure Guide three times annually and in other City publications. D. Has the organizaton taken steps to notify employees, participants, and applicants that the organization does not discriminate on the basis of disability? ................. ..... ... ....................... � 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 with the contracting organization? ........... ® Yes ❑ No It yes, briefly describe how they are notified: They are notified through the Employee Handbook, in all recruiting publications, and on the application. E. Do all organization forms, publications, and recruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the organizationdoes not discriminate on the basis t"1 ofdiisability?..... ....................................................................... M Yes ONo If no, indicate steps being taken to comply with this requirement: F. Does theorganization have a procedure to ensure that the remedial or corrective action has been or will be taken if non-compliance with non d'tscriminailon requirements is found by DHS, USDA, or the contracting a Yes ❑ No organization itself? ......................... ........ ......... If yes, explain: There is no policy in this regard; however the Pprconnpl nnartment would work to correct any problems Discrimination has not been found within the City of Lubbock. Texas Department Forth 15071January 199: of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR VHS USE ONLY SiTE INFORMATION r # 'QR ❑U Name of Food Service Site Telephone No. (ft Yellow House Washingtpn_Amer N/A Park Site Address of Site (Street City. State. zrP) 61st and Olive - Lubbock Tx 79401 Period of Operation of Food Service (moldayNr.-moldeytyr.) Number of Op- May �June jury ��t,g. .Sept. From: 6/ 15 3 through: 8 13 orating Days: 22 10 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp She Serving Prfmadly Migrant Children Other Slte 1. Indicate Type of Site: ❑ A. (serving one to four meats) ❑ C. (serving one to four meals) ® E. (serving one to four meals) Nonesidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meals) 2. Ust ALL counties served by this site: 3. A. Is your site open: ......................................................................................... WYes ❑ 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, Chapter II) ........................................... 57.2 D. If open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Wheatley Elementary E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? ................................ I ............ °/ 4. Did the site participate In previous years' SFSP? (SFSP Handbook; Chapter IQ-:-7::................................. ®Yes [3No if Yes, give name of contracting organization• City of Lubbock 5. Monitoring Plan (SFSP Handbook, Chapter Ill): Enter date of monitoring review to be conducted within: - 6/4 6. Meal Service Perod Information (SFSP Handbook. Chanter lil: 5/•93 - TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNiNG ENDING Breakfast A.M. Supplement Lunch 30 12:30 m 2:OOPM P.M. Supplement Supper _ ___ ,____._____ ._ �_�-�-�� �, �..- ........ �.. w..,, �... ..,.,.. v.w ..wr �.....wr .... �.. �w. v. ...r ...wv^. �.•-,. w. ..� 7. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter IQ On Site LJ Central Kitchen 1 ❑ tJsinq School Food Authority U0 Food Service Management Company (Includes All Year Contracts) Form 1507/Pape 8..Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter Cafeteria -style Children are Seated Children Une Up ❑ Meat Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other. S. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook Chapter ICI: TITLE OF POSITION No. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) ❑Indoor Meal Meat Service Service 0 Will Be Cancelled ❑ Other. 11. If the she feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are n, required for meals? 12.Are meals delivered to the site?..................................................................... ❑ Yes ❑ N IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook Chap. to: Site Personnel Will Contact Administrative Site Personnel Will Communicate © Staff, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook Chapter iq ..................... ® Yes ❑ N It no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of servic 15. If there is an excess of meals delivered, meals will be (SFSP Handbook Chapter Ito: ❑Stored In Refrigerator Thrown Away Returned to Vendor and Served the Next Day® at the Site ❑ for Disposal ❑ Other. 1 CERTIFY that the information on this form is true and correct to the best of my knowledge. 1 certify that this site has been visite and that It has the capability and facilities for the meal service planned for the number of children anticipated. i know that delibera, misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of Contraeting Agency City of Lubbock ftnatwe--OMCW of Contrse6ng Organization Date Name of official (please ype or priaq Title Paula Simpson I I Special Pro4ram Supervisor FOR FOR ❑ Approved ❑ Denied; reason: DMS USE ONLY° Signature—DHS Representative Date Texas Depaitmem Form 1507/January 199; of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OKS USE ONLY SITE INFORMATION .r.Xx 110R DU Name of Food Service Site ebphone No. (ino, Carter Park N/A Park Site Address of Sfte (SV"t. M State, LP) Globe and North Loop 289 - Lubbock, Tx 79403 Period of ration of Food Service (moldaytyr.-mojdayryr.) Number of 0 sty JuneM �AK Sept.From: 6/15/93 through: 8/13/93 oratingDays r 0 12'�Ju22 10 0 ATTACH A MAP WiTH THE SiTE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Site 1. indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) Q E. (serving one to four meals) Nonesidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to lour meals) 2. List ALL counties served by this site: 3. A. Is your site open:............................................................... ...................... QYes ❑ No S. is your site enrolled?..................................................................................... . ❑Yes Q No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) ....................... . ................... 94.5 % D. K open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Arnett Elementary E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What Is the percentage of free or reduced-prlee meals for the site? ........................................... % 4. Did the site participate In previous years' SFSP? (SFSP Handbook Chapter fl}-7 :...... :..................... ®Yes ENO If Yes, give name of contracting organization- City of Lubbock 5. Monitoring Plan (SFSP Handbook, Chapter Ili): Enter date of 6/ 15/93- 6/4/93 1 6/ 15/93- 6/25/93 6. Meat Service Pedod Information (SFSP Handbook. Chanter II): review to be conducted within: 5/93- TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDWO Breakfast A.M. Supplement Lunch 55 12 : 00 p.m. 1:100 p.m . P.M. Supplement Supper rn+s nuvnrwuu" rs wrwpprou uy uru gran s,,,V ww apWuv mean sarv= lever. twrar nan0000rs. t•fwier ty 7. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter In On Site L_) Central i(ftchen I ❑ Using School Food Authority (—y 1 Food Service Management Company (Includes Alt Year Form 1507/Page S. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter 1. Cafeteria -style Children are Sealed Children Line Up ❑ Meal Service ❑ and are Given Meals Mend Pick Up Meals ❑ Other. " 9. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN PosrTION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meat service during periods of inclement weather (SFSP Handbook, Chapter II) ❑Indoor Meal Meal Service Service © Will Be Cancelled ❑ Other. 11. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are no: required for meals? 12. Are meals delivered to the site?..................................................................... ® Yes ❑ Nc IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11): ® Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter IQ .................. ® Yes ❑ Nc If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 15. If there Is an excess of meals delivered, meals will be (SFSP Handbook, Chapter Iln: ❑Stored In Refrigerator Thrown Away Returned to Vendor and Served the Next Day at the Site ❑ for Disposal ❑ Other. 1 CERTIFY that the Information on this form Is true and correct to the best of my knowledge. 1 certify that this site has been visitec 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 Apency City of Lubbock Signature --Official or Contracting organiution Dais Name of Official (please type or prino Trtle FOR DNS USE ONLY ❑ Approved ❑ Denied; reason: al Program Supervisor Signature—DHS Representative Date Texas Depamr*m Form 15071januawNy 1993 of Hen Swilces SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OHS USE ONLY SITE INFORMATION I-,[3R ❑u Name of Food SecvWe Site Telephone No. (WW_ AqC) Mae Simmons Community Center — Address of Site (Street. CRY. Stau, ZtP) 23rd and Oak - Lubbock, Tx 79403 Period or Osorawn of Food Service (rnoldayNr.-mojday/yra Humber of Op- may June ,iuly Aug*�y sop' From: 6/ 15 93 through: 8/ 13 93 erating Days: 0 1 2 22 10 Y 0 ATTACH A MAP WiTH THE SiTE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) 0 E. (serving one to four meals) Nonesidential Camp Site Serving Primarily homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meals) 2. List ALL counties served by this site: 3. A. Is your site open: .................................................................... I ................ . ❑X Yes ❑ No B. 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, Chapter 10........................................... 66.7 % D. If open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Posey Elementary E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? ............................................. % 4. Did the site participate in previous years' SFSP? (SFSP Handbook; Chapter IIj :- .:........ I ... I .............. ❑Yes ❑ No If Yes, give name of contracting organization City of Lubbock 5. Monitoring Plan (SFSP Handbook. Chapter IQ): Enter date of monitoring review to be conducted within: week d Operation B First Four weeks of Operation C. Additional Reviews LZ- 6/4/93 6/ - 6/ 25 93 1 6 6. Meal Service Period Information (SFSP Handbook Chapter I1): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TiME BEGINNING ENDING Breakfast A.M. Supplement Lunch 137 11:30 a M. 1:00 P.M. P.M. Supplement -. Supper — wn",6 a 1 r w.0 Ivu QY vriw Wrwn ""Wv ore appraveo meal serv= Beyer. (wrwr rw=Q K, utia w u) 7. Method of Food Preparation by Contracting Organization (SFSP Handbook Chapter 1Q Son-P7epsrabon Vended 0 On Site ❑ Central Kitchen I ❑ Using School Food Authority ® Food Service Management Company (Includes Aft Year Contracts) Form 1507113age S. Indicate the system to be used for the serving of meals and the supervision of children during meat service period (SFSP Handbook, Chapter Cafeteria -style Children are Seated Children lane Up El Meal Service ❑ and are Given Meals ❑ and Pick Up Meals ❑ Other. S. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter to: TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal Service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service ® Service ❑ Will Be Cancelled ❑Other. 11. If the she feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are nc required for meals? 12. Are meals delivered to the site?..................................................................... ® Yes ❑ N IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II): ❑Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter 10 ..................... D Yes ❑ N if no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of servicE 15. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter Iln: ❑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 visite and that It has the capability and facilities for the meat service planned for the number of children anticipated. I know that dellberat misrepresentation or withhoiding of Information may result In prosecution under applicable state and federal statutes. Name of Contracting Agency City of Lubbock signature —Official or Contracting orgaNzatan Date Name of Official (please ype or print) rule Paula Simpson I Special Program Supervisor FOR ❑ Approved ❑ Denled; reason: DNS USE ONLY signature—DHS Representative TRIe Date Texas Deponent Forth 1507/Jana of Hun'n S°rvs°°' SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OHS USE ONLY SITE INFORMATION 'TX R 6th and Ave. T. - Lubbock Tx 79401 Period of Operation d Food Service (m jcIayJyr.- w4daylW) Number of Op- � May �J" �J* �AW,j A Sees.From: 6/15/93 through: 8/13/93 trating Days: !1) ATTACH A MAP WITH THE SiM SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) ® E. (serving one to four meals) Nonesidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meals) 2. List ALL counties served by this site: ul 3. A. is your site open:............................:............................................................ [X]Yes ❑ No B. is your site enrolled? ...................................................................................... []Yes (ENo C. She Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter Iq........................................... . 97 - 9 % D. If open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Ramirez Elementary E. For enrolled sites, Form 1531 will be used to document eligibility. K the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the she? ............................................. % 4. Did the site participate in previous years' SFSP? (SFSP Handbo* Chapter :.- _ .. . :.................... . QYes []No If Yes, give name of contracting organizattom City of Lubbock 5. Monitoring Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: A week or Operation B. First Four weeks of Operation C. Additional Reviews 6/15/93 - 6/4/93 1 F/15/93 - 1 1;/15/93 - A /i wwi 6. Mead Service Per'od Information (SFSP Handbook. Chapter In: TYPES OF UFAI S NUMBER OF ELIGIBLE CHILDREN TO BE SERYED• MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 100 12:15 P.M. 1:30 p.m. P.M. Supplement Supper — Ww 11Mw w %4Agb $WU Ur wnQ nman sewrq aw approves W,= aerv+oe wvet. tarar nawwoK. %Awwr a) 7. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter H) Sell -Preparation vended ❑ On Site ❑ Central Kitchen 1 ❑ Using School Food Authority ® Food Service Management Company (Includes All Year Contracts) Fonn 1507/Page S. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter Caleterla-style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ID and Pick Up Meals ❑ Other. 9. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POS=N SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help to Serve Meal J.T.P.A. Worker 2 Help Serve Meal 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) ❑ indoor Meal Meat Service Service ® Will Be Cancelled ❑ Other. 11. If the site feeds primarily homeiwss children, what methods are used to ensure that money, food stamps, or in kind services are n, required for meals? 12. Are meals delivered to the site?..................................................................... ® Yes ❑ N IF YES, COMPLETE ITEMS 13, 14, do 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11): ®Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ..................... U Yes ❑ N If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of servic 15. If there is an excess of meals delivered, meats will be (SFSP Handbook, Chapter lln: ❑Stored in Refrigerator Thrown Away Returned to Vendor and Served the Next Day ® 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 visite and that It has the capability and facilities for the meal service planned for the number of children anticipated.) know that delibera, misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of Contracting Agency City of Lubbock Signature—Otfi6al of Conuac&V Organization Due Name of Official (ptease type or print) Taw Paula Simpson Special Program Supervisor FOR OHS USE ONLY ❑ Approved ❑ Denled; reason: Title Signature —DNS Representative Dais Taxes Oepartrmm Forth 1507Wanuar im of Human Se"" SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR VHS USE oNLY . SITE INFORMATION ..L Name of Food Servim Site Teraprwne No. (aic Copper Rawlings Community Center (806) 767-2704 40th and Ave. B - Lubbock, Tx 79404 Ponod of Operation of Food Service (moJdayM•-=JdayM•) Number of Op. may AM "Y AW sepL From: 6/ 15/93 through: 8/ 13/93 crating Day:: 0 12 22 10 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) © E. (serving one to four meals) Nonesidentlal Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meals) 2. List ALL counties served by this site: 3. A. Is your site open:..................................................................................... .. ®Yes []No B. Is your site enrolled?...................................................................................... ❑Yes K No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) ........................................... . 94.7 % D. If open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Harwell Elementary E. For enrolled sites. Form 1531 will be used to document eligibility. ff the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? .........:................................... /a 4. Did the site participate in previous years' SFSP? (SFSP Handbook; Chapter fly---::- :..: :........................... ❑Yes [--]No K Yes. give name of contracting organization, City of Lubbock 5. Monitoring Plan (SFSP Handbook, Chapter IIQ: Enter date of 6/ 15/9} 6/4/93 1 6/15/93 - 6/25/93 6. Meal Service Perlod Information (SFSP Handbook. Chanter In: review to be conducted within: 6/15/93 - 8/13/93 TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' {MEAL SERVICE TIME BEGINNING ENDING Brealdast A.M. Supplement Lunch 11:00 a.m. 12:30 p.m. P.M. Supplement Supper .Tim L/���..-� L ��-_�-__� �.I�un .. �._- �_.u_� r_ ___�_ _ ._.._• .n ems...- u__��__.. ��__._. .w 7. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) swaj:.r& MTL-%n I Vu.v1aA On Site H Central Kitchen I f1 Usino School Food Authority nv 1 Food Service Management Companv (Includes All Year Form 1507/Page 8. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter Cafeteria -style Children are Seated Children Line Up ID Meal Service ❑ and are Given Meals 0 and Pick Up Meals ❑ Other. 9. List site personnel who will be involved to any extent In the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Supervise Meal Asst. Center Su ervisor 2 HelD to J.T.P.A. Worker, 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) Indoor Meal Meal Servlca ® Service ❑ WIII Be Cancelled ❑ Other. 11. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are nc required for meats? 12. Are meals delivered to the site?..................................................................... ®Yes ❑ N� IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. Iq: 0 Site Personnel Will Contact Administrative Site Personnel WIII Communicate Staff, Who WIII Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook Chapter 10 ..................... ® Yes ❑ N� If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of servicE 15. If there is an excess of meals delivered, meals will be (SFSP Handbook Chapter 110: ❑Stored In Refrigerator Thrown Away- Returned to Vendor and Served the Next Day ® at the Site ❑ for Disposal ❑ Otherr CERTIFY that the Information on this form Is true and correct to the best of my knowledge. 1 certify that this site has been visite, and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberat misrepresentation or withholding of Information may result In prosecution under applicable state and federal statutes. Name of Contracting Agency City of Lubbock Signature--0rScW of Conracting Organization Date Name of OKicW (please Type or prinQ Title Paula Simpson Special Program Supervisor FOR Fs Approved [:)Denied; reason: USE ONLY Title Signature—DHS Representative Date Texas Department or Human Services Hollins Park 1st and Temple - SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION FOR OHS 115E ONLY N/A Park Site R ❑U Period or Operation or Food service (moJdaylyr.-moldayM.) Number of Op- May J" .,uiy wuo• Sept. From: 6/ 15/93 through: 8/13/93 crating Days: n 12 22 10 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp She Serving Primarily Migrant Children Other She 1. indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to lour meals) ID E. (serving one to four meals) Nonesldential Camp She Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meals) 2 list ALL counties served by this site: 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, Chapter IQ ........................................... 97% % D. If open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Jackson Elementary E. For enrolled sites, Form 1531 will be used to document eligibility. H the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? ............................................. 