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HomeMy WebLinkAboutResolution - 3609 - Grant Application - TDHS - Summer Food Service Program For Children - 05_09_1991Resolution No. 3609 May 9, 1991 Item # 18 HW:dw 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 grant application and related documents with the Texas Department of Human Services for funding for a summer food service program for children, attached herewith, which shall be spread upon the minutes of the Council and as spread upon the minutes of this Council shall constitute and be a part of this Resolution as if fully copied herein in detail. Passed by the City Council this 9th ATTEST: L .2-r Rane to Boyd, City Secretary APP4OVE TO CO TENT: Director o Pars ancF— Recreation APPROVED AS TO FORM: Hatoflatold WiTis an City Attorney day of May , 1991. c • B. C. McMINN, MAYOR Resolution No. 3609 May 9, 1991 Item #18 Page 1 of 8 ATTACHMENT 2 GRANT PROPOSAL EVALUATION FORM COVER SHEET GRANT NAME: Summer Food Service Program GRANT AGENCY: Texas Department of Human Services GRANT FISCAL PERIOD: May 29, 1991 - August 31, 1991 MONTH/DATE/YEAR TO MONTH/DATE/YEAR CITY DEPARTMENT/INDIVIDUAL PREPARING GRANT: Susan Bailey, Indoor Recreation Outreach Coordinator (Whom to contact in case of questions) APPROVALS: DEPARTMENT HEAD ASSISTANT CITY MANAGER OR CHIEF OF POLICE 7-h44 tirl BUDGET & RESEARCH DIRECTOR & C'-.-� DEPUTY CITY MANAGER Upon completion of approvals, return to: Park & Recreation by April 22, 1991 CITY DEPARTMENT OR SECTION DEADLINE DATE (IF APPLICABLE) DATE DATE s-�g1 DATE DAT Susan Bailey ext. 2691 INDIVIDUAL A25 - 1 CITY OF LUBBOCK GRANT PROPOSAL EVALUATION FORM INSTRUCTIONS: Page 2 Of 8 This form must be completed and signed by the appropriate individuals in order for a grant application to be evaluated and approved by the City Manager. 1. State, as clearly as possible, the goals and objectives of proposed project for which a grant is being sought. This project will provide a nutritious noon meal, catered and delivered through Lubbock I.S.D.., for youths one to eighteen years of age. The program will operate June 3, through August 16, 1991 four community center sites (Rodgers, 3200 Amherst; Rawlings, 40th & Ave. B: Simmons, 23. & Oak; Woods, Zenith & Erskine) and eight CDBG funded playground sites (Burns, 23rd & Ave. K; Carlisles, 28th & X; Pioneer, 6th & Ave. T; Hollins, 1st & Temple; Chatman, E. 29th & Juniper; Carter, Globe & N. Loop 289; Yellowhouse Canyon, E. 61st & Olive; Mahon Elementary, 2010 Cornell) Monday through Friday. The program will provide an alternative meal opportunity for low income and latch key children in identified City neighborhoods. It is anticipated that an average of 953 meals will be served daily. The program will also foster involvement of these children in not only the lunch program, but other supervised, positive activities provided through the Parks and Recreation Department. A. Is this the fulfillment of an identifiable community (Lubbock) goal? If so, list the source of the identified goal. It is the mission of the Indoor Recreation Section to. provide activities and services which contribute to our client's mental and physical health and to the social and economical well-being of our community. The goals of this section specifically address the need to plan these services and programs and to evaluate specific citizen and community needs and address identifiable needs within the community. In addition, the alliance for the 90's - Lubbock Needs Assessment identifies the need to provide programs and services for children, specifically during unsupervised times, such as after school and during the summer. The lunch program, coupled with the CDBG funded Summer Satellite Program provides supervision and guidance for Lubbock children. A25 - 2 2. 3. 4. Page 3of8 B. Is this the fulfillment of an identifiable community (Lubbock) need? If so, please provide quantifiable data (studies, etc.) that illustrate the community need and how this grant will meet that need: In the 1991 Summer Food Service Program, an average of 763 children per day were served nutrition lunches at four community centers and eight playground in low income areas. Due to the success of the 1991 program, staff anticipates a 25% increase in meal service. According to Lubbock I.S.D., over 5,300 of the children living in neighborhoods served by the lunch program, are receiving free and reduced lunches in school. The school lunch has the same goals relating to health, childcare, and public service, as the Summer Lunch Program. List a least three measures by which City Staff and City Council might be able to evaluate the program in order to determine that it has reached the goals and objectives described in Question 1. (a) Twelve lunch sites will be opened and serving nutritious noon meals to youth ages 1 - 18 years old, June 3 through August 16, 1991 (b) An average of 953 nutritious meals will be served daily. (c) A staff of twenty-four (24) supervisory staff with volunteer and JTPA personnel will be used to supervise