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HomeMy WebLinkAboutResolution - 5492 - Agreement - TDHS - Summer Food Service Program. Best Scan Possible. - 05_22_1997RESOLUTION NO. 5492 Item #20 May 22, 1997 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 Summer Food Service Program Agreement funded by the Texas Department of Human Services, and all related documents attached hereto and which Agreement 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: / � Lftj,,�' Kayt t� In Darnell, City Secretary TO tAliamus, Manag ni & Leisure Services APPROVED AS TO FORM: Iltedald G. Vandiver, First Assistant City Attorney ncv:gs/FooaProxes April 28, 1997 22nd day of May , 1997. E WINDY SIT , MAYOR t` rep Agency on Aging A PROGRAM OF THE SOUTH PLAINS ASSOCIATION OF GOVERNMENTS June 5, 1997 Susan Bailey, Supervisor City of Lubbock P.O. Box 2000 Lubbock, Texas 79457 Dear Ms. Bailey: The South Plains Association of Governments, in its capacity as the Area Agency on Aging, contracted $118,500.00 of Older Americans Act and State monies to provide services to the elderly in the City of Lubbock. This contract is numbered A100 and extends from October 1, 1996 through September 30, 1997. This letter constitutes the authority to amend the total FY97 budget as follows: Transportation $12,567.00 and Congregate 83,344.00.. This amendment will purchase a maximum of 3,290 transportation.units if a total of 11,376 units are ,served and a maximum of 16,769 congregate units if a total of 60,736 units are served. The unit rates will remain the same. The total consideration of this contract is $95,911.00. The provisions regarding termination will remain unchanged and the original contract remains in effect. These agreements, as specified above, will become effective upon being duly authorized and executed by the CITY OF LUBBOCK. Sincerely, Robert V. Marshall Director of Aging Programs RVM/em ATTEST: a� 1 1. AJ Kay a Darne'1111 City Secretary For: CITY OF LUBBOCK Authorized Signature 1323 58th St. • P.O. Box 3730 Freedom Station 6 Lubbock, Texas 79452-3730 • 806-762-8721 0 1-800-858-1809 o Fax 806-765-9544 Partially Funded by the Texas Department on Aging 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 TDHS. 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 osonW6om+of="ttlernent�aAny-.3odit.exeVtions-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 TDHS.or the United States Department of Agriculture (USDA). This responsibility applies to this contract, and all subcontracts hereunder. C. The contractor will apply to TDHS 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 TDHS at least five (5) calendar days before the requested effective date for the change or the field trip. Contractors will notify TDHS 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 TDHS aW the contractor. Extensions are considered as separate contract periods. B. The contractor and its subcontractors will allow TDHS and USDA officials and other appropriate officials determined by TDHS to inspect facilities and records and to audit, examine, and copy records at any reasonable time. This includes access to all records of costs paid, even in part, by TDHS. Non School Sponsm - Page 2 KtbuLulLuv NV. 74yc Item #20. May 22, 1997 SU N ER FOOD SERVICE PROGRAM AGREEMENT STATE OF TEXAS COUNTY OF TRAVIS I j01 lv�h h The Texas Department of Human Services, hereinafter referred to as TDHS, AND CITY OF LUBBOCK 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 Q Code of Federal Regulations [CFR), Part 225). I. MUTUAL AGREEMENTS The Parties mutually agree: A. If the contractor fails 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, if such mutual consent cannot be attained, then and in that event, either party to this contract may consider it to be canceled without cause by giving thirty (30) days notice in writing to the other party and this contract shall thereupon be canceled upon the expiration of such thirty (30) day period. Nothing in this paragraph shall be construed to prohibit immediate cancellation pursuant to above paragraphs A and/or B. V1. CERTIFICATIONS A. Immigration Reform and Control Act of 1986 - The contractor agrees to comply with the requirements of the Immigration Reform and Control Act of 1996 regarding employment verification and retention of verification forms for any individuals hired after November 6, 1986, who will perform any labor or services under this contract. B. Regarding Debarment, Suspension, Ineligibility, or Voluntarily Exclusion For Covered Contracts - The contractor certifies, by execution of this agreement, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in this contract by any federal department or agency or by the State of Texas. By making.thi&. certification -the contractor agrees to the following terms- 1. The above certification is a material representation of fact upon which reliance was placed when this contract was entered into. If it is later determined that the contractor knowingly rendered an erroneous certification, in addition to other remedies available to the federal government, the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, or the Texas Department of Human Services may pursue available remedies, including suspension and/or debarment. 2. The contractor shall provide immediate written notice to the person to which this certification is submitted if at any time the contractor learns that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 3. 'The words 'covered contract," "debarred,' "suspended," "ineligible,' "participant,' "person,' *principal,* "proposal," and "voluntarily excluded,' as used in this certification have meanings based upon materials in the Definitions and Coverage sections of federal rules implementing Executive Order 12549. Usage is as defined in the attachment. 4. The contractor agrees by submitting this certification that, should the proposed covered contract be entered into, it shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, and/or the Texas Department of Human Services, as applicable. 5. The contractor further agrees by submitting this certification that it will include TDHS Form 2046 tided '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 subcontractor that 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. Noe School Sponsors - Page 4 IV. CIVIL RIGtrrS 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 TDHS 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 TDHS and USDA: and hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement. H. 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 TDHS. 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 TDHS or USDA. The person whose signature appears on this contract is authorized to make this assurance on behalf of the contractor. V. TDHS CLAIMS PAYMENT TDHS will, subject to the federal appropriation and availability to TDHS 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 TDHS based on the date of receipt of a fully executed copy of this contract. Non School Sponsors - Page 3 VIY. EFFECTIVE DATE AND SIGNATURES For the faithful perforatance of the terms of this contract. the parties hereto in their capacities stated, affix their signatures and bind themselves. ATTEST: city of Lubbock Name of the Contracting Organization (Please Print or Type) Original Sig a of the authorized representative of the contracting organization Susan Bailey Na—mw'vfthe authorized r%xesenutive of the coutrawn organization (Please Prim or Type) Recreation outreach Coordinator Title Please print or type, in the spacas provided above, the name mA title of the mathorized representative signing this agreement on behalf of the contracting organization. x TEXAS ©l'AFt7MEi11`r��3 H SR CES � t -' ...._:<...... :: ... ::. ..... i Effective Dates: through By: Date: Revised February 1994 tom, School sponsors - Pup 6 VI. CERTIFICATIONS (continued) 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 suspender!, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to -the federal -government, Department of Health and Human Services, united States Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Human Services may pursue available remedies, including suspension and/or debarment. C. Regarding Federal Lobbying - This certification applies only to this contract and is a material representation of fact upon which reliance was- placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. The contractor certifies, to the best of his or her knowledge and belief, that: 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 malting of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. 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 employee of any agency, a member of congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federally funded contract, subcontract, subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. 3. The contractor shall require that the language of this certification be included in the award documents for all covered subawards at all tiers (including subcontracts, subgrants, anti contracts under grants, loans, and cooperative agreements) and that all covered subrecipients shall certify and disclose accordingly. 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. Non School Sponsors - Page 5 TezU t?apertnWN of Human Sarviara Few aiel JL* Im CERTIFICATE OF AUTHORITY This Is to certify that Nmw of Autnorwd OffcW (PWm type a print) Tine Susan Bailey I Outreach Coordinator Signature--Au"wited OfkW Is designated as the authorized representative of Name of Contracting Orp wW*ion City of Lubbock A&VM (Strati. City. State. ZW) P.O. Box 2000, Lubbock, Tx 79457 The representative designated above Is authorized on behaEf of Ow contrat:MV organization to make written agnw ments with the Texas Wpartinent of Human Services to operate a food program, to sign downwft or reports about the agreement, and to present ciaima for reimbursement, when appropriate, to the depaRmant. SO* of p uric ATTEST: r Darnell --._ City Secretary FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: AgraWhW No. Rac.n.d ft o.te TX- •R" if pw A. Q aI SFSP Coss wttidt wN be dsli for roimbea's KTWVt for1. Estst"M OPtre 710"L axt mw0mm Yam COOos Pr Wam tabor 3705 Fdngo Bed 666 63455 N m400d Suppla 1432 WON 0 tent 0 EqutMwe the Fes 0 tlentat of EgUonw t 0 v.r mrr Trwaponadlon ; : 0 TOTAL t: prowlim Mr. 169MAT tJ ADfaF#f� ttAWn COM mnm CooRmOSIM AdmkftVIM tabor M«fr. clerk} 3794 F&W 8wwft 642 pontm d Oft@ spew 0 ass 0 0moe sworn 967 Ohtoe Bu dtq mwmm e 0 Equipment the Fie 0 AuSt Feet 0 L"w Fees 0 a« m* Trttrtspon on 40x.315x49days 617 TOTAL. 2: 6,020 EL kxftmm proocod income 10 ttte rood service from ap sou= other tan SFSP Wit. Wenb7y exactly Vw costs #a tnoorne w cover. (Do not Include state or tederai hmids.) album AmasY VMtoUNdter. Am Al YVa De used for se Tm 04mXAGEYENT PLAN A. an U@t a �ry ��� . food �t� reapota m�mer�i who aged ftw orkV d 1t►e SFSP. (too not kw*xk sfe wp ar m vnu of POartM Nummat P IN> C FM sE�WKa MMM t�cf"C>Es Rec. outreach Coord. 1 Director of City of Lubbock SFSP Rec. Supv. II 1 Assistant Director of SFSP Monitor 1 Personnel Training, Manage Food Service, Personnel Records cr fiwrnen Senrfose SUMMER FOOD SERVICE PROGRAM APPLICATION FOR PARTICIPATION NOTE. Give as much Information as possible. Attach addidonai sheets N needed; please Identify each attachment with the name of the contracting organization. SEr-InON I. -SPONSOR INFORMATION contrw&q ogiari+xawn Name vendor 0 W. Taisph" N& t iodine No. City of Lubbock 17560005906000 ( 806 ) 767-26751.(806)767-2673 Mailing Addres3 (Sveet or P.O. Box. CITY. Siaae. ZIP) 00 Lubbock, Tx 79457 Street Address (Y diMsrenq 916 Texas Avenue Lubbock, Tx 79401 Name Adrrinistraror Susan Bailey The Recreation Outreach Coordinator A. Contracwr ClasSlticabon (Chad* SN that apply): R"Identialft4onresidential Unit of Government -Contractor oerliTies that all food ❑ National Youth Sports Pmgrwn ❑ Summer Camp service sftes are operated directly by fhe contractor. ❑ School Food Authority ❑ Sc�uous Cakridar ❑ Private NwHrollt B. Is your program a year-round progf � m?................................................................................... ❑ Yes l._J Na C. Type of contractor. © Public Entity (explain): Is your agency considered to be state owne fterated?..................................................................... []Yes ® No Do you deposit your program � directly into to Slate Treasury? ........................................ ❑ N/A []Yes Q No Do you deposit your program reinftm ierd into a local bank? ..................................................... ❑ NIA ❑Yes []No ff yes, is 0 direct deposit? ............................................................................................ []Yes tb..i No ❑ Private Nonprofit organizailon-Tax-exempt status established. Attach letter of detemmriatlon (IRS 501-A d tax-exempt status from IRS. Do you deposit your program reirnbtirsement ifo a Total bank?..... . ................ .............................. ❑ NIA ❑Yes ❑ No tlyes, is it direct deposit?............................................................................................ ❑Yes U No D. Does the organization provide an ongoing year-round service to the community that is to be served by the Summer Food Service Program(SFSP)?.............................................................................. ®Yes ❑ No if no, which of the following circumstances applies? ❑ Residential Camp l_! Failure to operate would deny program to a poor area ❑ Serves Migrant Children ❑ Faffure to operate would deny a significant number of ciilldren access to program E.1. floes the organization receive $100,000 or more in fed" funds yearly? .................................................. (Dyes ❑ No 2. Does the organization receive more than $25,000 but less than $100,000 in federal funds yearly? ........................ ❑ Yes ENO, 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 ISM POW 4 3.1f the contracting organization is sponsoring a camp or other enrollment program that charges separately for meals, the contracting organization has read Attachment B to this application, 'Additional Assurances for Camps and Other Enrollment Programs that Charge Separately for Meals', and assures OHS that all requirements have been or will be met. B. Public Release 1.7be contracting organization will make efforts to ensure that the local news media will make a public announcement of the program and will supply them with a news release: 11 the contracting organization is sponsoring a camp or other enrollment program, this release must contain, at a minimum, a list of all approved sites, a list of the current standards for determining free and recuded price eligibility, and the following statement: "The [Name or #* a aMrrE Mn W announce* the sponsorship of the Summer Food Service Program. Income eligibility will be based on family size and income using the Standards for Determining Free and Reduced -Price Eligibility, provided by the United States Department of Agriculture. Meals will be provided at the alte(s) listed. People who are eligible to participate In the program must not be discriminated against because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who believes that they have been discriminated against should write Immediately to: Director, Civil Rights Dhfhdon, MC W 106, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714 M or the Secretary of Agriculture, Washington, D.C. 20Ct50. NOTE: Discrimination complaints based on religion or political beliefs must be referred only to the Director, CIvR Rights Division, Texas Department of Hunan Services." For all other programs the announcement must contain, at a minimum, a Rd of all approved sites and the following statement: "The (Name 0"92nE!a929 orearLur oni announces the aponsorshlp of the Summer Food Service Program. Meals will be provided at the site(s) listed. People who are eligible to participate In the program must not be discriminated against because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who believes that they have been discriminated against should write immediately to: Director, Civil Rights Division, MC W-106, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 787149030 or the Secretary of Agriculture, Washington, D.C. 20250. NOTE; Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services." 2. This public release was or will be published in the following news n NAME OF MEDIA OUII T DATE OF RELEASE Avalanche Journal 5_4-97 Southwest Digest 5-15_97 El Editor 5-15-97 iedia oudetfsi: NAM OF MMA OUTLET DATE OF RELEASE All Radio & TV 5-1E & 5-31-97 3. Attach a copy of the contracting organization's public release statement as submitted to the news media and any other materials used to publicize the program's availability and nondiscrimination requirements. SECTION Vl- 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 will be claimed only for approved meals served to eligible children during the hours they are in attendance at approved sites. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. she-orrwia€ of eonuac" OmwtxaWn DOW Name (pease"or pnnQ Tltb FOR DHS USE ONLY []APPROVED []DENIED If denied, reason: Approved lor Food DisWbuWn Doe El Yes 13 No � If yes, give date Form 1608 sent to FDD: Title segnan,re-mfir�a! a comp Organi�a5on Date Form I= Page : 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 Q No If yes,1. For Operational Costs?........................................................................................... ❑ Yes ( No 2. For Administrative Costs? .................................... . ................ [:]Yes X No D. If meal service is self -preparation, do you want to receive commodities? ...................... ............................. ❑ Yes 0 No If yes, Form 1608, Apptkadon and Agreement for Coommodfdes, must be completed. SECTION IV --PROGRAM OPERATION A.1. Beginning and Ending Data of Meal Service: From June 2, 1997 through August 3, 1997 2. Number of sites :.............. --..........................................................................--.............. 11 B. List dates and topics of SFSP training: DATES TOPICS lay 19-23,1997 Explanation of Prograla, Site Management, Pecord Keeping Meal Requirernlents/Inventory Nondiscrimination C.Is the organization planning to contract with a food service management company for the preparation of unitized meals?................................................................................ . ..... a Yes ❑ No If yes, and the contract will exceed 510,000, attach a copy of the invitation to tad. Also give: aace of W Puobcanon plem a Pub+icauon JoMay at. d sIa rime a as April '20, 1997 Lubbock Avalanche -Journal 14 1997 3 .m. Is as iX_P_Wed W be sloo.000 or ffx"? iI yw, care slow of W opening: Yes 3 No Also, attach a copy of an 11-day-cycle menu including all specific menus to be used. D.Is the organization contracting with a year-round food service management company? ....................... - ....... ❑ Yes I^ I 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 site(s) indicated on the attached Site Information sheet (Form 1507). SECTION V—ASSURANCES A. Free Meal Policy Statement 1,The contracting organization assures the Texas Department of Human Services (DHS) that all children at the sites described on the Site(s) Information Sheets for the Summer Food Service Program, will be offered the same meals with no physical segregation of, or other discrimination against, any child because of race, color, disability, age, sex, national origin, religion, or political beliefs. No separate charge will be made for any meal except in accordance with attachment B of this application. 2. The contracting organization assures DHS that, N It is sponsoring camps or other enrollment programs: • The contracting organization has or will obtain family size and income data about all children whose meals will be reported as free or reduced -price: and • The children claimed as free or reduced -price meet the current family size and income standards set by the United States Department of Agriculture, DHS Form 4504, Standards for Determining Free and Reduced -Price Eligibaity. �. MW mere any poikies or practices that rmA in wwquat treatment In the delivery of benefits Or services to participants, appifcam, or em pwtsei acco"ft to Wabryity7................................. ❑ Y083 N If Yea. explain- C. Does the contracting organization employ 15 or more people? ......................................... ® Yes ❑ N tf yes: i. Enter the name and title of the coordinator who will work with OHS to ensure that Section 504 requirements are met. Nam Andrews re. Director of Personnel Mary 2. Has fhe organization established grievance procedures that incorpome appropriate due n process standards?....................................................................ED Yes ❑ NC If yes. do these procedures provide for the pram and equitable resolution of complaints the siisp an action prohibited by Section 504 of the Rehabilitation Act of 1973? ................. ® Yes ❑ Ne 3. Has the erg orgardxa*m informed the public of the right to fife a complaint and �� ❑ of tits filing procedure?.................................................................. Yes No 0 yea, briefly describe how tt*e pdit was Informed: The Section 504 information is published i6 the Leisure Guide and in other City publications. 4 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 noffied include those with impaired vision or hearing and members of unions or protessional organizations holding top X*M barge g or prof ai agreements with the contracting organization? ..... _ .... , Yes 0 No If yes, bristly describe how they are notified- They are notified through the Employee Handbook, in all recruiting publications, and on the applications. F. 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 No tf no, indicate steps being taken to comply with this requirement: F. Does the organization have a procedure to ensure that ?he remedial or corrective action has been or wifl be it Win -compliance with nort discriminaiton requirements =s found by OHS' USDA, or the contracting Q Yes D No organ if yes, explain: all non-compliance complaints will be handled through the Personnel I fem isesrAVAchn,.M A ►+ +^ s SUMMER FOOD SERVICE PROGRAM FOR CHILDREN JW%W 1"o CIVIL RIGHTS QUESTIONNAIRE I. COM RIGHTS ACT OF 1964 A. 1. Fstimate, 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 lnama of sit•, school. Camp, ale.) AMERICAN INMAN A�.ASKAN NATIVE P,MM t3LA NVOt BLACK HISPANIC w►iITE Burns Park 3 2 113 864 527 Carlisle Park 5 10 75 417 790 Chatman Park Hollins Park 6 5 3 2 500 137 200 1,176 50 726 Pioneer Park 1 43 152 323 891 2. Describe how this projection was made {i.e., based on comparative enrollment in sites, observation of students, student surnames. etc_ Census B. Does the organization have specific membership requirements which result in the denial of program benefits to specific groups?............................................................... ❑ Yes 0 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? Publicity, P,S.R., Fliers, Word -of -Mouth 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 have an equal opportunity to participate in the program? E. Has any federal agency notified the organization of non-compliame with the Civil Rights act of 1964? .............. ❑ Yes i;_ No It yes, give details including dates, names, and results: if. REHABILITATION ACT OF 1973 (Section 504) A. Does ttte 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? ........ L ! Yes ® No it yes, explain: _Vv V. 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 Lr1v N( If Yes, explain: 4, C. Does the contracting organization employ 15 or more people? .................... . ........ . ........... ® Yes ❑ Nc If yes: 1. Enter the name and title of the coordinator who will work with DHS to ensure that Section 504 requirements are met. Mime Title Mary Andrews Director of Personnel 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 that allege an action prohibited by Section RX of the Rehabilitation Act of 19737 ................. � Yes O No 3. Has the contracting organization informed the public of the right to file a complaint and of the fling procedure?.................................................................. 