4. Did the site participate in previous years' SFSP? (SFSP Handbook Chapter fir :-: �- ..::....::..................... E) Yes [] No If Yes, pave name of contracting organization• City of Lubbock 5. Monitoring Plan (SFSP Handbook, Chapter Ill): Enter date of monitoring review to be conducted witiiln: k Fret week or Operation 8. Fuss Fora weeks of Operation C. AdcMkx t Reviews 6/15/93— 6/4/93 6/15/93— 6/25/93 6/15/4— 8/13/93 6. Meat Service Period Information (SFSP Handbook, Chapter 10: TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 55 P.M. Supplement Supper ...0 ■■u.ni■u�n. w Knu.w�w ur vru wrrwn seuinp riM apprwea rtaar service wyer. tarzr nanaaouN uwpwr nI 7. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) Sell -Preparation vendee ❑ On Site []Central Kitchen ❑ Using School Food Authority ® Food Service Management Company (includes All Year Contracts) Form 1507IP2ge 8. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter ❑ Cateterla•style Children are Seated Children Line Up Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other. 9. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter to: TITLE OF POSITION No. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help -to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) ❑indoor Meal ce Service 9 WiltMeaf BeServiCancelled ❑ Other. 11. It the site feeds primarily homeiwss children, what methods are used to ensure that money, food stamps, or in kind services are nc required for meals? 12. Are meals delivered to the site?..................................................................... ® Yes ❑ N IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11): ®Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter IQ ..................... © Yes ❑ N If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of servic 15. If there is an excess of meats delivered, meals will be (SFSP Handbook, Chapter Ilq: Slared In Refrigerator ❑ and Served the Next Day ❑ at the Site wn ay ❑ or Disposal Returned to Vendor ❑ 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 visite and that It has the capability and facilities for the meal service planned for the number of children anticipated. i know that deliberat misrepresentation or withholding of information may result In prosecution under applicable state and federal statutes. Name of Contracting Agency City of Lubbock sipnatwe--Official of contraang orgaNzatan Date Name of Official (please type or pmo Titla FOR ❑ Approved ❑ Denied, reason: OHS USE ONLY Signature—DHS Represenwive Date Texas Department aE Human Servloes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION 23rd and Ave. L - Humber of Op- h May hJ "1° " FOR OHS USE ONLY x I—]U N/A Park Si I From: 6 j 1 C/ q3 through: I orating Days: I U i 19 T 22 T 10 i f ATTACH A MAP WiTH THE SITE SERVICE AREA IDENTIFIED Residential Camp She Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) ® E. (serving one to four meals) Honesldentlat Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meats) 2. list ALL counties served by this site: 3. A. is your site open: ............................................................. .......................... (Eyes ❑ No B. Is your site enrolled?...................................................................................... [_]Yes ®No C. Site Eligibility: Enter the percentage of children eligible for free ancVor reduced price meals for the she (SFSP Handbook, Chapter 11) .................... q3 - q % D. It open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Bean Elementary E. For enrolled sites, Form 1631 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What Is the percentage of free or reduced -price meals for the site? ........... % 4. Did the site participate in previous years' SFSP? (SFSP Handbook Chapter::....::..................... ®Yes ❑ No It Yes. give name of contracting organization_ City Of Lubbock 5. Monitoring Plan (SFSP Handbook. Chapter lid: Enter date of monitoring review to be conducted within: A. Frst week d Operation B First Four weeks of Operation C. AddiborAl Reviews 6/15h93- 6/4/93 6/15/93- 6 25 93 15/93- 6. Meal Service Perod Information (SFSP Handbook, Chapter 14: TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Sr"Wast A.M. Supplement Lunch 90 11:00a.m. 12:30 p.m. P.M. Supplement Supper - r r= rnrormauon rs oon=weo cy uru wnen semrp aye approves flow aeN" rave+. (w-w- nan=oou, cnapter iq 7. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) Sea -Preparation vended 0 On Site ❑ Central Kitchen ❑ Using School Food Authority ® Food Service Management Company (Includes All Year Contracts) forth 15071page S. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter Cateteria-style Children are Seated Children acne Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other. 9. List site personnel who will be involved to any extent In the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Senvice Summer Recreation Wk. 2 HeID to Serve J.T.P.A. Worker 2 MR to Serve Meals, 10. indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service ❑ Service ® Will Be Cancelled ❑ Other. 11. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are required for meals? 12. Are meals delivered to the she?..................................................................... 0 Yes ❑ N IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11): ®Site Personnel Will Contact Adminlslrailve Site Personnel Will Communicate Stafi, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook Chapter IQ ..................... ® Yes ❑ N If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 15. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter IIQ: Stored In Refrigerator ❑ Thrown Away Resumed 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. 1 certify that this site has been vlsite and that it has the capability and facilities for the meal service planned for the number of children anticipated. i know that dellbera! misrepresentation or withholding of Information may result in prosecution under applicable state and federal statutes. of Contracting Agemy Name City of Lubbock signature— orfiaal of corxr.+ccng orgaNzation Date Name of OtficW (please " or pMQ Title Paula Simpson - Special Program Supervisor FOREl DNS Approved USE ONLY 13 Dented; reason: 7iUe 1 Sigrnture—DIS Representmive Due Texas Department of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Carlise Park 26th and Ave. W - Lub Farm 1507/Jams 1993 ^� FOR DKS USE ONLY <"'"MR �U N/A Park Site renoo Gr L"ration or Foos servae lm0l0ay1Yr.-mo4Gay1)r.) Number of Op- mar rugs ,nny pup. �eP[ From: 6/ 15/93 through: 8/ 13/93 erating Days: 0 t 9 22 10 0 ATTACH A MAP WITH THE SrM SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) E. (serving one to four meals) Nonesidential Camp She Serving PrimaMy Homeless Children ❑ B. (serving one to four meals) ❑ 0. (serving one to four meals) 2 list ALL counties served by this site: 3. A. Is your site open:............................................................... ....................... ©Yes [:)No S. Is your site enrolled?...................................................................................... ❑ Yes M No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook. Chapter II) ........................................... 93.5 % D. If open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document she eligibility, as applicable: Dupree Elementary E For enrolled sites, Form 1531 will be used to document eligibility. K the enrolled site used school data, list the school used to document the site: F. What Is the percentage of free or reduced-prioe meals for the site? ............................................. % 4. Did the site participate in previous years' SFSP? (SFSP Handbook; Chapter tt} :7 :.- ..::....:...................... ®Yes []No If Yes, give name of contracting organizations City of Lubbock 5. Monitoring Plan (SFSP Handbook, Chapter IIQ: Enter date of monitoring review to be conducted within: A. Fkst week d Operation & Fist Fax weeks of Operation C. Addltiatial Review: 6/15/93 - 6/4/93 1 6/15/93 - 6/25/93 1 6/15/93 - 8/13/93 6. Meal Service Period Information (SFSP Handbook. Chapter in: TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TiME BEGINNING ENDING Breakfast A.M. Supplement Lund' 65 12:30 p.m. P.M. Supplement Supper ......, ...o., . a w.w+v.w ur v 10 --wir sawnp are awrvvao meal sarvrcw rermc tarar- n wxxxx ti. I.'(Wwr nr 7. Method Of Food Preparation by Contractinn Oreanization (SFSP Handbook. Chanter IIi Sod-Preparabon vended 0 On Site ❑ Central Kitchen ❑ Using School Food Authority ® Food Service Management Company (Includes All Year Contracts) Form 1507/Pagc S. Indicate the system to be used for the serving of meats and the supervision of children during meal service period (SFSP Handbook, Chapter Cafeteria -style Children are Seated Children Una Up ❑ Meal Service ❑ and are Given Meals � and Pick Up Meals, ❑ Other. 9. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter IQ: TITLE OF POSITION NO. IN POSRION SPECIFIC FOOD SERVICE PROGRAiA DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) ❑Indoor Meal Meat Service Service L—Ai Will Be Cancelled ❑ Other. 11. if the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are nc required for meals? 12. Are meals delivered to the site?..................................................................... 0 Yes ❑ N IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook Chap. 11): coSite Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook Chapter IQ ..................... []Yes ❑ N If no, describe arrangements within standards prescribed by local heath authorities for delivery and holding of meals until time of servic: 15. If there is an excess of meals delivered, meals will be (SFSP Handbook Chapter 110: ❑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 visite and that It has the capability and facilities for the meal service planned for the number of children anticipated. i know that deliberat misrepresentatlon or withholding of information may result In prosecution under applicable state and federal statutes. Name or Contracting Agency City of Lubbock Signature —Official of Coi v ng Organization Date Name of Otr+ctal (please type or print) Tide Paula Simpson Special Program.Supervisor FOR ❑ Approved ❑ Denied; reason: DHS USE ONLY Tide Signature —OHS Representative Date Texas Deparunord ofHu=Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION FOR VHSWE ONLY y pa UI Mahon Elementary Park 2010 Cornell - Lubbock Period of Operation or Food Service (mo4"yM.