and distribute the meals. Will this program benefit the Lubbock community as a whole? If not, please provide a detailed profile of the individuals or groups that will benefit from the program. There will be twelve (12) sites open to the public, four (4) community centers and eight (8) playground sites. However, any youth age one to eighteen who comes to any of the twelve sites will receive a nourishing noon meal and be supervised by site staff. Are other agencies (other than the City of Lubbock) available to administer this program? If so, list the agencies: Yes, Lubbock I.S.D., another capable agency, administered the program in the summer of 1988. However, they are entirely disinterested in administering this program due to the costs associated with supervising children in a cafeteria setting. A25-3 Page 4 of 8 5. Are other agencies administering similar programs? If so, list the other agencies. If not, why not? A similar program is not being offered in Lubbock. It does not appear that any agency is interested in providing this program. We assume most agencies do not have the scope, facilities, or public service direction (with the exception of LISD) to provide this program. The Texas Department of Human Services, which provides the grant, is pleased with the City's involvement and success in 1990 and is encouraging the City of Lubbock to provide this program again. 6. Is the program or activity provided by this grant required by state or federal law or required as a condition of other ongoing state or federal programs? Please explain: NO 7. Does the grant require a local match? If so, in what amount? Is the match in the form of cash or an in -kind contribution? NO 8. Is the grant for capital or operating programs? Please describe specifically what the funds will be used for (personnel, supplies, services, capital outlay, capital project, etc.). The grant is for operating costs. The funds will be used for professional services (meal contract, part-time and full-time staff, and meal service monitors) and supplies (office and copy supplies for documentation), and equipment used in providing service and maintaining the site according to established operating and health standards. A. If the grant is for capital outlay or a capital project, will it result in ongoing City operational costs? If so, explain in detail. Capital outlay will not be funded through this grant. A25 - 4 Page 5 of 8 B. If the grant is for an operating program or programs, is it a one-time grant which will result in ongoing City expenses, if the program is to be continued in the future? The funds for this program's operation have been available for at least twelve (12) years. It is not anticipated that the funds provided by the Texas Department of Human Services will be eliminated. C. Does the grant require continuation of the program, at City expense, after grant funding has expired? If so, how long will the City be obligated to expand local funds, and in what areas? Be specific. The grant does not require continuation of the program at the City's expense; however, the public may expect the city. to continue applying for the grant in order to continue the program. 9. Is the grant a one-time grant, a one-time grant with an option to renew the grant, or an on -going grant? If the grant is ongoing, how many years has the grant been provided to the City, and what year does the upcoming period represent (2nd year, 5th year, etc.). If the grant has an option to renew, how often can it be renewed, and what are the terms of renewal? Please explain. This is a onetime grant with an option to renew. It is necessary to reapply for this grant on an annual basis. 10. Are indirect costs reimbursed by the grant? Some indirect costs are reimbursed by the grant. These include some administrative and personnel staffing costs. For every meal served, $.155 is paid for administrative expenses - the more meals served, the more administrative costs recovered. All direct costs are reimbursed. 11. Are grant audit costs reimbursed by the grant? Yes, audit costs are reimbursed by the grant, if enough administrative reimbursements are secured. A25 - 5 Page 6 of 8 12. What is the immediate (twelve-month) impact of the grant program on City employee allocation and utilization? How will this affect their work hours, productivity, etc. on City programs and activities? On all selected sites, the plan is to use part-time staff for meal service. This should cause a minimum effect on full-time supervisory staff. Administrative reimbursements will be used to hire a contractual food service monitor. 13. What is the long-term (five-year) financial and manpower impact of the grant program both on the community and on the City organization? This Summer Lunch Program will fund 1.36 man years of labor that would not normally have been employed for this fifty-four (54) day program. Over a five (5) year period this produces 6.8 man years of employment if the scope of the program remains the same for its duration. 