0 Yes ❑ No If yes, briefly describe how the public was informed: The Section 504 information is published in the Leisure Guide 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 tlsose with impaired vision or hearing and members of unions or professional organizations holding collective bargaining or professional agreements with the contracting organization? ........... [D Yes 0 No If yes, briefly describe how they are notified: They are notified through the Emplogee 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 an the basis ofdisability? ......................................... .._................. ........... ........ .L_AJ Yes ❑ No It no, indicate steps being taken to comply with this requirement F. Does the organization have a procedure to ensure that the remec:al or corrective action has been or will be taken if non-compliance with non discriminaiton requirements is found by DHS, USDA, or the contracting rV_1 organization itself?.............................I ...... ........................... .L^J Yes Q No If yes, explain: All non-compliance complaints will be handled through the Personnel Department. axas vay.,=„m„. fontt ISWAttschm*nt A If Human 5enWes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN Ja1i°ry 1990 Civil. RIGHTS QUESTIONNAIRE I. CIVIL RIGHTS ACT OF 1964 A. 1. Estimate, by raciallethnic 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, efc.) AMERICAN INDIAN ALASKAN NATIVE ASIANJ PACIFIC ISLANDER BLACK HISPANIC NfHiTE Clayton Carter 3 1 23 432 383 C. Rawlings Community Center 6 6 35 1,605 767 Rodgers Community Center 7 18 45 1, 820 739 Mae Simmons Community Center 3 0 783 237 87 Woods Community Center 2 0 1,746 1,060 113 2. Describe how this projection was made (i.e., based on comparative enrollment in sites, observation of students, student surnames, etc. Census B. Does the organization have specific membership requirements which result in the denial of program benefits to specific groups? ........... . ................... . ..................... . .... . .... ❑Yes L V 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? Publicity, P.S.R., Fliers, Word -of -Mouth D. What other outreach stop$ will be taken by the organization to ensure that minorities in the area from which it draw$ its attendance will have an equal opportunity to participate in the program? 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: II, 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? ........ 0 Yes ® No If yes, explain: ro ; B. Are there any polldes or pracdme that rwa in unequal Vestment in the deWeny of benefits Or savfm to participants, aptcants. or mnployess woording 10 disabOty?................................. [:]Yes Nc If Yea. e4ain: C. Does the contracting WWizatiw employ 15 or snore people? ......................................... Yes lJ No n yes; 1. Enter the name and We of the cowdinator who wO work with MS to ons ue that Section 504 requlramards am met. Now Tow Mary Andrews Director of Personnel 2. Has the organization esMWWW WWwanee procedures that incorporate appropriate due process standards?.....................................................................[0 Yes El No It yes, do them Proceduroa prryvkle for the protrtpt and equitable ramoiAion of complaints that etiege an action prate bW by Section W4 of the Hehebft*m Act of 19M ................. ® Yes ❑ No 3. Has the contrU*V orgwtetlort blonrrod the PUM of the nett to tie a complaint end � of the filktg �?.................................................................. (Dyes El No If yes, briefly descfte her ths.pubk was informed: The Section 504 information is published ih the Leisure Guide and in other City publications. D. Has fire organizaton taken stops 10 nO tty en yeas, participants. and applicants that the organization does not dachminate on the basis of disability? ............. . . ........................................ El Yea ONo it yes, do the people naffed include those with k npoked riaion or hearing and mewbsm of unions a professional No organtzabons hotdintp co5ecs3ve banlparnkrg or Profassionw agreements with the contracting organization? ........ El Yes E yes. brieN de$vtbe how they are no~. They are notified through the Employee Handbook, in all recruiting publications, and on the applications. E. Do an organization forms, pubikadons. and reesui mont materials which inform the public of program benefits and erttpioyment opportunities contain do assurance that the organizationdoes not discriminate on the bases ofdisabtWt...................................... ....... .................................... Yes No tf no, indicate steps being taken to corrnply with this requirement: ' F. pose the organization have a procedure to ensure that the te"*d:at or corrective action has been or will tee taken if on r!npliartce with non discriminaiton requ►rements is found by OHS. USDA, or the contracting omanizatio ? x Yea No ii yes, explain. All non-compliance complaints will be handled through the Personnel 1 " F�R1f1 ISWAMN*NAW A of aww« SUMMER FOOD SERVCE PROGRAM FOR CHILDREN jr•mn'"n' CIVIL RIGHTS QUESTIONNAIRE I. CW L MOWS ACT OF 1964 A. Estimate, by racialleriutio group. the number of chkVw that wig pardc#" to in the program at each alto. V the program cc Win of several camp sessions, specify to projected number of children by $ite and date of msion: SM f of sfto, rehon . cmw. are.) AULABOAX Do" AusKArt NATM ASM PRAM au►ac teWArac wfett Clapp Park 5 55 400 537 3. Devon* haw ride proJee6on wea wAde ([.e., based an =ffVwWa sivc*. errt In sWc abeervWon d etfxdwae. @kxdeft wAwnes. W- Census a. Does ow organiz0on have ipacft mermberehip requirwmft which result in the dwW of proprarm berwft ro W C& p*%W........................... .....I.............................. 0 Ye. ID No a yiw desorft these nkfArWFW tx C. Whet efbrte w1 be merle by ttr orylrt zW m 1D oW"d Mnority► and grass roots orgenit abons ebioulrli appp Rfrfky ID penkipare Into p aWw? publicity, p.s.a., fliers, word of mouth D. Whst cow cutreech:tape wN be than by the argartugon to encore OW Mrtorttlee In 1M area tYai which R dram Its anendana we tare r 9*W opportunity a paNdpab in the program? E Has arry *Wd agaxy n MW ft orpra+tration of rwr - ornpwnoe wilh the Chr6 N" /d of "64? .............. 0 Yee ' Na ri yes. give detak inoiudbq darts, names, and muAW IL PANABUJTATM ACT OF I Moadw I" A. Dag the =X*0cting orgert Udw hate eny Policies, pracdoec w wdflbeMwW barriers alai k*,defry. ar ��y --wage participation in I* Wagram or arpioymwd by the ccntrwft orga izoon beta m of disabMryr'1 ........ El LJ Yes F3 No a yse, expfaiM U.i �. 1n pliMa b be used for M as *4 of neck aed"VWmm of Ned mial PwIo& WI F mmt fi c, chmoory, Cl�fidrea w eeW WOO []� ❑aarl en oM raoY uoswim ❑aW: 10. uet silo person*who wf1 be i wOved Io snit eamnt iR >tw n+ W aervroe. (SFSP Handbook. CtrapW W. +ro►ar�oarr�orr ro Paco weer+ MOmr m oum.Worker � Su ervise & Serve Meals 2 11e1 serve meals Fs7,ne'r { it. dens, wedw.WWWWWal Chaplerff) GmOWNMeCino" �pMr Cla2p Party_ House, 4bl+h b Ave. U _ �...�.YrY ,M S" stie iee& V*mdV hwn0 ss ($Mw rArt r+ +a i sm um d le lr m frt owdyteod ftvpR ar it *d j mr dcme ere ra mo*vd for Aw*? I& An mesh d*40W to"OUT ........................................................................................... am Ow IF YES. COMPLETE fn3WI4.15. a 15, IF 19% FM *COMPLETE LETE *XW T FM CkA1 1TM AT OO TTOM. 14. - A I 's 91011 of cormnu ricion wish to rwrdm whkh M be arced io 04uet MW ddk*Ws. WI P Hartdw* Chap. 5) VA Per eor nri MITT Coelret AdmirdetratM ltie lean WN Cowwwar t =8tW4 wb 0 MIE CantadVWAW 0marf W%V*m" - be rrt�r► arts hoer d >ha load eeE+rip. paelod? (SFSP FMrebraok, Clrepler q...................................... �Yos ❑ NO 15. Wl1 ddmea . wmrqwnwft w!t#* $W darde p uaft ed by kXW toM1 aWhoe W for detrwry end h0ft a ms* wd Erne at ssMoe. 1E, It ie r wraps of nieak defF+wrad. wiR be (SpSfs iferA00i Chaplet IR I CERTiFY tip t. viormd* n wn Worm r vw ara can wrx a fie beat a ny is a ledge I m�V fW tfs;fae has beer* viaitad and fwrt ft b'rs rio cap►sf�Y � fac�os for fie rnsal aervla pw+ed for twe nuribr#r a r�e#dnn anlcipaeed, t trww ttiet dslberw► trrisrapressrrttlion a V a won may nwA in prasocxri m wndat spic*b stata and imd- etavbae. CITY OF 1�UB MCI fm [:IAWOVW 00wi d. re m& USE n. orar 4 46nd Fow 6-2- t�qR t� u®E OeeyY _ ..Tx + —' � 1 r 22 TACH A UM WTHE Sf1E $MICE AREA WENT*1E�t? AT� itaider 6 cow rMe" tsar $k ,. kwoosse Type d slt: ❑ Apt err 1e Ricca ms" ❑ GMT en to %se me" O E ON I ar re 6m us" NeareelA l as Ca" at swaq r lb0elest cwmm 0 a(�1 ees 1e Roos taeai� ❑ D. m Eoro. eterie� Z. Ull ALL WSdW served by fttfe adcjpu =0 S. A. b your sit openc.....................................................................................................Of" 13, S. b your tale enroiled?.................................................................................................D" 0I C. she Erwer ft vet of ditm siols for free wm$w ae*xW price wmstat far h d * (W Kwwdbmk Chww 4 ... , 81.6 D. E open sees, submit documeruatian supporting this P I c Irwtepe ftM Ouah a oansue deft. edwod daty. For open An wing s&4ol da let the erhoc is used to doarnarrt she e5gbW, attach fo mda used by tdwooi dhL to astdAsh p a centog m of free a reduced prleew d00 Brown Elementary. Wheelock Elementary E. For enroled altos. Form 1531 Abe used to doournent elgbilty. (NaftW Youth Spoft PnWm-refer to SFSP Har400k Choprer 2 K the onroW site used s&cd dta, let ft sdwod used to document ire sits. F. What is to percentage of free or mduou4mios meals for M silo? ................................................... 4. Did the sae participate in provious yearn SFSP? (SFSP Hemdboolr. C.haprrr v)........................................... 13-08 0 S. E E Ye& gee ewaine of ON*ac*v Plan (SFSP Handbook. Chapter llf): Enter dot d 6-2-97/6-6-91 16-2-97/6-27-9 rmwew 1b be conducted Whim -2-97/8-8-97 LUM Servioe Period Wonmabon (SFSP Hawdtook Ch&Pier W rVIS of a EALS uuneEtt of tRt<J1t lBNrtCat T VAN" CLOWN TO ME sE rtw ascot" we" R;E 100 12:30 p.m. 2 p.m. P.ld_ supoement Supper 7w,—, rontl om is oorw ww oy uq Wwn www ffm Avvv..p m m wvv w— W--- rWWWWW14 %."Ww y 7. Cb ynu plan to food d ldren undar one (1) year old?............................................................ oyes 1: 6_ lrfettwod of Food Preparation by Con"Okig Organdabon (SFSP Handbook ChVW 1) 1 n On Sae [ � school tief�q Food service Yaneler4d ulkq Pdvats Ner A4c t Gntrel MWW Food Al Year Contracts) awet is sa �. kx10 a to syrpm to be used for ft sar*q of r u and to xpro don of oltNdi, dtrdtp meal wryly period. f WW l lw ct m'- I X:1np* Ill Ip. Ch&Mm we $weld M Lint tip Ousd�strvice ❑sad see Gkin MeatsO Up W* ❑ Or+. 10, Lht she perso wW who wla be Involved to any MUM In ne meal WAOR. (SFSP fialldf)OOK, 0"W I1): TITLE CMS POSMON NO. IN POSrr10M lPWP C FOOD SERVIM PROGRAM DtftTi>s CENTER SUPERVTSOF 1. HELP SUPERVISE MEAL SERVICE SIIMMER REC. WORK R 2 HELP SERVE MEALS J.T.P,A 2 HELP SERVE MEALS 11. Mtd mb provisions wfN be made for mad service during pubds of hdMuaMW Handbook ChspW h frmdoormom JAW Sevkt r�_-- ❑swvlot OWN et cano" lam: F F FA T T I_ S S C H 0 Q L 2401 DATE A V E. !2 I ttr sits feeds prirrrarity haneiea: dren, what n>edtods am wed to snare l* money, bad starrtpt, cr h4*W suvtoea am not rm%imd for muk? I& An meats debwW to the eits?........................................................................................... [Dye* ❑ Nc F'YES, COMPL M nIJO-14,15, & 1a. F NO, FORM IS CON LM EXCEPT FOR CERTFICATION AT BOTTOM. 