-rno4aayryr.! I Number of Op- may .+urw Jury p. Sept From: 6/15/93 through: 8/13/93 Orating Days: 0 19 2 2 scu1 [l ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other SRO 1. Indicate Type of Site: ❑ A (serving one to four meals) ❑ C. (serving one to four meals) ME. (serving one to lour meals) Nonesidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meals) 2. List ALL counties served by this site: 3. A. Is your site open: ...................................................................................... LA Yes ❑ No B. Is your site enrolled?...................................................................................... []Yes QX No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced rice meals for the site SFSP Handbook, Chapter I D. It open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Mahon Elementary E. For enrolled sites. Form 1531 will be used to document eligibility. It the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? ............................................. % 4. Did the site participate in previous years' SFSP? (SFSP Handbook Chapter .. :................... .. ®Yes ❑ No If Yes. give name of contracting organization• City of Lubbock 5. Monitoring Plan (SFSP Handbook. Chapter Ili): Enter date of monRorkv review to be conducted within: A. First week or OperaWn B. First Four weeks of Operation C. Addrtionat Reviews 6/ - 6/4/93 1 6/ - 6/25/93 1 6 - 8 13 93 6. Meal Service Period Information (SFSP Handbook. Chapter In: TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TVAE BEGINNING ENDING Breakfast A.M. Supplement Lunch 39 P.M. Supplement Supper — wwkwrrw l w wiu .M'VU Ur WFu wean sawry aye approved meal somme ,ever. tQr, r rmn000m. %Awwr III T. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter In Sea -Preparation Vended 0 On Site ❑ Central Kitchen ❑ Using School Food Authority ® Food Service Management Company (includes A8 Year Contracts) Form 1507IP2ge . S. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter I ❑ Caleleda-style Children are SealedChildren Una Up Meal Service ❑ and are Given Meals ❑ and Pick Up Meals ❑ Other. 9. List site personnel who will be involved to any extent In the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) ❑Indoor Meal Meal Service Service ® Will Be Cancelled ❑ Other. 11. If the site feeds primarily homelwss children, what methods are used to ensure that money. food stamps, or in kind services are nc required for meats? 12. Are meals delivered to the site? .......... ........................................................ © Yes ❑ Nc IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11): ®Site Personnel Will Contact Administrative Site Personnel WIII Communicate Staff, Who WIII Contact Vendor ❑ Directly With vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter 14 ..................... ® Yes ❑ Nc if no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 15. It there is an excess of meals delivered. meals will be (SFSP Handbook, Chapter itij: ❑Stored in Refrigerator Thrown Away Retumed 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 visatec and that It has the capability and facilities for the meal service planned for the number of children anticipated. i know that deliberat, misrepresentation or withholding of Information may result in prosecution under applicable state and federal statutes. Name of Contracting AQency City of Lubbock 5ipnatura--OtRcial of Contracting organization Date Name of official (please type or pmo rills Paula Simpson I Special Program Supervisor FOR DHS USE ONLY ElApproved ❑ Dertled, reason: II Signature—DHS Representative Dore Texas Department of HumanSeMoes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Rodgers Community Center 3200 Amherst - Lubbock, Tx 79415 Form 15071janw FOR OHS USE ONLY TX 11R. 806) 767-2702 Period of Operation of Food Service (m04"Y1W--M04"YA1-) Number of Op- May dww .wry ^up- aevL From: 6/ 15/ 93 thigh: 8/ 13 / 93 erating Days: n 12 99 l fl 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp She Serving Primarily Migrant Children Other She 1. Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) ® E. (serving one to four meals) Nonesidential Camp She Serving Primarily Homeless Children ❑ 8. (serving one to four meals) ❑ ( (serving one to four meals) 2 List ALL counties served by this site: 1993 UI 3. A. Is yoursite open:......................................................................................... ® Yes [:]No S. is your site enrolled?...................................................................................... ❑ Yes ® No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced 77.4 price meals for the site (SFSP Handbook Chapter IQ .......................................... . D. If open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: McWhorter Elementary (94.7%) Tubbs Elementary (60.1%) E. For enrolled sites, Form 1531 will be used to document eligibility. If fhe enrolled site used school data, list the school used to document the site: F. What Is the percentage of free or reduced -price meals for the site? ............................................. % 4. Did the site participate In previous years' SFSP? (SFSP Handbook Chapter fly :-: ::....::..................... QYes []No If Yes. give name of contracting organization- City of Lubbock S. Monitoring Plan (SFSP Handbook Chapter 110: Enter date of monitoring review to be conducted within: A First week of Operation 8 First Four weeks of Operation C. AddtionW Reviews 6A5/93 - 6/4/93 6/15/93 - 6/25/93 6 5/93 - 8 13 3 6. Meal Service Per'od Information (SFSP Handbook Chapter In: TYPES OF iAEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED• MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 108 P.M. Supplement Supper r nu auonnauon a cwmioereo oy vru wren semnp ale approves meai samm never. tbrzir nana000rc, t;napter rq 7. Method of Food Preaaration by Conbmctina Organization SSFSP Handbook- Chanter In Sea -Preparation vended ❑ On Site El Central Kitchen ❑Using School Food Authority ®Food Service Management Company (Includes All Year Contracts) form 1507/Page 8. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter I Cafeteria•style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals M. and Pick Up Meals ❑ Other. 9. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter Ii): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Supervise Meal Service Asst. Center Supervisor 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) 0 Indoor Meal Meal Service Service ❑ Wlll Be Cancelled ❑ Other. 11. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are nc required for meals? 12. Are meals delivered to the site? ..................................... ............................... ❑ Yes ❑ Nc IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. IQ: ©Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter IQ ..................... © Yes ❑ N If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 15. It there is an excess of meals delivered, meats will be (SFSP Handbook Chapter HI): ❑Stored In Refrigerator Thrown Away Returned to Vendor and Served the Next Day ® at the Site ❑ for Disposal ❑ Other. 1 CERTIFY that the Information on this form is true and correct to the best of my knowledge. 1 certify that this site has been visite and that It has the capability and facilities for the meal service planned for the number of children anticipated.) know that deliberat rnlsrepresentation or withholding of Information may result In prosecution under applicable state and federal statutes. Name of Contracting Agency City of Lubbock signature- O ficW or Contracting organization Date Name of OffcW (please ype or print) TWO Paula Simpson Special. Program Supervisor FOR ❑ FOR Approved ❑ Denled; reason: DN USE This ONLY Signature—DHS pepresentative Date Texas Depwunent Fwm 1507/January 1993 of Human SenAces FOR DHS USE ONLY - SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SiTE INFORMATION ❑R °❑U Name of Food Service Site Telephone No. (ina /VC) Chatman Park N/A Park Site 27th and Ivory - Lubbock, Tx Period of Operation of Food Service (moJdaylyr•-aioJday1Yr•) Number of Op- May �J" AAugR�pL I From: 6/15/93 through: S/11/4-j eratingDays: 0 12 99 Y 10 y 0 ATTACH A MAP WiTH THE SiTE SERVICE AREA IDENTIFIED Residential Camp She Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) Q E. (serving one to four meals) Nonesidentlal Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meats) 2. List ALL counties served by this site: 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 57.2 price meats for the site (SFSP Handbook, Chapter II) .......................................... . D. if open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Wheatley Elementary E. For enrolled sites. Form 1531 will be used to document eligibility. if the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? ............................................. % 4. Did the site participate in previous years' SFSP? (SFSP Handbook; Chapter try --- ..::........................... ® Yes O No If Yes, ghre name of contracting organization.• City of Lubbock 5. Monhorino Plan (SFSP Handbook Chapter Ill): Enter date of monitoring review to be conducted within: A. FkV week of Operation B. FxV Far weeks of operation c. Additnal Reviawa 6/15 93 - 6/4/93 1 6/15 93 - 6/25/93 1 6/15 - 8 13 93 6. Meal Service Period Information (SFSP Handbook Chanter In: TYPES OF MEALS NUMBER OF EUGIBLE CHILDREN TORE SERVED' MEAL SERVICE TiME BEGINNING ENDING Breakfast A.M. Supplement Lunch 40 11:15 a.m. P.M. Supplement Supper vp a+r-Su Wmm" sewnp ure apprwiw mew service revel. tQrar nanODoq-K. agWwr n1 7. method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 10 Sea-Preparabon vended C]On Site []Central Kitchen 1E] Using School Food Authority ® Food Service Management Company (includes Ali Year Contracts) Form 1507/Pape S. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) Indoor Meal Meal Service ❑ Service ® Will Be Cancelled ❑ Other. 11. If the site feeds primarily homelwss Children, what methods are used to ensure that money, food stamps, or in kind services are nc required for meals? 