14. Provide, in as much detail as possible, a 5-year Revenue and Expenditure Projection for the grant related program beginning with the current year or the first year this grant will be in effect. Show any on -going costs to the City, even if the grant is only for one year. If the grant is renewable or ongoing, show the estimated revenues and expenditures for future years that you intend to renew/continue the grant (up to five years). Be sure to fully explain the source and type of revenues (in -kind contribution, reimbursement of expenses, etc.) and fully explain the specific types of expenditures (payroll for 112 time clerk, purchase desk, capital project construction, etc.). Attach additional sheets if necessary. A25 - 6 Page 8 of 8 * Based on 953 meals per day. ** Expenditures are averaged much higher than anticipated. This grant reimburses the "highest" reimbursement amount. For this reason, I overestimated the site supervisory needs (expenses) in case we add personnel. This grant will reimburse all direct expenses associated with the program. A25 - 8 Kj ADMINISTRATION Administrative Labor 1. Indoor Recreation Outreach Coordinator-( Susan Bailey) Director of Program Budget Preparation 12 hours Budget to Council and Park Board 6 hours Developing Training 3 hours Site Inspection 6 hours Ordering and Supplies 8 hours Conducting Monitor and Site Supervisor 8 hours Personal Training 5 hours 48 x 10.62 = $510 4 hours/day x 54 days = 216 hours $10.62 hour x 216 = $2,294 $2,804 2. Recreation Supervisor (CC) (Bob Goodwin) Assistant Director Training in Midland 12 hours Developing Training Manual 5 hours Preparing Orientation 3 hours Hiring Site Staff 10 hours 30 x 11.35 = $341 1 hour/day x 54 days = 54 hours 54 hour x $11.35 hours = $613 $954 3. Senior Citizen Center Supervisor (Paula Simpson) Bookkeeper (place meal orders, call weekly reports, make copies, check monitors records/amounts track expenses, etc. = 11 hours (prior to June for preparation) June - August, One (1) hour/day x 54 days = 54 $8.47 hour x 54 hours = $457 $8.47 hour x 11 hours = $ 93 550 Administration Page 2 4. Indoor Recreation Superintendent (Kay Stiner) Area. Supervisor Training 12 hours Budget 18 hours Dive Train 3 hours Site Inspection 6 hours Order 4 hours Monitor Train 4 hours Personal Train 4 hours $20.02 hours x 51 hours $1,021 5. Monitor (Gwen) Four (4) hours/day x $7.00 hour x 54 days = $1,512 Site inspection 6 hours Personal Training 4 hours Site Supervisor Training 4 hours 14 hours x $7.00 = 98 1,610 Administrative Labor $6,939 Fringe Benefits $5,329 (FT Salaries x .25 (Benefit Package) = $1,332 Office Supplies ($625 general Supplies) Postage and Mailing $.40 per letter = OPERATIONAL COSTS BUDGET Program Labor Playgrounds (sum rec workers) Eight (8) sites x 2 personnel x 2 hours x $5.04/hr x 54 days = $ 8,709 Community Centers (asst.) Four (4) sites x 2 personnel x 2 hours x $5.04/hr x 54 days = $ 4,355 Community Center Supervisors Susie - 2 hours x $ 14.93 x 54 days = $ 1,612 Larry - 2 hours x $ 10.10 x 54 days = $ 1,091 Olevia - 2 hours x $ 13.16 x 54 days = $ 1,421 Maxine - 2 hours x $ 7.78 x 54 days = $ 840 4,964 Program Labor $18,328 Fringe PT $13,364 x .0765 Soc. Sec. _ $ 1,022 FT $4,964 x .25 Benefits = $ 1,241 Fringe Benefits 2,263 Food 41,181 (1st and 2nds in 1990) x 25% increase = 51,476 x $1.55/meal ($20 more than 1990) _ Food = $79,788 Non Food (Plastic trash bags, tables, coolers, thermometers, hoses, brooms, dust pans) Non -Food = $ 1,956 Operational Costs Budget Page 2 Transportation Four (4) Community Center Supervisor x 54 days x 1 trip/day x over 12 mile/day = 2,592 miles $.25 per mile x 2,592 miles = $ 1,306 Texas Department Form 1506/Attachment A of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN January 1990 CIVIL RIGHTS QUESTIONNAIRE 1. CIVIL RIGHTS ACT OF 1964 A. 1. Estimate, by racial/ethnic group, the number of children that will participate in the program at each site. If the program consists of several camD sessions, specifv the protected number of children by site and date of session: SITE (name of site, school, camp, etc.) AMERICAN INDIAN ALASKAN NATIVE ASIAN/ PACIFIC ISLANDER BLACK HISPANIC WHITE K81 gRd'0rHi8eddCaWy?g 0 - 0 396 7 19 Carter Park #21 4 - 2 20 777 996 Carlisle Park #58 13 - 20 29 266 1,729 Burns Park #7 5 - 21 130 1,287 1,782 Chatman Park #116 6 - 3 1,362 368 157 2. Describe how this projection was made (i.e., based on comparative enrollment in sites, observation of students, student surnames, etc. Total racial/ethnic groups in census neighborhoods in 1980. B. Does the organization have specific membership requirements which result in the denial.of program benefits to specific groups?............................................................... ❑ Yes FX1 No If yes, describe those requirements: C. What efforts will be made by the organization to contact minority and grass roots organizations about the opportunity to participate in the program? The program will be publicized widely through minority schools; weekly, ethnic newspapers, and through the minority centers. D. What other outreach stops will be taken by the organization to ensure that minorities in the area from which it draws its attendance will have an equal opportunity to participate in the program? The program will be announced at neighborhood meetings. E. Has any federal agency notified the organization of non-compliance with the Civil Rights act of 1964? .............. ❑ Yes )FX] 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? ........ El Yes ❑ No If ves. explain: Some park/playground sites are not handicap accessible. At these sites, staff will assist handicap participants. Form 1506 / Attachment A Page 2 B. Are there any policies or practices that result in unequal treatment in the delivery of benefits or services to participants, applicants, or employees according to disability? ................................. 0 Yes ❑ No If Yes, explain: C. Does the contracting organization employ 15 or more people? ................................ I ........ ❑ Yes ❑ No If yes: 1. Enter the name and title of the coordinator who will work with DHS to ensure that Section 504 requirements are met. Name Title Mark Bell Director of Personnel 767-2315 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 504 of the Rehabilitation Act of 1973? ................ ® Yes ❑ No 3. Has the contracting organization informed the public of the right to file a complaint and of the filing procedure?.........<........................................................1� Yes ❑ No If yes, briefly describe how the public was informed: The Section 504 information is published in the Parks and Recreation Leisure three times annually and in other City publications. D. Has the organizaton taken steps to notify employees, participants, and applicants that the organization does not discriminate on the basis of disability?......................................................... 0 Yes ❑ No If yes, do the people notified include those with impaired vision or hearing and members of unions or professional organizations holding collective bargaining or professional agreements with the contracting organization? ........... � Yes ❑ No If yes, briefly describe how they are notified: They are notified through the Employee Handbook, in all recruiting publications, and on the application. E. Do all organization forms, publications, and recruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the organizationdoes not discriminate on the basis of disability?................................................................ F Yes ❑ No If no, indicate steps being taken to comply with this requirement: F. Does the organization have a procedure to ensure that the remedial or corrective action has been or will be taken if non-compliance with non discriminaiton requirements is found by DHS, USDA, or the contracting organization itself? ........... ........................... ... El Yes ❑ No Ifyes,explain: There is no policy in this regard; however the Personnel Department would work to correct any problems. Discrimination has not been found within the City of Lubbock. Tems Depamnent of Hurnm Sens SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CIVIL RIGHTS QUESTIONNAIRE Form 150WAttechment A January 1990 1. CIVIL RIGHTS ACT OF 1964 A_ 1. Estimate, by racial/ethnic group, the number of children that will participate in the program at each site. If the program consists of several camp sessions, specify the projected number of children by site and date of session: SITE (name of site, school, camp, etc.) AMERICAN INDIAN ALASKAN NATIVE ASIAN/ ISLANDEF BLACK HISPANIC WHITE Rodgers Community Center #5 5 - 21 63 1,329 1,62-4 Rawlings Community Center #39 3 - 3 34 814 699 Simmons Community Center 6 3 1,455 551 283 Woods 'Community Center #18 3 - - 2,692 1,'405 663 Hollins Park #88 18 - 7 148 1,647 1,602 2 Describe how this projection was made (i.e., based on comparative enrollment in sites, observation of students, student surnames, etc. Total racial/ethnic groups in census neighborhoods in 1980. B_ Does the organization have specific membership requirements which result in the denial of � program benefits to specific groups?, ............................................................ ❑ Yes ^L : No If yes, describe those requirements: C. What efforts will be made by the organization to contact minority and grass roots organizations about the opportunity to participate in the program? The program will be publicized widely through minority schools; weekly, ethnic newspapers, and through the minority community centers. D. What other outreach stops will be taken by the organization to ensure that minorities in the area from which it draws its attendance will have an equal opportunity to participate in the program? The program will be announced at neighborhood meetings. E_ Has any federal agency notified the organization of non-compliance with the Civil Rights act of 1964? .............. ❑ Yes 1(J No If yes, give details including dates, names, and results: If. REHABILITATION ACT OF 1973 (Section 504) A. Does the contracting organization have any policies, practices, or architectural barriers that limit, deny, or discourage participation in the program or employment by the contracting organization because of disability? .... ® Yes ❑ No If yes, explain: Some park/playground sites are not handicap accessible. At these sites, staff will assist handicap participants. Form 15061 Attachment A - .... .. .. Page 2 B. Are there any policies or practices that result in unequal treatment in the delivery of benefits or services to participants, applicants, or employees according to disability? ................................. ❑ Yes El No If Yes, explain: C. Does the contracting organization employ 15 or more people? ....... : ........................ ........ © Yes ❑ No If yes: 1. Enter the name and title of the coordinator who will work with DHS to ensure that Section 504 requirements are met. Name Title Mark Bell Director of Personnel 767=2315--- 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 504 of the Rehabilitation Act of 1973? ........... ... ® Yes ❑ No 3. Has the contracting organization -informed the public of the right to file a complaint and of the filing procedure?. ..... , . ®Yes ❑ No If yes, briefly describe how the public was informed: The Section 504 information -is published in the Parks and Recreation Leisure three times annually and in other City publications. D. Has the organizaton taken steps to notify employees, participants, and applicants that the organization does not discriminate on the basis of disability? . ; _ ................ . , ... ® Yes ❑ No If yes, do the people notified include those with impaired vision or hearing and members of unions or professional organizations holding collective bargaining or professional agreements with the contracting organization? ........... Yes ❑ No If yes, briefly describe how they are notified: They are notified through the Employee Handbook, in all recruiting publications, and on the application. E. Do all organization forms, publications, and recruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the organizationdoes not discriminate on the basis of disability? .. ................ ..................... .... 0 Yes ❑ No If no, indicate steps being taken to comply with this requirement: F. Does the organization have a procedure to ensure that the remedial or corrective action has been or will be taken if non-compliance with non discriminaiton requirements is found by DHS, USDA, or the contracting organization itself? .. ... ..... ............... ........................ .. .... . 0 Yes ❑ No If yes, explain: There is no policy in this regard; however the Personnel Department would work to correct any problems.; Discrimination,has not been found within the City of Lubbock. Texas Department Form 1506/Attachment A of Human services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN January 1990 CIVIL RIGHTS QUESTIONNAIRE 1. 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, etc.) AMERICAN INDIAN ALASKAN NATIVE ASIAN/ ISLANDER BLACK HISPANIC WHITE School #54 3' - 1 140 915 652 -Mahon Pioneer Park #72 1 - 89 133 357 1,278 2. Describe how this projection was made (i.e., based on comparative enrollment in sites, observation of students, student surnames, etc. `Tota-1 racial/Ethnic groups in census ne=i'-ghborkoods in 1980. S. Does the organization have specific membership requirements which result in the denial of ((''''�� program benefits to specific groups?............................................................... ❑ Yes T No If yes, describe those requirements: C. What efforts will be made by the organization to contact minority and grass roots organizations about the opportunity to participate in the program? The program will be publicized widely through minority schools; weekly, ethnic newspapers, and through the minority community centers. D. What other outreach stops will be taken by the organization to ensure that minorities in the area from which it draws its attendance will have an equal opportunity to participate in the program? The program will .be.announced_ at ne-iihborhood meetings. - E. Has any federal agency notified the organization of non-compliance with the Civil Rights act of 1964? .............. ❑ Yes I-XNo If yes, give details including dates, names, and results: 11. REHABILITATION ACT OF 1973 (Section 504) A. Does the contracting organization have any policies, practices, or architectural barriers that limit, deny, or discourage participation in the program or employment by the contracting organization because of disability? ........ � Yes ❑ No If yes, explain: Some park/playground sites are not handicap accessible. At these sites, staff will assist handicap participants. •0 a ; Form 1506 / Attachment A Page 2 B. Are there any policies or practices that result in unequal treatment in the delivery of benefits or services to participants, applicants, or employees according to disability? ................................. ® Yes ❑ No If Yes, explain: C. Does the contracting organization employ 15 or more people? ..... ............... ..... .......... ® Yes ❑ No If yes: 1. Enter the name and title of the coordinator who will work with DHS to ensure that Section 504 requirements are met. Name Title Mark Bell` Director of Personnel 76T-2315*. 