14.. Indicate the mamas of conxrxuacOm wih the vendor wlid wNl be used to adjust meml daiiye WL (5 W ftidbook ffNp.1) Sib Personnel WIN Contact AdmkftV*n sNe Psrsmtml w0 C,omm unicals (gStW, Who Wtitl Cordac! Vendor ❑bMsdty WNh Vendor 15. tMN 6*4" be within one hour d the food secvios period? WW Hwdmk, Chaprr N)...................................... [1fes ❑ Nc d no, descrbe wrarQwTw to within sw dw* pr*KdW by b W healh a dwrbw for dWW&y and hd ft of mush and Iime of suvk)e. ta. d here is an excess of meats doWerad, rneais w* be (SFSP Handbook Chmpler UQ Slored In Rdumed ID p Served Day ® � � V� ❑oat. I CERTIFY that the rdormabw on his form is tree and correct to rie best of my Wxwhedge. I c&* that his sfte has been visited and that I Ms the cap "ty and faciRtm for the meal "row piarrred for the number of cf*kw wWdp m& I Mm that delberate rrtim spesenbbon o+ withhOUM of information may result in proseaudw urrdar appficabie soft and federal sbdubm Nam CTTY OF LUBBOCK or 0"kj l ipwam" or pnnq l m SUSAN RATELY RECREATTON OUTREACH COORDINATOR Km ow use ONLY ❑AWE CJDenied, mom i Texas DeparuneM Form lmnlsnurr�r 19' Of FNxnst± servioes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN - rm OHS Um OMY SITE INFORMATION r_� _; = > -A- Name of Food Service Sire TOWOMO Nm CHATMAM PARK. Address d Site (street. CAY. State. ZIP) 27th R TV0PY IUBROCK TY 7940-0 Period Of ogwfabm of Fo w .Service filW" of op- h -W Y �W `��i�• From: � - P - 57 through: 8-8 -97 eraW. Days.0 2 1 22 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Pr6n W4y)MgnVd Ct �( 0OW She 1. Indicate Type of Site: 0 A. (serving one to #m meaW) ❑ C. (serving one b tfiree meals) L_.f E (serving one to ft" meals) Nomesidentlal Camp Site serving Prff wty Home%" Bran 0 8. (senft one to throe meals) ❑ 0. (smviny one loft" wa*) 2 List ALL counties served by thus site: LUBBOCK 3. A. is your site open: .................................................................................................... Ls Nc B. Is your site enrolled? ................................................................................................. ❑Yes Nc C. Site Eligibility: Enter ft percentage of Ctlidren 089RM for free andW induced price meals for the site (SFSP Handbook, Om ptet fl).... 84.7 °/ D. it open sites. submit doc urnent"m supporting this percentage figure (such as census date, schaot Bata). For open sites using spool data, list the schools used to docw*nt site eligibility. attach formula used by school dist. to estabbsh percentage of free A reduced price children. Wf4FATI_EY E(_EMENTARY E. For enrolled sites. Form 1531 wilt -be used to document effgt4ty. (Nadonal Youth Sports Program -refer to SFSP Handbook, Chapter 2.) 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 site? ................................................... % 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter to ........................................... Dyes ❑ No It Yes, give name of contracting organization: (•TTY OF ._I IIRROU 5. Monitoring Plan (SFSP Handbook. Chapter It : Enter date of numRDring review to be conducted within, A. First Week of Operation B. Fku Four weeks of OperaWn C. Additlond #ievtews 6-- -a76- -Q l..iW.:,.2-O A-2-117 - -Q e. Meat Service Period Information (SFSP Ha)dbook, Chapter IQ- i OF • -tltt w4ormamon is Oohs cw0d Djf um wren 30=V vie apptvvea now fierYlOs WVW karJr rwKwom . t.rw w e) 7. Do you plan to feed children under one (t) year old? ................. .................................................... ❑Y*% n No 8. Method of Food Preparation by Contracting Organization (SFSP Handbook. Chapter IQ Serf-Preparaw Vended Usi" Sc}ippl mg Food Service Kiianapmerit lfsirlg Private Non -Profit n On Site rj Central Kitchen ❑ Food AuDwity Company (lffcltt ks Aft Year Contacts) ❑ 0%antzation that is Self --Prep t kWkx to to rysWn to be two for the se"ft of rtleata and ft sWerA*n a c ftm dwft rrneal aervloe period ESOP Hw4wi4 Owptor III nwe Sedw [ Cfteriberan uipa.lf�m s❑�❑w 000W. 10. List site Personnel who will be ktA*W to arty eXtent in the meal service. (SFSP Handbook Chapter 19: TITLE OF POSrT ON m ai POsmoN SPECIFIC FOOD SERVICE PROGRAM DV"= CENTER SUPERVISOR 1 SUPERVTSE MEAL. SERVICE ASST. CENTER SUP - 2 HELP TO SERVE MEALS J. T.P.A. 2 HELP TO SERVE MEALS 11. kl *m* what provisions will be made for meal service durktp periods of inclement wo0w. (SFSP Handbook. Chapw 4) Indoor Meal Meal Service Inser,rice ❑Wl9 Be Cancelled ❑06W. 12. E the site feeds prir wry k neless 05dren, what methods amused lo ensue that money. food stomps, or h4drld =vim are not m*ked for meals? 13. Are meals d*iered to the site?.......................................................................................... 0 Yes ❑ Ng IF YES, COMPLETE fT1=fY(5-14,15, & 16. IF NO, FOAM IS COMPLETE EXCEPT FOR CEATIF1CATM AT BOTTOM. 14. kt k*W the means of communication with the vendor which will be used io adjust meal deliveries. (SFSP HanbooK Chap.1) Stta Personnel WHI Contact AdrWnist m#n Sloe Personnel WN communipfs ❑ Staff, Who Will Contact Vendor ❑ Dhcdy With Verndor 1 S. Will delivery be within one hour of the food service Period? (SFSP Handbook. Chaplerln...................................... 0Yes ❑ W tf no. de=be arrangements within standards Prescribed by local health wd*rA= for delivery and hokkrlg of meals urd time of service. I& if there is an excess of meals derwed, meals wig be (SFSP Hand)ook, Chapter 110 ❑Stored In Refrigerator Throw Served the e Day ®ate Site 0 Wried to Vendor ❑Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. I that Cris site has been visited and ftiat t has the capability and facilities for the meal service planned for the number of children anticipated. I know that delloerate wftrepmsentation o withholding of information may result in prosecution under applicable state and federal statutes. Name of CITY OF LUBBOCK S�,aars-t>��a�u of Ccntra*+q O�yanitation Dow_ r4—W�4 Off%XW (please M" a P"M I aim SUSAN BAILEY RECREATION OUTREACH CQORQTNATOR DW USE ONLY ❑ Approved ❑ Derlled, reason: $ipna>tsr pF{5 Reprosantativr Ow Texas Dspafuroe t Of Human servtoss SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION FOR DM USE ONLY r� RODGER,S COMMl1N1TTY CENTER 3200 AMHERST Of oa 6+ or9 7 Food sar.�ce ( vewmk S 8}- ° 7 I waft Days: 0 �Jww 21 �J*22 �AW'6 �SOPL 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Reslde"tw Camp Site serving Prlmafly gent aft" Dttrer SRO 1. Indicate Type of Site: Q A. (servkg one to three meals) Q C. (servlty one loom Mak) ® E. (serving one to three memts) iiatresWantW tamp SPoe "Or Pttnhomeless Ctsilldmt 8. (aervirg one to those meals) ❑ Q. (servSaing oning e to ttwee)arly meals) 2. 1..ist ALL counties served try this Me: I I I R R D f' K 3. A. is your site open:.....................................................................................................®Yes ❑ N, B. Is your site enrolled?................................................................................................ E] Yes L4—j N, C. Site Etigibilhty: Enter fie pwcw age of civldren eigtk for tree w4or reduced price meals for the sib (SFSP Handbook. Chapter m.... 82.7 D. If open sites, submit documentation supporting this percentage figure (such as census date. school data). For open sites using school daft list the schools used to document site eligibility, attach formula used try school dist. to esteMsh percentage of free & reduced prier children. MCWHORTER ELEMENTARY f93.31T[IRBS ELEMENTARY (72.07) E. For enrolled sites. Form 1531 wff be used to document eligiTity. (National Youth Sports Program -refer to SFSP Handbook, Chapter 2.) If the entailed site used school data. W 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 IQ ................ ........... El Yes ❑ Nc ...................... If Yes, give name of contracting organization: CITY OF LUBBOCK 5. Monitoring Ptan (SFSP Handbook, Chapter 111): Enter date of monitoring review to be conducted wNhhin: 6-2-97/6-6 97 1 6-2-97/6-2', -07 1 6-2-97/8-8-97 E- Meal Service Period Information (SFSP Handbook. Chapter IQ: j ` TYPES OF MEALS NUMBER of ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGtNi" ENOMG Breakfast A.M. Supplement Lunch 120 11:30 a.m. 1:00 P.M. I P.M. Supplement Supper ' -nxs w4ormabon 13 Opflixhe(ea ay Nn.) wnen wwW ms approved mom aarvice w#vL harsr^ nano oK. wMwr a) 7. Do you plan to feed children under one (1) year old? ....................... . .......... .. ❑Yes E] No 8_ Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) SeN•Preparatxm verew Using Schoch thing Food Service Management using Private Non -Profit []On Site [] Central Kkdwn I ❑ Food Authority [Company (Inodudes AN Year Contracts) ❑ Organtutbn that is Sel!-I M I.] 10. Irldlcale the syslern to be used for the swAV of meals and the M4*vWon d dti *m during renal service porkxL WW Hwwftok. Cloplor IQ � ❑ t'ri IMM L1110 up ❑ md. Pick BP MWe ❑ 00W. Ust site personnel who wiQ be Ym*md to any extent In the mead service. (SFSP HaWbook, GWter 11): TrTLE OF POSMON NO. N POSMON SKCM FOOD SERVICE PROGRAM OUTM CENTER Sl1PV. 1. SUPERVISE MEAL SERVICE ASST. CENTER SUPV 2 HELP TO SERVE MEALS J.T.P.A. 2 HELP TO SERVE MEALS 11. lrldicw what provisions will be made for meat service durirg periods of inclement weather. (SFSP Handbook, Chapiv 1) 10mloor mew Meal Service 0;;;❑ so Can4eilled ❑00W. m It the slta feeds prlmar4 homeless I*n n. what methods are used b ensure thst fenny. food AwTVs. or h4drxi services are not t+eQaied for meals? I& Ara meals delivered to the sft?........................................................................................... aes ❑ Ni IF YES, COMPLETE 171E30-14.15, i 16.1F NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. indicate the meads of oorrurunicatim with the vendor which wil be used to adjust meal "veriea. (SFSP Handbook. Chap. 1) Site Personnel Will Contact Administrative Sta Peracrnnei WE C nummigte 10Staff, Who Will Contact Vendor ❑Directly"VKWW 15. Will delivery be withm one hour of the food swvmx Period? (SFSP Handbook, Ctivw 14...................................... aes ❑ N It no, describe arrangements within standards pnwribed by local health authodjes for delivery and hoidirq of meals urtl time of service. 16. If there is an excess of meals deWered, meals will be (SFSP Handbook. Chapter III) Stored In Rofr4er&W 0 #W Sk � ❑ Vendor 000W. I CERTIFY that the information on this form is true and correct to the best of my talowtedge. I cert;fy that this site has been visited and that 1 has the capability and facilities for the meal service planned for the number of children anticipated I know that deliberate misrepresentation o withholding of information may result in prosecution under applicable state and federal statutes. CITY OF LUBBOCK a cona*,o aWz , I S Ar 4 "RATLa7v I IMRECREATTON OUTREACH COORnTNATOR .0, ❑ Approved ❑ IkM4 reason. Too S01W"rs-QKS PAPM er"ADY9 Dow Tsuae t 11,14k onift Porm 12977jovjw 199, or mwneh servims SUMMER FOOD SERVICE PROGRAM FOR CHILDREN V� FM Ms USE oKr SITE INFORMATION ,� �. . _ u or good Service S1Wetepr�arr .."" MAF SIMMONS COMMUNTTY CENTER (8n91 767-?Inn Addressor side (Stress. CRY. Stahe, ZIP) 23rd & OAK L11BBOCK TX 70403 I mar o"m n Q Food service tmo� -w -) - Q 7 h m" June ? �J�i!► ��0 fi n ATTACH A MAP WITH THE SITE SERVICE AREA 1115ENTIFIED RG"MW CUIP She Servkhg Pftwoy mgmt Clhmn Ohlhet She 1. Indicate Typed site: ❑ A.(ee 4q one %* throe rn6*) [] C.(aerving one b tone ) ® E. (SWAV one to those Bak) Norurltldenflet Camp Sloe Servbhg pmarfiy Ito "hos Oft" ❑ 8. (sarv{tg one tv three ahem) ❑ D. (serving one b three Bhe�] 2. List ALL counties served by tit she: 3. A. Is you site open: ..................................................................................................... SYes ❑ No ta. is your site enrolled?................................................................................................. OYes ® No C. Site Eligibility: Enter the percerftge of dddren eligible for tree w4br reduced price meals for the site (SFSP Hanftok Owier 4 ... 9Z.4 % 0. t open sites, submit doaunentahor supporting this percentage figure (such as census date, school data). For open sites using school data, list the schools used to document site eligibility; attach fomhula used by school dia to establish percentage of free S reduced price children. POSEY ELFMFNTARV E. For enrolled sites, Form 1531 411be used to document eft WIty. (National Youth Sports Program -refer to SFSP Kandbook. Chapter 2.) if the enrolled site used school data,19 the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? ................................................... 11/4 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter IQ ........................ ®Yes []No t Yes. give name of contracting organization: C T T v OF LUBBOCK 5. Monitonng Plan (SFSP Handbook, Chapter Ill): Enter date of monitoring review to be conducted within: a Frrsh Week or Operation B fret Faun V ooO of OperaWn C. Add* W hevie 6-?