12.Are meals delivered to the site?..................................................................... ® Yes ❑ Nc IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which wilt be used to adjust meal deliveries. (SFSP Handbook, Chap. II): Site Personnel Wi►l Contact Administrative Site Personnel Will Communicate Staff, Who Wilt Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter It) ..................... © Yes ❑ Nc If no, describe arrangements within standards prescribed by local health authorities for deliveryand holding of meals until time of service 15. If there is an excess of meals delivered, meals wilt be (SFSP Handbook, Chapter Ili): Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Nett Day ® at the Site ❑ for Disposal ❑ Other. r 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 visitec and that it has the capability and facititles 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 Agency City rf Lubbock Signature--OtficiW of Contrxsng Organizatan Data Name of Official (plea" type or prinQ Tolle Paula Simpson Special Program Supervisor FOR [] Approved ❑ Denied; reason: DKs USE ONLY TKle ftnalure—DHS Representative Dale Taus Department of Hurrun Servloes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Form 1507/Jaru3Nry 1993 FOR OHS USE ONLY "L7R i�U Woods Community 806 767- Addres3 of SRe (Street CtY, State, ZIP) Zenith and Erskine - Lubbock. Tx 79403 F enoo of OperaWn of food Samom (=4(3ayNf.- 4=yNr.) Number of 0 may �w �o ~y ^-W. From: 6/15/93 through: £/13/93 eratingDays� 0 12 22 10 0 ATTACH A MAP WITH THE SiTE SERVICE AREA IDENTIFIED Residential Camp She Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) ®E. (serving one to four meals) Nonesidentlal Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meats) 2. Ust ALL counties served by this she: 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, Chapter II) ........................................... . 92 % D. if open sites, submit documentation supporting this percentage figure. For open sites using school data. list the schools used to document site eligibility, as applicable: Hunt Elementary (87.5) Parkway Elementary (96%) _ E. For enrolled sites, Form 1531 wM be used to document eligibility. If the enrolled site used school data, fist the school used to document the site: F. What Is the percentage of free or reduced -price meals for the she? ............................................. f�—� % 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter Ii}•:-: ::.....:..................... ®Yes LJ No B Yes, give name of contracting organizations City of Lubbock 5. Monitoring Plan (SFSP Handbook Chapter Ili): Enter date of monitoring review to be conducted within: A. Frst week of Operation e. First Four weeks of Operation C. Addioonat Reviews 6/15/93- 6/4/93 1 6/15/93- 6/25/93 1 6/1'5/93- 8/13/93 6. Meal Service Per'od Information (SFSP Handbook, Chapter I1): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED* MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 96 P.M. Supplement Supper sou ■aounawn,s vy uru vffwn semnp me appmvea mast zamw raves. (zorbr rfen0000a, wwpwr u1 7. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) Sett -Preparation I Vended ❑ On Site ❑ Central Kitchen ❑ Using School Food Authority ® Food Service Management Company (Includes All Year Contracts) Form 1507/Page S. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter Cafeteria -style Children are Seated Children Une Up ❑ Meal Service ❑ and are Given Meals ❑ and Pick Up Meals ❑ Other. 9. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Asst. Center Supervisor 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) Indoor Meal Meal Service 0 Service ❑ Will Be Cancelled ❑ Other. 11. If the site feeds primarily hometwss children, what methods are used to ensure that money, food stamps, or in kind services are nc required for meals? 12.Are meals delivered to the site?..................................................................... ® Yes ❑ N IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II): ®Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter IQ ..................... 13 Yes ❑ N If no. describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 15. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter IIQ: ❑Stored In Refrigerator Thrown Away Returned to Vendor and Served the next Day D 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 visite and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that detlberat misrepresentation or withholding of Information may result In prosecution under applicable state and federal statutes. Name or Contracting Agency City of Lubbock siWWize—O f4W or Convac&V organization Date Name of Orf+cW (per type or print) Tice Paula Simpson Special Program Supervisor FOR DHs ❑ ATproved ❑ Denied; reason: USE ONLY Title Signature—DHS Representative Due Texas OeparOnertt Form 1507Jams I of Human Services FOR OIiS USE ONLY . SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Castle Garden 1102 58th St. - Lubbock, Tx Period of Operation of Food Service (moJdaytV.-molaay"r.) Number of 0 May .%M jury aep� From: 6/ 15/93 through: 8/ 13/93 *rating Days p 19 ' 99 1(1 n1 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A (serving one to four meals) ❑ C. (serving one to four meals) ® E. (serving one to four meals) Nonesldentlal Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meals) 2 List ALL counties served by this site: 3. A. Is your site open: ...................................................................................... QYes ❑ No B. Is your site enrolled?...................................................................................... ❑Yes ® No C. Site Eligibility: Enter the percentage of children eligible for free andfor reduced price meals for the site (SFSP Handbook, Chapter IQ ........................................... 84 % D. If open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Hodges Elementary _ E. For enrolled sites, Form 1531 wits be used to document eligibility. If the enrolled site used school data, list the school used to document the site• F. What is the percentage of free or reduced -price meals for the site? ............................................. % 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter tip : ..::........................... ❑Yes Q No If Yes, give name of contracting organization S. Monitoring Plan (SFSP Handbook, Chapter 110: Enter date of monitoring review to be conducted within: A. Fist week of operation 8. First Four Waeks of operation C. Additionat Reviews 6/15/93- 6/4/93 6/15 - 6/25/93 6/15 8/13/93 6. Meal Service Period information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CWLDREN TO BE SERVED* MEAL SERVICE TiME BEGINNING ENDING Breakfast A.M. Supplement Lunch 90 11:00 a.m. 12:30 p.m. P.M. Supplement Supper - r na raomrauon is comoered Dy arts wnen semng we approved mean samm raver. ibmi- rtanaDom umprer a) 7. Method of Food Preparation by Contracting Oroanization (SFSP Handbook Chapter In 5atl•Pn►paraDon Vended []On Site ❑ Central Kitchen ❑ Using School Food Authority ® Food Service Management Company (Includes All Year Contracts) Form 1507/Page 8. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter Cafeteria -style Children are Seated Children Line Up Meal Service ❑ and are Given Meals ❑ and Pick Up Meals ❑ Other. 9. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSRION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) ❑Indoor Meal Meal Service Service 1 A, Will Be Cancelled ❑ Other. 11. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are nc required for meals? 12. Are meals delivered to the site?..................................................................... 0 Yes ❑ N IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. to: ®Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter Iq ................:.... ® Yes ❑ N If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 15. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 111): ❑ Stored In Refrigerator Thrown Away Returned to Vendor and Served the Nerd 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 visite and that it has the capability and facillties for the meal service planned for the number of children anticipated. I know that dellberat misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. of Contracting Agency Name City of Lubbock signature —Official of Co aracting orgaruzatan Oats Name of Official (please type or print) I Titie Special Procirams Supervisor FOR []Approved ❑Denied; reason: DNS USE ONLY Title Signature—DHS Representative Date Texas Oepnrtrnent Form 1507/Jan Of Human SsMaes F ? FOR DHS USE ONLY SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION ti ' nR Atzlan Park I N/A Pa I 27 & Avenue H - Lubbock. Period of ration of Food service (moJdA*r--4M4ay/yra Number of 0 MAY �j,runs July rio SeaFrom: 6/ 15 93 through: 8/13 93 erating Days T 0 1' 2 ATTACH A MAP WiTH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) Q E. (serving one to four meals) Nonesidential Camp Site Serving Primarily Homeless Children ❑ 6. (serving one to four meals) ❑ D. (serving one to four meals) UI 2 Ust ALL counties served by this site: 3. A. Is your she open:......................................................................................... QYes ❑ No B. Is your site enrolled?...................................................................................... []Yes 0 No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) .......................................... D. If open sites, submit documentation supporting this percentage figure. For open sites using school data, list the schools used to document site eligibility, as applicable: Guadalupe Elementary _ E. For enrolled sites, Form 1531 will be used to document eligibility. It the enrolled site used school data, list the school used to document the site, ai F. What is the percentage of free or reduced -price meals for the she? ............................................. % 4. Did the site participate In previous years' SFSP? (SFSP Handbook; Chapter fly--- ::: :........................... []Yes ®No K Yes, give name of contracting organization• 5. Monitorina Plan (SFSP Handbook Chanter lin: Enter date of monitcidna review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews 6/ 6/4/93 6 - 6 25 93 6 13 3 6. Meal Service Perod Information (SFSP Handbook Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TiME BEGINNING ENDING Breakfast A.M. Supplement Lunch 30 11:15 a.m. 12:30 p.m. P.M. Supplement Supper r rrs "orriumm a coru+omw oy wru wrien "uuV ale approves meai serV= revel. tZ�rar nana000r , L�napur u) 7. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter IQ 5el-Omparabon Vended []On Site ❑ Central Kitchen I []Using School Food Authority [X] Food Service Management Company (includes All Year Contracts) Form 1507iP2gt 8. indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter Cafeteria -style Children are Seated nn Children line Up ❑ Meal Service ❑ and are Given Meals LXU and Pick lip Meals ❑ Other. 9. List site personnel who will be involved to any extent In the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSMON SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service El Service ® WiII Be Cancelled ❑ Other. 11. If the she feeds primarily hometwss children, what methods are used to ensure that money, food stamps, or in kind services are required for meals? 12.Are meals delivered to the she?.....................................................................E Yes ❑ h IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11): ©Site Personnel Will Contact Administrative Site Personnel W111 Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter It) ..................... ❑ Yes ❑ i, If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of servic 15. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter IIQ: Stored in Refrigerator ❑ Thrown Away Returned to Vendor and Served the Next Day ® 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 visits and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that delibera misrepresentation or withholding of Information may result In prosecution under applicable state and federal statutes. Name of Contracting Agency City of Lubbock Signature --Official of Contracting Organization Date Name of Offieial Ugease type or prino Title Paula Simpson Special Program Supervisor FOR FOR ❑ Approved ❑ Dented; reason: DKS USE ONLY Title Signature—DHS Representative Dale Tows Department Fo+m 1507iJanuary 1999 or Human Servlaea SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR oils USE ONLY SITE INFORMATION f YTX.QR ❑U Nara or Food Service SRO Telephone No. (mc. AIQ Skyview N/A Park Site Addross of Site (Street. City. Slate. ZJP) 3808 N. Ivory - Lubbock, Tx 79403 Period of Operabon of Food Service cmo,roayM--+o4Q&y1Vn•r Number of Op- ""�' '""" '"'ry AM9. oepL From: 6/ 15/93 through: 8/ 13 j�3 eratfng Days: 12 2 2 10 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp She Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) ® E. (serving one to four meals) Nonesidential Camp She Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meals) 2. list ALL counties served by this site: 3. A. Is your site open:......................................................................................MV LajYes ❑No S. Is your site enrolled?................................................................................... ❑Yes QNo C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter 11)........................................... 94.5 % D. if open sites, submit documentation supporting this percentage figure. For open sites using school data, Ust the schools used to document site eligibility, as applicable: Arnett Elementary E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? ............................................. % 4. Did fhe site participate In previous years' SFSP? (SFSP Handbook Chapter fl} : 7 : ::........................... ❑Yes ®No K Yes. give name of contracting organization• 5. Monftodnc Plan 6/15/93 - 6/4/93 Handbook. Chapter IIQ: Enter date of monitoring review to be conducted wMiln: 6/15/93 - 6/25/93 6. Meal Service Period information (SFSP Handbook. Chapter 111: TYPES OF MEi I S NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TiME BEGINNING ENDING Brealdast A.M. Supplement Lunch 25 5 P.M. Supplement Supper erns —uffrk xcn ra cQn5KK w ey urn when semng ate appmvea meal seance ievOL (JF,f' rfan=00K. LTAPW U) 7. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter In Sea-Preparaf*n vended ❑ On Site ❑ Central Kitchen 1 0 Using School Food Authority ® Food Service Management Company (Includes All Year Contacts) Forth 1507/Page 8. indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter Cafeteda•styla Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other. S. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Wk. 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 10. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal ❑ Meal Service Service 0 Will Be Cancelled ❑ Other. 11. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are nc required for meals? 12. Are meals delivered to the site?..................................................................... ® Yes ❑ N IF YES, COMPLETE ITEMS 13, 14, & 15. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 13. Indicate the means of communication with the vendor which will be used to adust meal deliveries. (SFSP Handbook, Chap. I1): Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor ( 14. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter Ii) ..................... Q Yes ❑ N If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of servic 15. it there is an excess of meals delivered, meals will be (SFSP Handbook. Chapter 111): ❑Stored In Refrigerator Thrown Away Returned to Vendor and Served the Next Day 0 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 visite and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberat, misrepresentation or withholding of Information may result In prosecution under applicable state and federal statutes. Name of Contracting Agency City of Lubbock signature —Official of Contracting OManization Dale Name of Official (please type or prinq Title Paula Simpson Special Program Supervisor FOR ❑ Approved ❑ Denied; reason: DHS USE ONLY Title 5igrutwe—OHs Representative Due ..%as Department of Human Service$ I. CIVIL RIGHTS ACT OF 1964 SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CIVIL RIGHTS QUESTIONNAIRE Form 1SOWAltachmer January I A. 1. Estimate, by racial/ethnic group, the number of children that will participate in the program at each site. If the program consi of several camp sessions, specify the Droiected number of children by site and date of session: SITE (name of site, school, camp, tic.) AMERICAN INDIAN ALASKAN NATIVE ASIAW PACIFIC ISLANDER BLACK HISPANIC WHITE Rodgers Community Center 7 -- 18 65 1,632 1,739 Rawlings Community Center 5 -- 3 35 872 814 Simmons Community Center 4 -- 3 1,563 437 187 Woods Community Center 2 -- -- 2,746 1,360 613 Hollins Park 12 -- 5 137 1,876 19726 2. Describe how this projection was made (i.e.. based on comparative enrollment in sites, observation of students, student surnames, et Total racial/ethnic groups in census neighborhoods in 1990. B. Does the organization have specific membership requirements which result in the denial of program benefits to specific groups?............................................................... ❑ Yes ❑ N If yes, describe those requirements: C. What efforts will be made by the organization to contact minority and grass roots organizations about the opportunity to participate in the prograrr ThP program will jbe pUblicized widely through minority schools weekly, ethnic new,gpapprs, and through the minority centers. D. What other outreach slops will be taken by the organization to ensure that minorities in the area from which it draws its attendance will ha)i an equal opportunity to participate in the program? The 2roQram will be announced at neighborhood meetings. E. Has any federal agency notified the organization of noncompliance with the Civil Rights act of 1964? .............. ❑ Yes E N If yes, give details including dates, names, and results: If. REHABILITATION ACT OF 1973 (Section 504) A. Does the contracting organization have any policies, practices, or architectural barriers that limit, deny, or discourage participation in the program or employment by the contracting organization because of disability? ........ El Yes ❑ N If yes, explain: Some park/playground sites are not handicap accessible. At these sites, sta will assist handicap participants. Form 150E / Att.chm•nt Pase B. Are there any policies or practices that result in unequal treatment in the delivery of benefits or services to participants, applicants, or employees according to disability? ................................. ❑ Yes ® N If Yes, exptaln: C. Does the contracting organization employ 15 or more people? ......................................... ❑ Yes ❑ N If yes: 1. Enter the name and title of the coordinator who will work with DHS to ensure that Section 504 requirements are met. Title 2. Has the organization established grievance procedures that incorporate appropriate due process standards?..................................................................... Q Yes ❑ t 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? ................. U Yes ❑ !" 3. Has the contracting organization informed the public of the right to file a complaint and of the filing procedure?.................................................... ...........ID Yes ❑ If yes, briefly describe how the public was informed: The certion qD4 iofarmatjOn isP ubLisheri in the Parks and Rprrpatinn Ieisure Guide three times annually andinOther City ntthlir�tinnc- D. Has the organizaton taken steps to notify employees, participants, and applicants that the organization does not discriminate on the basis of disability?..................................................... ©Yes 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 with the contracting organization? ........... © Yes l_ i If yes, briefly describe how they are notified: ThAy are .. .. ,.. - E. Do all organization forms, publications, and recruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the organizationdoes not discriminate on the basis of disability? .......................................... ......................................... � Yes CC' If no, indicate steps being taken to comply with this requirement: F. Does the organization have a procedure to ensure that the remedial or corrective action has been or will be taken if non-compliance with non discriminaiton requirements is found by DHS, USDA, or the contracting organization itself? .............................. ......... El Yes C , `► Te .as C apartment Form 16061Atlachmenl A uI HVman SYNlces SUMMER FOOD SERVICE PROGRAM FOR CHILDREN Janu" IM CIVIL RIGHTS QUESTIONNAIRE I. CIVIL RIGHTS ACT OF 1964 A. 1. Estimate, by racial/ethnic group, the number of children that will participate in the program at each site. If the program consists of several camp sessions, specify the projected number of children by site and date of session: SITE (name of site, school, camp, ete.) AMERICAN INDIAN ALASKAN NATIVE ASIANJ PACIFIC ISLANDER BLACK HISPANIC WHITE Yellowhouse Canyon 2 --- 0 396 10 5 -Neighborhood Carter Park 1 --- 0 15 600 850 Carlise Park 10 --- 21 50 350 1,500 Burns Park 0 --- 10 80 700 1,750 rChatman Park 6 --- 1 3 1,500 400 130 2. Describe how this projection was made (i.e., based on comparative enrollment in sites, observation of students, student surnames, etc. Total racial/ethnic groups in census neighborhoods in 1990. B. Does the organization have specific membership requirements which result in the denial of program benefits to specific groups?............................................................... ❑ Yes FE No If yes, describe those requirements: C. What efforts will be made by the organization to contact minority and grass roots organizations about the opportunity to participate in the program? The program will be publicized widely through minority schools weekly, ethnic newspapers, and through the minority centers. D. What other outreach stops will be taken by the organization to ensure that minorities In the area from which it draws its attendance will have an equal opportunity to participate in the program? The program will be announced at neighborhood meetings. E. Has any federal agency notified the organization of non-compliance with the Civil Rights act of 1964? .............. ❑ Yes 0 No If yes, give details including dates, names, and results: 11. REHABILITATION ACT OF 1973 (Section 504) A. Does the contracting organization have any policies, practices, or architectural barriers that limit, deny, or discourage participation in the program or employment by the contracting organization because of disability? ........ ® Yes ❑ No If yes, explain: Some park/playground sites are not handicap accessible. At these sites, staff will assist handicap participants. corm 15061 Attachment Page S. Are there any policies or practices that result in unequal treatment in the delivery of benefits or services to participants, applicants, or employees according to disability? ................................. ❑ Yes ©Nc If Yes, explain: C. Does the contracting organization employ 15 or more people? ................................. 4 ....... ❑ Yes ❑ N If yes: 1. Enter the name and title of the coordinator who will work with DHS to ensure that Section 504 requirements are met. Name Title Mark Bell Director of Personnel 767-2315 2. Has the organization established grievance procedures that Incorporate appropriate due process standards?.................................................................. ® Yes ❑ N if yes, do these procedures provide for the prompt and equitable resolution of complaints that allequ an action prohibited by Section 504 of the Rehabilitation Act of 1973? ................. © Yes ❑ N 3. Has the contracting organization informed the public of the right to file a complaint and of the filing procedure?.................................................................. © Yes ❑ N If yes, briefly describe how the public was informed: The section 504 i nformation i s publ i shed in the Parks and Recreation Leisure Guide three times anually and in other City publications. D. Has the organizaton taken steps to notify employees, participants, and applicants that the organization does not discriminate on the basis of disability?..................................................... ©yes ❑ N 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 with the contracting organization? ........... © Yes ❑ N, If yes, briefly describe how they are notified: They are not fied through the Employee Handbook, in al l recruiting publications, and on the application. E. Do all organization forms, publications, and recruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the organizationdoes not discriminate on the basis of disability?......................................................... ........................ © Yes ❑ N, If no, indicate steps being taken to comply with this requirement: F. Does the organization have a procedure to ensure that the remedial or corrective action has been or will be taken if non-compliance with non discriminaiton requirements is found by DHS, USDA. or the contracting organization itself? .................................................................... © Yes ❑ Nc If yes, explain: There is no policy in this regard; however the Personnel Department would work to correct any problems. Discrimination has not been found within the City Lubbock. Texas Department Form 1506/Attachm, of Human services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN January CIVIL RIGHTS QUESTIONNAIRE 1. CIVIL RIGHTS ACT OF 1964 A. 1. Estimate, by racial/ethnic group, the number of children that will participate in the program at each site. If the program con: of several camp sessions, specify the projected number of children by site and date of session: SITE (name of site, school, Camp, eto.) AMERICAN INDIAN ALASKAN NATIVE ASIAW ISLANOER BUCK HISPANIC WHITE Mahon School 5 -- -- 180 869 600 Pioneer Park 1 -- 93 152 433 1,391 2. Describe how this projection was made (i.e.. based on comparative enrollment in sites, observation of students, student surnames, Total racial/ethnic groups in census neighborhoods in 1990. B. Does the organization have specific membership requirements which result in the denial of program benefits to specific groups?............................................................... ❑ Yes If yes, describe those requirements: C. What efforts will be made by the organization to contact minority and grass roots organizations about the opportunity to participate in the progr, The program will be puhlicized widely through minority schools weekly, ethnic newspa .M = L=M a711111 4 M- a I• 0. What other outreach stops will be taken by the organization to ensure that minorities in the area from which it draws its attendance will h an equal opportunity to participate in the program? ThP program will be announced at neighborhood meetings. E. Has any federal agency notified the organization of non-compliance with the Civil Rights act of 1964? .............. ❑ Yes F If yes, give details including dates, names, and results: Il. REHABILITATION ACT OF 1973 (Section 504) A. Does the contracting organization have any policies, practices, or architectural barriers that limit, deny, or discourage participation in the program or employment by the contracting organization because of disability? ........ ® Yes ❑ If yes, explain: Some park/playaround sites are not handicap accessible. At these sites, staff will assist handicap participants. rprm 1pUO I AnJU7mAr Aas B. Are there any policies or practices that result In unequal treatment in the delivery of benefits or services to participants, applicants, or employees according to disability? ................................. ❑ Yes 0 t If Yes, explain: C. Does the contracting organization employ 15 or more people? ......................................... ❑ Yes ❑ t If yes: 1. Enter the name and title of the coordinator who will work with DHS to ensure that Section 504 requirements are met Name Tilts Mark Bell Director of Personnel 767-2315 2. Has the organization established grievance procedures that incorporate appropriate due process standards? .................................... ............................... ® Yes ❑ 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? ................. ® Yes ❑ t 3. Has the contracting organization informed the public of the right to file a complaint and of the filing procedure?.................................................................. ® Yes ❑ i If yes, briefly describe how the public was informed: _ The serti on 504 information is published in the Parks And Rprreation leisure Guide three times annually and in other D. Has the organization taken steps to notify employees, participants, and applicants that the organization does not discriminate on the basis of disability?..................................................... ® Yes ❑ 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 with the contracting organization? ........... © Yes ❑ If yes, briefly describe how they are notified: They are notified through the- Fmployee Handhnok. in E. Do all organization forms, publications, and recruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the organizationdoes not discriminate on the basis of disability?.............................................................. ................... ® Yes ❑ . If no, indicate steps being taken to comply with this requirement: F. Does the organization have a procedure to ensure that the remedial or corrective action has been or will obe taken if rganization non-compliancewith non discriminaiton requirements is lound by DHS. USDA, or the contracting OYes ❑ If yes, explain: There is no policy in this regard; however the Personnel Department . would work to correct any problems. City of Lubbock. Discrimination has not been found with the 1` Texas Department Form 2046 of Human servim CERTIFICATION October 1990 REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS Federal Executive Order 12549 requires the Texas Department of Human Services (DHS) to screen each covered potential contractor to determine whether each has a right to obtain a contract in accordance with federal regulations on debarment, suspension, ineligibility, and voluntary exclusion. Each covered contractor must also screen each of its covered subcontractors. In this certification "'contractor" refers to both contractor and subcontractor; "contract" refers to both contract and subcontract. By signing and submitting this certification the potential contractor accepts the following terms: 1. The certification herein below is a material representation of fact upon which reliance was placed when this contract was entered into. If it is later determined that the potential contractor knowingly rendered an erroneous certification, in addition to other remedies available to the federal government, the Department of Health and Human Services, United States Department of Agriculture or other federal depart- ment or agency, or the Texas Department of Human Services may pursue available remedies, including suspension and/or debarment. 2. The potential contractor shall provide immediate written notice to the person to which this certification is submitted If at any time the potential 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 "voluntar- ily 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 as defined in the attachment. 4. The potential 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 partici- pation 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. Do you have or do you anticipate having subcontractors under this proposed contract? .................... ®Yes ❑Ho 5. The potential contractor further agrees by submitting this certification that it will include this certification titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts" without modification, in all covered subcontracts and in solicitations for all covered subcontracts. 6. A contractor may rely upon a certification of a potential 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 certifications from its covered subcontractors upon each subcontract'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. 8. 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 Agricul- ture, or other federal department or agency, as applicable, and/or the Texas Department of Human Services -may pursue available reme- dies, including suspension and/or debarment. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS Indicate In the appropriate box which statement applies to the covered potential contractor. ❑The po!ential contractor certifies, by submission of this certification, that neither it nor Its principals is presently debarred, sus- pended,.proposed for debarment, declared Ineligible, or voluntarily excluded from participation In this contract by any federal department or agency or by the State of Texas. ❑ The potential contractor Is unable to certify to one or more of the terms in this certification. In this Instance, the potential con. tractor must attach an explanation for each of the above terms to which he Is unable to make certification. Attach the explana- tions) to this certification. Name of Potential contractor Vendor ID No. or Social Security HS Contract No. (ifappicable) No. D City of Lubbock 17560005906000 152-1004 Signature of Authorized Representative Date PrintedffyW Name and Title of Authorized Representative Paula Simpson, Special Programs Su rvi or Form 20- P20C DEFINITIONS Covered Contract/Subcontract. (1) Any nonprocurement transaction which involves federal funds (regardless of amount and Including such arrangements as su grants) and are between DHS or its agents and another entity. (2) Any procurement contract for goods or services between a participant and a person, regardless of type, expected to equal or e ceed the federal procurement small purchase threshold fixed at 10 U.S.C. 2304(g) and 41 U.S.C. 253(g) (currently $25,000) and a grant or subgrant. (3) Any procurement contract for goods or services between a participant and a person under a covered grant, subgrant, contrz or subcontract, regardless of amount, under which that person will have a critical influence on or substantive control over that covert transaction: a. Principal investigators. b. Providers of audit services required by the Texas Department of Human Services or federal funding source. c. Researchers. Debarment. An action taken by a debarring official In accordance with 45 CFR Part 76 (or comparable federal regulations) to exclude person from participating in covered contracts. A person so excluded is "debarred." Grant. An award of financial assistance, including cooperative agreements, in the form of money, or property in lieu of money, by the fede al government to an eligible grantee. Ineligible. Excluded from participation in federal nonprocurement programs pursuant to a determination of ineligibility under statutory, e ecutive order, or regulatory authority, otherthan Executive Order 12549 and its agency implementing regulations; for example, exclu ed pursuant to the Davis -Bacon Act and its implementing regulations, the equal employment opportunity acts and executive order or the -environmental protection acts and executive orders. A person is ineligible where the determination of ineligibility affects suc person's eligibility to participate in more than one covered transaction. Participant. Any person who submits a proposal for, enters into, or reasonably may be expected to enter into a covered contract. Th term also includes any person who acts on behalf of or Is authorized to commit a participant in a covered contract as an agent representative of another participant. Person. Any individual, corporation, partnership, assiociation, unit of government, or legal entity, however organized, except: foreign gover ments or foreign governmental entities, public international organizations, foreign government owned (in whole or in part) or controlic entities, and entities consisting wholly or partially of foreign governments or foreign governmental entities. Principal. Officer, director, owner, partner, key employee, or other person within a participant with primary management or superviso, responsibilities; or a person who has a critical influence on or substantive control over a covered contract whether or not the persc is employed by the participant. Persons who have a critical influence on or substantive control over a covered transaction are: (1) Principal investigators. (2) Providers of audit services required by the Texas Department of Human Services or federal funding source. (3) Researchers. Proposal. A solicited or unsolicited bid, application, request, invitation to consider or similar communication by or on behalf of a persc seeking to receive a covered contract. Suspension. An action taken by a suspending official in accordance with 45 CFR Part 76 (or comparable federal regulations) that immec ately excludes a person from participating in covered contracts for a temporary period, pending completion of an investigation ar such legal, debarment, or Program Fraud Civil Remedies Act proceedings as may ensue. A person so excluded is "suspended. Voluntary exclusion or voluntarily excluded. A status of nonparticipation or limited participation in covered transactions assumed t a person pursuant to the terms of a settlement. Texas Department Form 2047 of Human services CERTIFICATION REGARDING FEDERAL LOBBYING OCOOef t980 (Certification for Contracts, Grants, Loans, and Cooperative Agreements) PREAMBLE Federal legislation, Section 319 of Public Law 101.121 generally prohibits entities from using federally appropriated funds to lobby the ex. ecutive or legislative branches of the federal government. Section 319 specifically requires disclosure of certain lobbying activities. A federal government -wide rule, "New Restrictions on Lobbying," published in the Federal Register, February 26, 1990. requires certification and dis- closure in specific instances and defines terms: Covered Awards and Subawards—Contracts, grants, and cooperative agreements over the $100,000 threshold need (1) certifications, and (2) disclosures, it required. (See certification term number 2 concerning disclosure.) Lobbying —To lobby means "to influence or attempt to influence an officer or employee of any agency (federaq, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with any of the following covered federal actions: • 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, and • the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan or cooperative agreement." Limited Use of Appropriated Funds Not Prohlblted—The prohibition on using appropriated funds does not apply to activities by one's own employees with respect to: • liaison activities with federal agencies and Congress not directly related to a covered federal action; • providing any information specifically requested by a federal agency or Congress; • discussion and/or demonstration of products or services if not related to a specific solicitation for a covered action; or • professional and technical services in preparing, submitting or negotiating any bid, proposal or application for a federal contract, grant ban or cooperative agreement or for meeting legal requirements conditional to receipt of any federal contract, grant, loan or coopera- tive agreement. (The prohibition also does not apply to such services provided by nonemployees for the same purposes.) Professional and Technical Services —Professional and technical services shall be advice and analysis directly applying any professional or technical expertise. Note that the professional end technical services exemption is specifically limited to the merits of the matter. Other Allowable Activities -The prohibition on use of federally appropriated funds does not apply to influencing activities not in connection with a specific covered federal action. These activities include those related to legislation and regulations for a program versus a specific covered federal action. Funds Other Than Federal Appropriations —There is no federal restriction on the use of nonfederal funds to lobby the federal government for contracts, grants, and cooperative agreements. Applicability of Other State and Federal Requirements —Neither the government -wide rule nor the law affect either (1) the applicability of cost principles in OMB circulars A-87 and A-122, or (2) riders to the Texas State Appropriations Acts which disallow use of state funds for lobbying. TERMS OF CERTIFICATION This certification applies only to the instant federal action for which the certification is being obtained 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 $10.000 and not more than $100,000 for. each such failure. The undersigned certifies, to the best of his or her knowledge and belief, that: 1. 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 with the awarding of any federal contract, the making of any federal grant, the making of any federal ban, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative cgreement. 2. 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 under- signed shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (If needed, contact your Texas Department of Human Services procurement officer or contract manager to obtain a copy of Standard Form-LLL.) 3. The undersigned 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. Do you have or do you anticipate having covered subawards under this transaction? ......................... ® Yes ❑ No Name of Contractor/Potential Contractor Vendor ID No. or Social Security No. OHS Contract No. (if applicable) City of Lubbock 17560005906000 1 152-1004 Name of Authorized Representative (type or print) Mcial Paula Simpson Programs Supv. Signature -Authorized Representative Date