-97/F- -97-2-07/6- -97 6-2-97/P-R-a7 �` E. Meal Service Period information (SFSP Handbook, Chapter IQ: TYPES OF MULS nusim OF ELKIBLE CHLOREN TO BE SERVEIr SAL SERVICE IM 6ECA604 EIyDM Brealdast A.M. Supplement Lunch inn 12:1.5 p.m. 1 :3n p.m. l P.M. Supplement Supper ''rrs inrormawn is conLs�weo oy rxss semy We apgwea Me sernce WNW tsror rMwKMO z, urep0r a! 7. Do you plan to feed children under one (1) year old? ....................................... [Dyes B No e. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) Isen-Preparason Vexes Using Sd" UWng Food Service Mamp bent lasing Private Nos -Profit ri On Site 0 Centro! Kitchen a Food Authority ©±;company (Inters Alit Year Contrxb) ❑ Orgw&atlor that is Self44v t 10. kKkato the syston to be used for the of meals and the suparvlslon of d> mail sarvioe period. (SFSP Kw4book. IQ MLim Up ew Service ❑ Clildrenareseww Given Meab w tip M h ❑ Oar. List site personae# who VAN be 3 VOW t0 any extent in NIS MON service. (SF5P Hsndboou, Chapter IQ: WLE OF POSMON No. a1 Posrnok WECO iC FOOO SERVICE PROGRAM Al TWO CENTER SUPERVTSOR 1 HELP TO SUPERVISE MEAL SERVICE SUMMER REC. WORKE 2 HELP TO SERVE MEALS U,T.P.A. 2 HELP TO SERVE MEALS 11. eta what p ovisions will be made for meal service dump periods of inclement wultw. WSP Hardback Chapter Mj hwkw nest Meal Service ������ 0Servlce ❑Will 8e Cancelled O FEED AT A p N T T SCHOOL 71 F. Q[ I F F_ N S 12 g QIe sibs feeds primarily horneless d*kw . what methods ere used MD ensure that money. food stemps, or h4dnd servioes are not mWAred for meals? I & Are meats delivered to the site?........................................................................................... ass (3 No IF YES, COMPLETE ITEiIr I4,15, 4k16. F NO, FORM i5 COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. m. kidimte the�means of communication with the vendor which wit be used to a*W meal deliveries. (SFSP Handbook Owp, 9) Contact Vendor wltl Contact Administrative Q C�Ixdcsa x , who Will CVendor 15. Will delivery be within one hour of the load service period? (SFSP Harxftook. Chapter m ...................................... EK*s ❑ No if no, describe arrargfnelft wit!» standards presaibed by local health autharhies for deWery and hoidinp of meals urtbl pnle of service. 1 & if there is an excess of meais delivered, meals will be (SFSP Hardbook, Chapter [IQ Storedrnd�' Away Vendor OwW S ]ER a mposw ❑Other: I CEFrnFlf that the information on this form is true and correct to the best of my Wiowledge. I certify that this site has been visited and that it has the capability and facsiities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or wiihho[dkV of infomnation may result in prosecution under applicable state and federal statutes. Nam• CITY OF LUBBOCK s4MOW-Om" ar C4MWwq ov-imon Owe Name of Ol odw (please tyre err WW4 T SUSAN RA TI_EY RECREATTON OUTREACH COORDTNATOR FM 0M USE ONLY QAWOvW ❑Denied, r om- Tills 5iprsaIIars-{ Rapeserga6ve Oahe Tears OMpsrtment -of F4lrntan 5erv1ess SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Nam* of FoW Sarvise Site Cla ton Carter r d&*= of SiM (StreSt, City. Stave. zL9 Globe and N. Loop 289, Lubbock, Texas 79403 Period of LVwxwn a rocs wwax lmo4oaynr.-"W4Q"r)T-1 Number of Op. MMY From: 6-2-97 throfigh: 0 21 $-$-97 eratiifNg Days: ATTACH A MAP W[TH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site ServhV Prima* fdigrant ChDdren 1. Indicate Type of Site: A. (serving one to three meals) ❑ C. (serving one b three wads) Nonr"W rtu camp Site Serving Prlmartty Homeless ChIldrm ❑ e.(servhrq one to three meals) ❑ D.(serving one b three mans) f FOR oft USE ONLY ti CIS C7 u N/A Parksite 1.1 Other site © E. (servInq one to three means) 2. List ALL counties nties served by this site: 3. A. Is your Ste Open: ..................................................................................................... © Us [3 No S. is your site enrolled?.................................................................................................Yes ® No C. Site Eligibility: Enter the percentage of dualdren eligible for free w4or reduced prim meals for the site (SFSP Handbook, Chapter IQ.... 84.7 D. If open sites, submit documentation supporting this percentage figure (such as census date, school data). For open sites using school data, fist the schools used to document site eligibility: attach formula used by school list. to establish percentage of free A reduced price children. Arnett Elementary E. For enrolled sites, Form 1631 vAt-be used to document eligibility. (National Youth Sports Program -refer to SFSP Handbeok, Chapter 2.) If the enrolled site used settocl data, list the school used to document the sibs: 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 IQ ........................................... ®Yes ❑ No If Yes. give name of contracting organization: City of Lubbock 5. Monitoring Plan (SFSP Handbook, Chapter 111): Enter date of monitoring review to be conducted within: A -2-97/6-6-97 6-2-07 1 6-27-97 8. Meal Service Period Information (SFSP Handbook. Chapter It): 6-2-9718-8-07 i TYPES OF MEALS MISER OF ELIGIBLE CHILDREN TO BE SERVED* MEAL, SERYM TIME BEGR#4M EtB)M Breakfast AM. Supplement Lunch 1-2:1-5 p.m. 1:30 p.m. i P.M. Supplement , Supper ''Eris information is cons,oerea oy tarnswmera semn um approves mom sen+r a arm. tarar rmwiwwR wwWw Al 7. Oo you plan to feed children under one (1) year old?..................................................................... Oyes Dla 8. !Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter IQ sae-f'►epara°o" ve" Using School Using Food Service Management Using Private Non -Profit n On Site ❑ Central Kitchen ❑ Food Authority 0r ompany (includes All Year Contacts) ❑ Organization that is Self -Prep �. kWk* a the syspn to be used for to serving of mein: Sid to r4mr0lion of �k durft real servke Period. (SFSP Mani! wl� Ig C]� ❑ c Mak M Up 00618r: 10, List site pemonrW who will be involved to any extent in the meal Eorvioe. (SFSP Handbook. Chapter IQ. i1Y1.t: of Posniom um N vosrnotr aPECIRC "M ai:W= PROGRAM cum CENTER SUPV. 1 HELP SUPERVTSE MEAL SERVJCE SUMMER REC. W ER 2 HELP TO SERVE MEALS J.T.P.A. 2 HELP TO SERVE MEALS • 11. tndkate what provisions w9 be made for meal aervlos during periods of inclement: we0W. (SFSP Har>ft* 1D hdoor " blest Serve* ❑ Serails ❑ YVti) Be Caft" MOW. FEED AT OUPREE ELEMENARY - 2O(I$ AVE T 12. j the she feeds primarily homeless &A&m what methods are used to ensure that money, load stamps. or hod nd savtces era not required for meats? 13. Are meals delivered 10 the site?....................................................................... ❑ ❑ .................... Yes N IF YES, COMPLETE ITEfYlS-14,15, & 1f1. F NO, FORM IS COMPLETE EXCEPT FOR CERTiFlCATWN AT BOTTOM. 14. indicate the means of corramucabon with the vendor whkh will be used to ar*rst meal deliveries. (SFSP Hsrmthook, prop+ 11) site Personnel Will Contact Admtrrlalrei " Site Personnel will Comnwr>ic" ❑ staff, Who Will Canted Vendor ❑micey with Vardar 15. Wo delivery be within one tour of the food service Period? (SFSP Handbook, Chapter U) ...................................... [Dyes ❑ m N no, describe arrangeam is within standards prescribed by local health authorities for d*v y and holding of meats and time of service. I& If there is an excess of meals delivered, meals will be (SFSP Handbook Chapter liq Storod In Refrigerator Thrown � ❑ate she the ❑for DbPosalV* War ❑ Served the 00tber: I CERTIFY that the information on this form is true and correcit to the best of my kmawledge. t 0W* that due site has been visited and that ' has the capability and facilities for the meal service planned for the number of dAdren anticipated. I know that deliberate misrepresentation 0 wti x)lding of information may result in prosecution under applicable state and federal statutes. NW" GJTY Of LUBBOCK a camac�nc o�psnitaoca now �wams or mew {pease nave or pnm �• SUSAN BAILEY RECREATTON OUTREACH COORDINATOR FW DW um ONLY ❑ AWcved fknied, rt 7iSOn: arts spn�Repmufft" Dee Texas 0oP* WA rwm iavLbr !M In ar Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN _ MR we USE ONLY SITE INFORMATION �TX OR Do Name of Food SwYce Site wo CARLISLE PARK NA PARK SITE Address of SAe (SVeet. City. State, ZIP) 26th & AVE W. LUBBOCK TX 79411 Penod of E - 2 FQ Servios (ffadaY .-M4d"hT.) - 9 7 �Mdy21 �J*22 �A-6 4 S0 From: �: ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Ca" $orving P&Lrltl WgrWd ChkWW Other she 1. Indicate Type of Site: ❑ A. (sewkg one to three Moak) ❑ C. (serving one to tMee weals) 0 E. OWAV one to tMee ate,) tforgumentbil camp Site sewing Pebnartfy Ymmiess cm*" ❑ is, (servuv one to three rt►eats) LJ o. (serving one to throe Meals) 2. U+st ALL counties served by this site: 3. A. Is your site Open: ............................................................................... .................. Yes ❑ Nc B. is your site enrolled? ................................................................................................. []Yes Q Nc C. Site Eligibility: Enter the percentage of digdren eligtie for free antyor reduced price meals ford* site (SFSP Hari6aolr. Chapter II).... 89.2 0. H open sites, submit documentation supporting this percentage figure (such as census date, school data). For open sites using sdtoof data list the schools used to document site eligibility; attach formula used by sdtool disL IQ establish percentage of free & reduced price dtgdren. E. For enrolled sites, Form 1531 vall be used to document eligft ty. (National Youth Sports Program -refer to SFSP Handbook. Chapter 2.) 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 sne?................................................... °/1 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter IQ ........................................... QYes ❑ No if Yes, give name of contracting organizatan: rr T Y OF LUBBOCK 5, Monitonng Plan (SFSP Handbook, Chapter III}: Enter date of monitoring review to be conducted wilfft a Frost we" of operatwn t3 Fret Four weeks of Operation C. Addr*,W Hevews 6-2-97/6-6-97 1 6-2-97!6-27-97 1 6-2-97/8-8-97 e. Meal Service Period information (SFSP Handbook. Chapter IQ: r TYPES OF MEALS NUMBER OF ELIGIBLE CKLDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ELIDING Brealdast A.M. Supplement Lunch 6!1 11:30 a.m. 12:45 p.m. P.M. Supplement Supper MS "Orrnauw A T 7. Do you plan to feed children under one (1) year old? ..................................... . ............................... ❑Yes BNo a. Method of Food Preparation by Contracting Organization (SFSP Handbook Chapter iq seu-Preparation VWKW Using School Using Food service Managewnt Using Private Non -Profit n On Site 0 Central Kitchen 1 0 Food Authority ElCompan (t 4kWes AN Year Contrails) ❑OrgacizaWn that is Se�Prep 9. Ir4cate the system to be used for the serving of MOSIS and oho oupervbion of ditw during moil service period. (SFSP Handbook Chapt , iq List site personnel who win be Involved to any extent in the meal ser Ace. (SFSP Handbook Chapter IQ: W E OF POSrr" No. R! PQSrr" VECV4 MW 4iOW= PROGRAM DVn U CENTER SUPERVTSOR 1 SUPERVTSE MEAL SERuTCE ASST. CENTER SIJP 2 HEf_p 1Q SERVE MEAI.5 J.T.P.A. 7 HELP To SERVE MEALS 11. Iniftale m" provisions will be made for meal service dwtV periods of inderrrerrt weadw. (SFSP Hvdbook, Chapter 1) Indoor Meal Meal server 8�ice ❑WIII so Cancelled 0Other: 12 If the site feeds pftarillt homeless 0ARm what methcxls are used 10 sr►s n fhst money. food stamps, or h4dW services are not required for meats? I& Are meals delivered to the site?........................................................................................... EDYes ❑ N( W YES. COMPLETE ITENP-14,15, & 19. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. h vScate ft+e means of communication with the vendor which will be used to must meal deliveries. (SFSP Handbook Chap. n) shoe POMMnet win Corstact Adralnistn" SW Panel WW Comm nkale - ❑ Staff, Who WAI Contact vendor ❑ EWeetty With vendor 15. wit doomy be within one hour d the food service Period? (SFSP Handbook, Chapter If) ...................................... UIles ❑ Nt If no, describe arrangements within standards pmsaUed by local health audwitiss for delivery and holding of meals until time of service. 16. ff #we is an excess of meats delivered, meats will be (SFSP Handbook, Chapter III) ❑Stored In Refrigerator Thrown arid Served tha Next Day ❑at the Sheer ❑far Dwprnw ❑0"W. I CERTIFY that the information on this form is true and correct to the best of my knowledge. I cm* that thus site has been visited and that i has the capability and facilities for the meal service planned for the number of d4dren anticipated. I Imow that delloerate misrepresentation o withholding of information may resuft in prosecution under applicable state and federal statutes. HMO CTTV OF 1_U8RnCK jai or corwrcGnp Qstlon Dees Nsea a OWi0W (q"" type or pnno SucAN RATI-Fv 4 C°EATi(!N OUTREACH rnORnTNA'TnR ❑ Approved ❑ Denied, reason: ITIU* 7111aupt t)epe+anent Form 130gariwrY i 9 of "#roan Somm SUMMER FOOD SERVICE PROGRAM FOR CHUXIREN z"" � KN Otis tl9E oNCY SITE INFORMATION Oft Name of Food Sar>i+W Sam aavha* ham. Oror- AP C1,F(1R(;F W0 00S rOMMIINTTY CENTER Address of SiFs (5hreet. CRY. 5G►te, Z1P) 7F:NTTH A FRSKTNF LUBBOCK Ty Mjf opwabw Food Service (�� � a � 7 I I � � � �J? � �� _ 22 ��. �� n ATTACH A MAP VI/TTH THE SITE SERVICE AREA IDENTIFIED P43161IMtlal Camp Slta serAl Prim* Www CthiTdraa other site 1. Indicate Type of Site: i _1 A.*9*q one b %M amab) ❑ C. (servkhg one b tires M0* ® I- Owvkhp one to flans Meals) Nonr+eslderhrial Camp ^ Site serov Pewarty Ibmeless Cth drsuh ❑ 8. (sarvtehq orha b three meals) t�J F3. (servlrhg one b 8hrae oh�lt) 2. List ALL counties served by this site: Lus$n�;K 3. A. Is your site OW: ..................................................................................................... BY** ❑ N B. Is your site enrolled?............................................................................---................ ❑Yes ON, C. Site Eligibird) : Enter the percentage Of chddren eligible for tree an4lor reduced price meals for the site (SFSP Handbook. Clhwo IQ.... 96 D. If open sites. submit documentation supporting this percentage figure (such as consus date, school data). For open sites using school data IW the schools used to document site eligibility; attach formula used by school disL to establish percentage of free & reduced price cl*hn. HUNT FLEMFNTARY (94.3) PARKWAY FLFMENTARY07.3) E. For enrolled sites. Form 1531 vih NU used to document eRglbility. (Naftial Youth Sports Program -refer to SFSP Handbook, Chapter 2.) If tile enrolled site used school data, gat the school used to document the site. F. What is the percentage of free or reduced -price meals for the stte? .................... 4. Did the site participate in previous years' SFSP? (SFSP Handbook. Chapter If) ........................................... QYes ❑ W if Yes, give name of contracting organization: CITY OF LUBUCK 5. Monitoring Plan (SFSP Handbook. Chapter Ill}: Enter date of monitoring review to be conducted woh: A. Feat We" of operation a First Four weeks or r]p eraoon C. Addbonab PAYiews I -�-d7' >^_�_a� 6-2-a7/h--2:'_97 6-2-o7/P.-8-47 E. Meat Service Period Information (SFSP Handbook, Chapter IQ: TYPES OF MEALS WiMMOF ELIGIBLECHILDREN TO 9E sERVEO' MEAL sERvrCCr: TIME 9EGROOM ENOM Breaidast AM. Supplement Lunch 6f) 12:30 p.m. 2.:110 p.m. l P.M. Supplement Supper • no information is corWxWrea oY [ma wnsn seumv use app=wea mean servws wru. k,r,r nagooaF a.n WW et 7. Do you plan to feed children under one (1) year old?................................................................. ❑Yes f.q Nc 8, method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter IQ Sell-Pnsparawn I VWi00a using SCIh001 Ming Food Service Management Ustihg Private Non -Profit ri on Site 0 Central Kitchen I ❑ Food Authority 10 Company (Includes AA Year Contracts) ❑ Organization that is Self -Prep 9.bvftW to syslarn lo be used for the ser ft of meats and ft =gwvWon of d6drpn during meal service period (SW k Chapter U) ❑� ❑ �ON" Mauls E3 sad Pldt Up Mesis ❑ 00wr: 10, List site personnel who wM be kwotved to any extent in the meal service. IMP Handiyooic, Chapter IQ: TrLE OF POSMON NO. IN Posmom SPEC F C FOOD SERM rROca M oUUM CENTER SUPERVISOR 3. HELP TO SUPERVISE MEAL SERVICE SUMMER REC. WORKE 2 HELP SERVE MEALS J.T.P.A. 2 HELP TO SERVE MEALS 11. what provisions will be made for meal service during periods of Inclement weWw. (SFSP Hwdbook Chapter g) Woormeal Mew service Oservics OWN 111e Candled ®Oliwr:.. FEED AT R A M TREZ EL EMf N I A R Y 7 Q 2 Axe. 12 If the sb feeds Prim* homeless QIAdr9n, what maihods are used to erasure that money. food stamps. or ir}Idnd services are not required for mob? 13 Are meals define ed to the site? .................................. ......................................................... Elyse ❑ N W YES, COMPLETE fTE4S-14,15, i 16. W NO, FORM IS COMPLETE EXCEPT FOR CER71 ICATION AT BOTTOM. 14. Indicate the means of motion with the ► endor which wM be used to adjust meal dehwries. (SFSP Hardook Chap 1) �Site Personnel Win Conted Adn�nisirative Site personnel WE C.ornn�lpde - l 3 Staff, who WIII Comsat V.rxIor ❑ Dkee fy With Vendor 15. VVW delvery be within one hour of the food service period? (SFSP Handbook, Chapter N)...................................... ®Y!s ❑ W If no, describe arrangements **On Standards prescribed by knot health audtorbes for deWwy and Wng of meals until lima of service. 1 & H there is an excess of meals delivered, meals wN be (SFSP Handbook, Chapter Ill) ❑Stored Sesrved the Next f*r Elat the SW Dfor mspo" ❑other: I CERTIFY that the information on this form is true and Correll to the best of my knowledge. I cei* that this site has been visited and that i has the capability and facilities for the meal service planned for the number of d v1dren anticipated I know that deliberate misrepresentation a wi **Wing of information may result in prosecAon under applicable state and federal statutes. NWO CTTY OF LUBBOCK NNW or official (oleos type or PrW q I eye SUSAN BATI_EY - -- RECREATTON OUTREACH COORDINATOR DW USE ONLY ❑ved ❑dell lesser,: TAM 5'�r+anas--OFIS iispnser�a�va Cate TUM Dspo"Ard Fam 1!2nJ&x ry 19' ae Hunan Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN RM DHS USE 0NLY , SITE INFORMATION Itt i U Name of Food Service See the N PIONEER PARK NA PARK SITE Addnas of sift {Street CRY. State. ZIP) Fth A Ave T LUBBOCK TX 79407. Period of operation of Food Service tr>aJ YM +r+oJdaYM$ - Q 7 I�unber of Op- h M+Y 0 21 22 Fi �'O From: 6-2-07 through: ersdrg Days: ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED ResIdentiai Cupp Site Serving Primarily Migrant Chft" Other ving 51te 1. Indicate Type of Site: ElA. (swvbg one to fhraa ma ❑ C. (serving one to three mash) " E. (serone W IIM aseak) ❑B. NonresidentW Camp Sb Serving PrlmarRy Homelon Children (serving WW to � sus) ❑ t3. (serving one to Ether meals) 2. List ALL counties served by this site: 3. A. Is your site open: ................................................................................................. BY** ❑ Nc R. Is your site enrolled? ...................................................... .............................. ,........... Dyes E3Nc C. Site Eligibility: Enter the percentage of children ebpft for free w4or reduced price meals for the site (SFSP handbook, Chapter It).... 93.5 0, D. U open sites, submit documentation supporting thk percentage figure (such as census date, school data). For open sites using scivol data list the schools used to document site eligibility; attach formula used by school disc to establish percentage of free & reduced price chilclren. E. For enrolled sites, Form 1531 vAU used to document eligibility. (National Youth Sports Program -refer to SFSP Handbook, Chapter 2.) If the enrolled site used school data. fist the scthod used to document the site: F. what is the percentage of free or reduced -price meats for the site? ................................................... e/ 4. Did the site participate in previous years' SFSP? (SFSP Handbook. Chapter tI) . .......................................... 11Yes ❑ No if Yes, give name of contracting organization: r.TTY OF LUBBOCK 5, Monitonng Plan (SFSP Handbook, Chapter 111): Enter date of nnonitoring review to be conducted within: 4 First week of Operation &. Frst Four wools of open ion C. Add xW Review: 6-2-r" 6-6-„ 1 6-2- 17! f,-27--n7 6-2-97/8-8-0-7 8. Meal Service Period information (SFSP Handbook. Chapter IQ: TYPES OF MEALS NUMBER OF ELKHOLE BENTO BE MEAL SERVICE TIME BEGAYdNG ErFE7HtiG Brealdast A.M. Supplement Lunch 100 11:50 a.m. 1:30 p.m. I P.M. Supplement Supper -rrs MM eMaWn a COnswerea oY una wr0n semry ale apprwva meal sernw wrar. larar n x=G4F. k4mW er x) 7. Do you plan to feed children under one (1) year old?..................................................................... ❑Yea (gNo 8_ Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter tl) SeN•P►eparatan 1"Ied Using School rising Foal Service tifanageawnt using Private Hoch -Prom I ❑ On Site ❑ Central achen I ❑ Food Authority Mtmpsny &KhAea AN Year Contracts] ❑ Organization that is Se8-Prep g. kdclde the sys�ern to be used for the servkg of meads and 00 sup4r0W0n of dfteth Ojtq nhaal sarvioe pWkXL WW IIfarhdfaookc, Ctgft 14 Wder"Ole Children we Subd Mak 10. List site personnel who will be Involved to any extant In the meal service. WSP Handbook, QWWr tq: WLE OF POSa M No. as Posmon SPECWIC FOOO SE RYCI PROORAMi CUTE$ CFNTFR SUPERAITSORI I SUPERVTSF MEAL SERVTCE ASST, LINTER SUPV 2 HELP TO SERVE MEALS J.T.R.A. 2 HELP TO SERVE MEALS 11. irfdicate MAW provisbns WIN be made for meal service durkV periods of knderrtent weather. (SFSP ffandbooi, Chapter n kukor "Mtal Mew servIN ❑ M Cancelled ❑Other. 12. N the site feeds prima* homeless rhildren, what methods are used to ensure that money, tool stamps. or Jn4dnd mvms are not required for meals? II& Are meals delivered to the sffe?........................................................................................... as* ❑ N4 IF YES, COMPLETE tT J4S-14,15, 31fi. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIMATION AT DOTTOK 14. lndhcate the means of cormnunumban with the vendor which Will be used to adjust meal deliveries. (SFSP Hw4bo* Chap. 9) �Personnel Will Contact Admk islrativ�e Site Personnel Will Cornraunlr� , Who Will Contact Vendor ❑ Directly With Vendor 15. Wil dewery be within one hour of to food service period? (SFSP Handbook, Chapter IQ ...................................... Byes ❑ N+ g no, describe arrangements within standards prescribed by local health authorities for delivery and hoidrg of meats until time of serum t& if there is an excess of meals cWwered. meals will be (SFSP Handbook, Chapter 110 ❑ftmd In Refrigerator wW Served oat do Site ❑ for DbpoaW ❑Otter: I CERTIFY that the inforrnabon on this form is true and owed to the best of my krnowledge. I certify that this site has been visited and that i has the capability and facilities far the meal service planned for the number of children anticipated. I know that defiberate misrepresentation o wW*XAding of information may result in prosecution under appticabie state and federal stahms. wm. of CTTv OF LUBBOCK S�r,at�s-affipal ofconaaak+p fltga'+izadon Deft NNW cr OrfiaN (please true Of VW19 ' W SUSAN BATE_FY RFCREATTON OUTREACH COORDjNATOR FOR cm USE ONLY ❑Approved ❑flanled, reason: roe S*UWr*-DHS Rsprasen ab" t]" ' Taoras D or Fk~ se-=* SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION AWLINGS COMMUNITY CENTER Address Of Site (Streeh. Vnr. bla4. 4 40th & Ave B - tide t�s use ora.Y • ❑ Ft Perwd of Operebw of Food Service Number of CIP. uw June OJ* �Auq. som 6-- 2 - 9 7 throlgh: ft - 8 - _ 7 eradng pay:;0 O 21 22 6 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Redden Camp ^ Sfte Savli g Pdmarily Wgrard Children Other Sble 1. Indicate Type of Site: ❑ A. (serving one to tree meals) U C. (serving one to three meals) E3 E. (saving one to tlM meals) Nonresidential Camp She Sawing Pdmarly homeless Children ❑ B.(serving one io Ihree meals) ❑ D.(senrin9 one loom" meals) 2 list ALL counties served by this side: LIIBBOCK I. 3. A. Is your site open:..................................................................................................... ®YOS ❑ Ni B. is your site enrolled?................................................................................................ ❑Yes []Ni C. Site Eligibility: Enter tthe percentage of cihildrerh eligible for free and/or reduced price meals for the site (SFSP Handbook, QWW dl).... 98.3 D. If open sites, submit documentarian supporting this percentage figure (such as census date, school data). For open sties using school date list the schools used to document site elobility; attach Wmula used by school diet. to estWiish percentage of free & reduced price children. E. For enrolled sites, Form 1531 v►ditbe used to document efigbirdy. (National Youth Spats Program. -refer to SFSP Handbook, Chapter 2.) If the enrolled site used school data, list the school used to document the site: F. What is the percentage of he or reduced -price meals for the site? ................................................... 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter If) ........................................... ®Yes ❑ Nc If Yes, give name of contracting organization: CITY OF LUBBOCK 5. Monitoring Plan (SFSP Handbook, Chapter Ild): Enter date of 6-2- 6-2-Q7/' 6-27-97 8. Meal Service Period infon'nadon (SFSP Handbook, Chapter IQ: nsview to be conducted within: 6-2-97/8-8-97 TYPES OF !MEALS Nt MSM OF ELIGIBLE ChiRMEN TO BE SERVEW MEAL SERVICE TWA BECJNNM ENOM Breakfast A.M. Supplement a Lunch 100 11:50 a.m. 1.30 p.m. i P.M. Supplement Supper . rdS wwormawn R ogn5l rvu Py urn m1wi warty uwe ""{ nme- aw...v+ terror r.a +cam L.nopwr ul 7_ €]o you plan to teed children under one (1) year old? ............ ......................................................... ❑Yes t__1 No 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter tl) Soti-Preparawn I v8f6°° Ding School Using Food Sankt Management Using Private Non Profit non Site n Central Kitchen 1 0 Food Authority Company (includes AN Year Contracts) ❑ OrgantmOon that is Self -Prep r.'V;p� g. mate the system lo be uaW ford* serving of mesh and tote d dtu rtQ MW Wvloe P@eQ& WW NWWbook Chapter tij CONW10-dyle gild sm Sailed thUM Line Up 01" Sarvlo. Q and am Gtv" dale 0.04lslofc Up Umb 0O ar: 10. List site personnel who will be involved to any extent In the meal sarvioe. (SW Hartidb * Napier S). TIME of POSMON NO. IN Postnotr troo©attnPffim" OUTM CENTER S U P E R V J S i.R I HELP SUPERVISE MEAL SERVICE SUMMER REC. WORK R 2 HELP TO SERVE MEALS J.T.P.A. 2 HELP TO SERVE MEALS 11. ktdicate what provisions will be made for meal servke 69ft periods of Indanlarg weedier. (SW Handbook gyp& In Indoor Meat 1W Service FEED AT B E N A SCHOOL 3001 A V E N. ❑Will Be canice d 000W. 12 >< the site feeds prirnm"ly homeless 04dren, what metircds are used to ensure that money, load stamps, or in-tdnd services are not re%*W for meats? 13. Are meals delivered to the sde?........................................................................................... 0Ye9 ❑ N IFYES, COMPLETE iTEfM1S-14,15, & 18. iF NO, FORM IS COMPLETE EXCEPT "CERTIFICATION AT BOTTOM. 14. Indicate the means of communicabon with the vendor which will be used to adjust meal dekAwiss. (5FSP mock, Gray.10 Site Personnel Will Contact Adminisbrattve Site Personnel Wig COmamnieata u1Staff, Who Will contact Vendor ❑wmictly w"h Vendor 15. VVE delivvery be within one hex of the food service period? (SFSP Handbook, Chapter N)...................................... ®Yes ❑ N If no. describe arrangements within standards, presaged by kxW heath authorities for delivery and hokimq at meals until We of service. 16. If there is an excess of meals delivered, meals will be (MP Hand)ook. Chapter III) Stared in Redgerator Thrown Away ReWradIQ Wndor 0uW Served the Next Day Inat the Site ❑for Disposal 000W. I CERTIFY that the information on this farm is true and c MK:t to the best of rrty lutowledge. I certify that Ibis site has been visited and that has the capability and facilities for the meal service planned for the number of children anbegated. I knave that deliberate misrepresentation c withholding of information may result in prosecul on under applicable state and federal status. wn,. CITY OF LUBBOCK RECREATTON OUTREACH COORDJNATOR []Approved Cam. reason: Sipr�AW03 av- [GIs Too Texas Department lg !snufry 18 a t1wnan Services SUMMER FOOO SERVICE PROGRAM FOR CHILDREN i- FM °M USIE ONLY SITE INFORMATION f TX R ' t Nan+eoffoSew"S+m PARtam K BURNS Nq PARK SATE 23RD AND AVE. L LUBBOCK TX 79405 Pencil of upemwn IN rMQ I Nundwatop. M" rw —P'. From: F-2-97 �; 8-8-97 gp 0 23 22` 6 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED �--Residential Camp Site S001% Prpaarlly I owd Cha " �( 00w at 1. indicate Type of Site: t-1 A. (sarrl V one tothree m ois) ❑ C. (sa ing ate b tttree to *) L.1 E. (swvk one to f;lhrr.a aheak) NonresidentW Camp site Serving P&ftd y Ifomdless Cthlldreht 9. (servlrhhg one to its meats) ❑ t). (serving one to titres meals) 2. List ALL counties served by this site: LUBBOCK 3. A. Is your siite open:.................................................................................................... • Byes Q N, B. Is your site enrolled?.................................................................................................Yes E3 N, C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Hwd600lc. Cthapler 11).... 97.5 D. if open sites, submit documentation supporting this percentage figure (suds as census date, school data). For open shies using school date list the schools used to document site eligibility: attach fornuila, used by school disc to establish percentage of free a raduc:ed prince children. BEAN ELEMENTARY E, for enrolled sites. Form 1531 vWWbe used to document eligibility. (National Youth Sports Program• -refer to SFSP Handbook, Chapter 2.) If the enrolled site used school data, W the School used to document the site: F. What is the percentage of free or reduced -prise meals for the efts? ................................................... ° 4. Did the site participate in previous years' SFSP? (SFSP Handbook. Chapter to ..................................... QYes ❑ Nc If Yes, give name of contracting organization: CITY OF LUBBOCK S. Monitoring Plan (SFSP Handbook. Chapter III): Enter date of nh wAoring review to be conducted within: AL F031 week of Operlbw B. Fret four Weeks of open f an C. Additional Re"m 6-2-97/ 6-6-9; 1 6-2-97/ 6-27-97 6-2-97/8-8-97 e, Meal Service Period Information (SFSP Handbook. Chapter 10: TYPES Of MEALS NLUBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TailE BEGRAGM ENDING Breakfast A.M. Supplement Lunch 75 1:AO I P.M. Supplement 1 Supper `rAS wdarMaWn is c"ac 9G Vy IR1a WFwn w=V Q i1WP nro aenAr asrrw. tarav rmwwow* \. wpw 41 7. Do you plan to feed children under one (1) year old?.....................................................................Yes nNo 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter In sen-h'reaatawn vended t3skhglwol ScFood Service Management Using Private No ~rl on Site ❑ Central Kitdwn 0 Food Auttq_rity � any (in s Aft Year Contracts) Q tfon that is Se"rep t kn k*W the sySen+ to be used for the d meals and 11 hs upwAsion d Mara+ dlrriny meal service period- (SFSP HauundbooK Chapter Il; 10. List she personnel who will be involved to any extent in the meal service. (SFSP Handbook. Chapter u): Tn.rt OF POWTloar fao, er I"o3rr>da+ sPECFIC POoo SERVICE PROW" txmas C>=NTEP SUPERVTSOF I HELP SUPERVISE MEAL SERVICE SUMMER REC. WORKER 2 HELP SERVE MEALS J.T.P.A. 2 HELP SERVE MEALS 11. Lnca what provisions will be made for meal service dtrktp periods d inderflent weater. (SW handbook Chapbr 4 tndoo>Ykal MGM Sake [3VMBecalcalted 00U r FEED AT JACKSON SHCOOL 201 VERNON AVE 12 d the she feeds prima* homeless Oidren. what mWw& are used to own that money, food stamps, or h4drnd sefvices are not required for nmb? I I Are rneals delivered to the site?........................................................................................... slides (3 N LF YES, COMPLETE ITEW14,15, A I& tF NO, FORM IS COMPLETE EXCEPT FOR CER-nMATM AT BOTTOM. 14. Indnce the means of communicatim with the vendor which will be used to s*Ist meal deliveries. WSP ftd*ok gyp. 9) �She Personnel VAR Contact A&Wnlatrativs Sfie Personnel Wilt a~ar rricate INA, who will contact VNXW ❑ Mreetiy with vendor I& Will delivery be within one hour d the food service period? (SFSP Handbook Chapter S) ...................................... aes Q N, It no, desafe an ngements within standards pre=bed by local health auttwribas for delivery and holding of meals awl time of service. 1 S. It there is an excess of meals delivered, meals will be (SFSP Handbook. Chapter 110 StioredOanid Served � Next Day ® eraW #* SSb Q Wspot+d Vendorn Amy RANOW to Other: I CERTIFY that the information on ibis form is true and correct to the best of my krwwledge. I certify that this site has been visited and that i has the capability and facilities for the meal service planned for the number of chkiren ant cood. I know that def Ovate misrepresentation o wdhtxgding of information may result in prosecuiiort under applicable state and federal smb tes. NaM {;TTY OF LUBBOCK S;p xs ti,c ai oe 5ear,+o omw inion Oete rllame of 0"imm tow" "a WM [! SUSAN BAILEY RECREATION OUTREACH COORDJNATOR FM Coed ODwkkw, ran: am USE ONLY $iq�epR! -0i i3 Reprewtattve Ore I Tazas Daparvwd of Human So"C" SUMMER FOOD SERVICE PROGRAM FOR Ct*LDREN SITE INFORMATION FOR"USE OWY x TXOR HOLLTNS PARK NA PARK SITE #ddresa of Site (Str084 City. State. M 1ST & TEMPLE LUBBOCK TX 79415 Period of Operation of Fwd Swvm (=1dsW.--RW4day&r.) MNY A" + Sept From: 6-2-97 h. 8-8-97 "aft Dam O 21 9-2 6 n ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED ^ Reside" Camp Slte Sewing pdms* W9AW Ch f " 0#W Site 1. Indicate Type of Site: U A. (WrAV one to Wee me*) ❑ C. (serov am to three mess) [ZYE. (ta t9 one to daft ttteais) Nonmlderhtlaf Camp Site Serving PlHo y meless Cthlldrert ❑ 8. (Serving one to tfree ) ❑ I?. (senlny one bed" meats) 2. List ALL ootsnties served by #-As site: LUBBOCK 3. A. Is your site open: .......................................................................---....[7Yes [3Nc B. Is your site enrolled?.................................................................................................(Dyes [340 C. Site Eligibility: tinter the percentage of children eliole for free &AW reduced price meals for the site (SFSP Handbook, Chapter 11.... 9 $ . 2 °/ D. H open sites, submit documentation supporting this percentage figuro (such as census date, school data). For open sites uskV school data, list the schools used to document site eiigibftr. attach forrnulaE used by school dia to establish percentage of free & reduced price children. JACKSON ELEMENTARY E. For enrolled sites, Form 1531 vArbe used to document eligibility. (NatiorW Youth Sports Program-4efer to SFSP Handbook, Chapter 2.) 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 34e?................................................... % 4. Did the site participate in previous years' SFSP? (SFSP Handbook. Chapter If) ........................ .... as$ n No if Yes, give name of contracting organization: C T T v OF LUBBOCK 5. Monitonng Plan (SFSP Handbook, Chapter III): Enter date of 6-2-97/6-6 -97 1 F-2-07/6- 27 0 E. Meal Service Period Information (SFSP Handbook. Chapter If): review to be conducted wv0m: -2-97/8-8-97 TYPES CW MEALS MWER OF El LE BENT061 MEAL SERVICE TM 9EGRr1iING EiiCItNG Breakfast A.M. Supplement Lunch 74 11:An a.m. 1.2:45 p.m. 1 l P.M. Supplement Supper • "n's aVormaoon is COM MM oY una wnan ssawV sus Wprwva UMM san+w 09"IL 1.7+'. 1- nanuoovR. %oFNW r 191 7. Do you plan to feed children under one (1) year old? ................................................. ❑Yes ao 8. Method of Food Preparation by Contracting Organization (SFSP Handbook. Chapter II) Sail-Preparawn I vended Using Scfool Using Food Service ManagemeM tieing Private Notr4hv& n On Site ❑ Centel Kitchen I C FoW AuU*rity 3 Company (Includes All Yea Contracts) Cl Organization that is See -Prep JL y y 1 u [JiN 1 XAt -, 1. Y ZAK Tax" Deparbnam of Htunan Sorwioes SPECIAL NUTRITION PROGRAMS SINGLE AUDIT IDENTIFICATION DATA Farm 1559 Novwr+bw 1995 Contractor Name Co t= Person Susan Bailey Address (Street or P.O. Box, City. State. ZIP) P.O. Box 2000, Lubbock, Tx 79457 TeWphorm No. Payee ID No. Contract No. ( 806 ) 767-2675 1-75-6000590--6000 Tax Exempt Contractor Fiscal Year End (mrnlddlyy) Type of Contract 9-30-97 0 For Profit Non -Profit ID Govemntental Check the appropriate box(es) to indicate the type(s) of program(s) in which you currently participate or for which you are applying: COMMODITY ASStSTANCE PROGRAMS ❑ A - National School Lunch 9 - Charitable Institutions ❑ C - Area Agency on Aging Q G - Summer Camps ® H - Summer Food Service J - Jails ❑ K - Soup Kitchen ❑ I - TEFAP Commodities CASE! REIMBURSEMENT PROGRAMS ❑ AD - Adult Day Care BL- National School LunctVBreakfast ❑ CC - CACFP Center ❑ DH - CACFP Day Home © SF- Summer Food ❑ SM - Special Milk TE - TEFAP Calve Lne Source ano amount of any rauwras ssnancsas assrswnce cnaz your agsrney recesvcs qutcr ufan from fnusa programs nsrecr auovC.- SOURCE I AMOUNT ❑ SINGLE AUDIT EXEMPTION-1 certify that I am not required to submit an audit under the Single Audit Act for the following reason(s): ❑ I am a for -profit organization. 111 receive less than $25,000 annually In total federal funding. El SINGLE AUDIT ASSURANCE -I understand that if I meet the requirements of the Single Audit Act, I will agree to submit: © An Annual ❑ A Biennial audit as a condition of eligibility to participate in the Special Nutrition Programs, and that failure to do so as required could result in adverse action, including the withholding of my claim for reimbursement payments and termination of my contract. I also understand that if 1 am a private non-profit organization subject to the requirements of the Single Audit Act and have a financial audit performed annually, I must also obtain a single audit on an annual basis. it � No Text Office of Account City of Lubbock P.O. Box 2C DO Lubbock, Texas 79457 BOB-767-2156 April 15, 1997 Texas Department of Human Services Special Nutrition Programs, Operations Division 2109-Avenue Q Lubbock, TX 79405 To whom it may concern: We are in the process of compiling information for the single audit report, which is performed in accordance with the Single Audit Act of 1984 and OMB Circular A-128. We anticipate that this will be completed and published in May of this year. If you have any questions, please feel free to contact me at (806) 767-2151. Sincerely, Becky Garza Grants Accountant xc: Susan Bailey, City of Lubbock No Text 450 of Ts ,Idy 199D CERTIFICATE OF AUTHORITY This is to certify that NAM CO AUftnnd OffK41 O►.aSe type a PM0 Tift Earl Hilton III I Recreation Superintendent 0MOW is designated as the authorized representative at NWft d C4ntr&C0% OrWrmz*Wn City of Lubbock AWr Mt tSor K CMy. Sm.. ZIP} P.- 0. Box 2000 Lubbock, Tx 79457 The representative designated above Is authorized on behatf of the contracting organization to make written agree- w enta with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to the department. SiWMtUw-0l5tui of CaWacfi" Agw4y DaW Windy Si/tAon 1710, 1- PRO owl Darnell, City Secretary FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: ^gMwr K No. Pamved By tau TX. No Text . . _ w ....r... %r--,ra w4 vI t ^ t ivty r%jm tStU rqu t:UNTK^C i This 600tlf►!A1 contsku an ir*►Mst10R 10• two !orrice Poo raw rq mom for mb C*M.tat of iNarrru100n is enonogw?"t aarmsrAs 10 bid for tht furtt1vwjq of unittrito ts4ataea so trrltra" 29 hotn-w ,"*w*L vxhomv im line malls to Og 3Rrve12 10 Chj*on psrtt¢iofttnq i1 me Stttrrmer for r;wrlwitl9 itsjvXxbris. 3400101s os<lsutg !fits Sotxees. Food Strvict program tSFSP? whnrfiod by Stmton tS of tm , p6etrgig trio rrttieua" it* mia me-ed. go tat+piaturg ura Nvxx►sl Siv 4oi Lurteh Art. AM =&rated umW Part 225 of 00 r"wwV tho. ceo nsier► of htarns gxL 3wd Cort*rttrai regWOMq US. Qepsrsrw+W of Agrbill1ire A ZDA) reguslbr+s. This 04 bones entme or stir omw and of m mutter, of tfotltum Teti forth the 1611m are Conditions "atkabto •10 tiro YtfonrnstwL kwudkv sstggestions for rotweWg 1Mt b11r0att to pro=Sa0 PrgewerrAtt. tlPM Mtliotartet it-9 i CNWittfie the DliYetrewN of tea. Ckaw" ott w.0"4. no" contrav betweetl 010 tmw W4 iha Spoenor MM@d WOW. oaf-w. QC. 2m0: rto m fete Wks of t�+tee:riuicnn ana ort► A11*L Ottidt of a wwgwvwom ww fit! wst+tttg 0% Im M03. SPONSOR 810 G1PENiNG St01 SCA AGREEMENT 1ALMSER ae GmJE GATE • Be K^4KR A r'it z0, 1997 97100 N"IE DATE -gity of Lubbock • MY 14, 1997 ACDRESS tftlude Ciy. Stitt. Zlp CWW Tye City of Lubbock kno L=TQN A.O. Sox 2000 Lubbock, Texas 79457 1625 - 13tb Street Room L-04 Lubbock, Texas 79401 iUEPNCiK NUM ER CCINTACT AEASQN SpC TO EWER�TED PfA•i3 Gf tfEat.S WED1T 806 7 7-2575 Susan Sa�i1e pm 11n -to BE � or 1K IMER ptttatr owt tt+e++s.rs NIe efr lipt�catae MTALS per "m a of +rterS CONTRACT DATES i�JMartENtwMENT - June 2, 1997 BAST i._.�...� X.�,.—•—.. t�..�.r--.. UPPAT10ht August 8, 1997 sm"Z''� ' x- 557 0,..0 ._ Ltlfs�V ER >t —• x ! S t , 0�0b_ 8D BtM PF;;=- AGE PZGU EO SSoo aot sluff room tram oppropriatt pareen►sgo 511. i0 107.) LSTg"72� ;SAL g57 PFOWPT PAYAAEtItT DaWXT tto fie inssrtl0 Ds the WWW 5% 1 "•+" g tar ownent om, r PUMWAW.w = 0 it�AGE F:2 :14gD CRUZ ogtnCY 211811 fraw fllibi'of7rtite mvvu ge tmm 10-1 t0 2ST3 11 HOLIDAY INN CIVIC CENTER STREET ADDRESS ttrtmuda City. Slate. Zb Coot) 801 AVENUE Q LUBBOCK, TEXAS 79401 GONE r4tWEIR 806-763-1200 c wpAr-T mimout FORM FNS-62e Previmis •ditiam obsolete. N&W fPrrtt or Twpet Russ Swim r?nE AGM - F&B Director p4Z May 12, 1997 'ANCE spoom NAME DATE P#ge t E0•$ t�9TZ1,9L969@QI and X00gf=nj A0 A110 SV:ge L6-ST-56 No Text ..i_-n i +r1VA 1 C OF INDEPENIEW PRIGS DEMMINATI0111 SECTION 8 M) By submission of this offer, the offsror certifies and to the base of a Joint offer, each party tharato eartifks as to Its own organisatlan, that In conow0nn with this pirocurement- t 1f The prices in this offer have bum arrived at Independently, withnnt consultation, communication or agreement, for the purpose of restrlctitlg competition, as to any matter reiatiag to sucli prices with any other offetar or with. any competitor; i2} Unless otherwise raslukad by law, the. prim which have been cpatgd In this offer have not been knowingly disclosed by the offeror and will sot knowingly be disclosed by the offeror prior to Opening In the case of an advertised procurement, or prior to award In the case of a negotiated pi oacuremsnt, directly or indirectly to any other offeror or to any =mpotitpr {M No attempt has been made or will be made by the offeror to Induce any person or firm to submit or not to submit, an offer for the purpose of rasaicting competition. t133 EMA person signing this offer certtne: that: t'p lk or she Is the person In the offeror's " erganization responsible within that wgwdzation for the decision as to the Vices being offered herela snd that he or shs has not paldpated, and will not participate, In my action contrary to W t U Waugh GAI CM above., or • M suer or she Is not the person IR the afferoes organization responsible ■Ithtn that organization for the decision at ter the prices being offered herelrl, but thai ire or she has been wAadzed In writing to sat as agent for the pment responsible Ur such derision in certifying that such parsons have not paMaipated and will ant participate. In nay scan contrary it W M through W Gal above, and as SW agent does hereby so certify; ad he or she has not participated, and will not particpate, In any salon eaasrary to cal t 1l Waugh tat M above. SChvah'1Jr1£ OF vtr, AUTHM= to. MTE _AItPFSENrA3rr3 i F&B Director May 12, 1997 In accepting this offer. the sponsor Certifies that thi sponsar's adficars, employees or agents have not taken any actlon which may have jeopardized the Independence at the offer referred to above. SONATLXq OF AUTHORIZED SPON= AMSEMAVVE tAc cepting a bidder's after does net constitute acceptance of the cantractJ NOTE Spansor and Bidder stroll execrate this Certificate of bidependent Arica Daterminatlnn. Pape 2 b9I?,L9L998�QI dad X30,11HQ'I AO h1I0 VV:80 LB--01--80 No Text UNIT PRICE SCHEDULE INSTRUCTIONS: VENDOR: Complete items (dI and (a) for each SPONSOR: Complete items (a) - (C) for ear-h Meal Type Meal Type. Total Meals % Cost 1, Total Cast. (al MEAL TYPE 04 AVMGi DAILY t Lei TOTAL WLSA EA 2 le$ UNIT 3 (Lt. Lee<U WALS I�EEtIEO Of MEALS COST M TOTAL 1iQ Lunch 612 309000 ! 1.90ea x 57,000 ADJUSTMENTS If the average daily mails biped Is less than the average daily meals needed (per item (b) above) a one time adjustment to the unit price will be mode as follows: AVgRAGS DAILY S ai 4 AYE.RN,AGE QAttY LE0 81 - scm 71 - 80% 81 - 70% 51 - 50 0 BOX OR BELOW e AMOUTcaST- 14 1.05 1.10 1.15 L20 1.30 EXAMPLE: It the average daily shoals billed - by the "average dally meals needed' Qtem b above) .82 at 82%, multiply the 'usdt cost` (item d above) by 1.0& The contractor will Invoice the sponsor at the 100. unit cost indicated above bl�-weekly. Ito determine If an additional cast per meal is -duo the vendor, complete the following ealc.ulation. Divide the total number of maxis billed by type Hunch, breakfast or supplement) for the total length of the program by the total number of days the. program was operated. Any addltlaanai charges resulting from this higher 'adjustment' will be reflected In the fsnal statement from the vendor. NOTE The unit cost per meal rn;l) slot exceed the tt7iucenwm operational relmbmsement far each meal type as stated In Part 7 CFR 225 at the federal regulations. 1. Obtained from Columns (M and S. Schedule A, by dividing tootal, meals for each specific meal type by the greatest number of days operated by a site In Column M. 2. Obtained from Schedule A by totaling C41umn (51 for each specific meal type. 2. Unit cost spedflad Is that cost band at 100% Average Meals Needed Per Day. page 20 zz.d ti9T�L9L9&g�QI and X00SBA'I A0 AII0 VG:88 LS-ST-SO No Text U.S. DEPARTMENT OF AGRICULTURE Certxficatlon Rqgglng Debarment, Suspension, InetigibWty and Voluntary ion • Lower Tier Covered Tramsactinns This certiGattion is required by the regulations Implementing Ext:Cyidiv Order 133.19, Debarment and Suspension. 7 CFR Part 3017. Section 3017.510, Participants' responsibilities. The regulations were published as Part N of the January 30, 1989. Federal RtSiste(pages 4722-4733?. Copies of the regulations may be obtained by contacting the Department of Agriculture agency with which this transaction arigiAwed. (BEFORE COMPLETING CERTIFICAMON, READ INSTRUCTIONS ON REVERSE) s 1) The prospective lower tier participant etnities. by submission of this proposal. that neither it nor Its principals is presentiv debarred. suspended. proposed for debarment. declared ineligible, or voluntariir tacluded from participation its this transaction by any Federal department or agency. t21 Where the prospmthe lower tier participant is unable to certify to any of the statements In this eertitication. such prospective partidpant shall attach an explarmtIve to this proposal. Holiday Inn Civic Center 801 Avenue Q Lubbock, Texas 79401 onlod gion tiame t'it/AW104 Nualber or rrejeet ;leas Russ Swim AGM/F&B Director 1pn,stst and rakisi ut authorized Aeprsimmivvisi jicnnturetsi date Form A.D-10sn c t /0-21 Page 12 t, j • a vq r z4gL9es ma i Etna xaossnz do Al I o es : ee 46-S i -99 No Text Texas Department Form 4508 of Human Services July 199D CERTIFICATE OF AUTHORITY This Is to certify that Name of Authorized Official (please type or print) Title Windv Sitton Nfa lIlk1 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 TX 79457 The representative designated above is authorized on behalf of the contracting organization to make written agree. ments with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to the department. L 114"1 Signature --Official of Contracting Agency Name of Official (piease type or prim) Title ATTEST: " Raythie Darnell, City Secretary FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: Agreement No. Received By Date TX- No Text Texas Department of Human Services Form 4506 July 1990 CERTIFICATE OF AUTHORITY This is to certify that is designated as the authorized representative of Name of Contracting Organization CitY..Of Lubbock Acl&ess (street. City, State, ZIP) P Q Box The representative designated above is authorized on behalf of the contracting organization to make written agree- ments with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to the department. Signature —Official of Contracting Agency Name of Official (please type or print) ATTEST:(Inturw '� tptr�lt+u 1:0A DEPARTMENT OF HUMAN SERVICES USE ONLY: to- q. q1 Date Agreement No. Received By Dale TX - No Text