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. 504 of the Rehabilitation Act of 1973? ........ :..: FXI Yes ❑ No _ 3. Has the contracting organization informed the public of the right to file a complaint and of the filing procedure?.. ..... , : _ ...... ®Yes .0 No If yes, briefly describe how the public was informed: The Section 504 information is published -in the Parks and:Recreation Leisure three times annually and -in other City publications. - D. Has the organizaton taken steps to notify employees, participants, and applicants that the organization does not discriminate on: the basis of disability? _ ............ _... ®Yes ElNo If yes, do the people notified include those with. impaired vision or hearing and members of unions or professional 9 9 bargaining P 9 9 9-•.. El organizations holding collective bar ainin or professional agreements with the contracting organization? - ..... _ They are notified through the Employee Handbook, If yes, briefly describe how they are notified: in all recruiting publications, and on the application. E. Do all organization forms, publications, and recruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the organizationdoes not discriminate on the basis of disability? ............... ....................... ................. .. . 0 Yes ❑ No If no, indicate steps being taken to comply with this requirement: F. Does the organization have a procedure to ensure that the remedial or corrective action has been or will be taken if non-compliance with non discriminaiton requirements is found by DHS, USDA, or the contracting organization itself?. .... .... . ...................... .... ..... . ® Yes ❑ No If yes, explain: There is no policy in this regard; however the Personnel Department would work to correct any problems. Discriminatiori has not been found within the City of Lubbock. ' cl Form 1506/Attachment B SUMMER FOOD SERVICE PROGRAM FOR CHILDREN . January 1990 ADDITIONAL ASSURANCES FOR CAMPS AND OTHER ENROLLMENT PROGRAMS THAT CHARGE SEPARATELY FOR MEALS As required in Section V of this application, the contracting organization assures the Texas Department of Human Services that: 1. The method of collecting meal payments will protect the anonymity of children who receive free meals. 2. The organization has or will establish a hearing procedure for families wishing to appeal a denial of an application for free meals, which provides the following: A. That a simple, publicly announced method will be used for a family to make an oral or written request for a hearing; B. That the family will have the opportunity to be assisted or represented by an attorney or other person; C. That the family will have an opportunity to examine the documents and records supporting the decision being appealed both before and during the hearing; D. That the hearing will be reasonably prompt and convenient for the family; E. That adequate notice will be given to the family of the time and place of the hearing; F. That the family will have an opportunity to present oral or documentary evidence and arguments supporting its position. G. That the family will have an opportunity to question or refute any testimony or other evidence and to confront and cross- examine any adverse witnesses, H. That the hearing will be conducted and the decision made by a hearing official who did not participate in the action being appealed; I. That the decision will be based on the documentary evidence presented at the hearing and made part of the record; J. That the family and any designated representative will be notified in writing of the decision; k. That a written record will be prepared for each hearing, which includes the action being appealed, any documentary evidence and a summary of oral testimony presented at the hearing, the decision and the reasons for the decision, and a copy of the notice sent to the family; and L. That the written record will be maintained for a period of three years and 90 days following the conclusion of the hear- ing, during which it will be available for examination by the family or its representatives, and officials of the Texas De- partment of Human Services (TDHS), the United States Department of Agriculture and other relevant officials as deter- mined by TDHS at any reasonable time and place. 3. If a family requests a hearing, the child(ren) will continue to receive free meals until a decision is rendered. Form 1506lAttachment B SUMMER FOOD SERVICE PROGRAM FOR CHILDREN Page 2 COLLECTION OF PAYMENT OPTIONS FOR PROGRAMS THAT CHARGE SEPARATELY FOR MEALS (Camps and Other Enrollment Programs Only) COLLECTION PROCEDURE 1) Each day, children can buy tickets in the food service manager's office, but they do not receive the tickets. The food ser- vice manager sends the purchased tickets and tickets for free meal recipients to the site each day. The site supervisor distributes the tickets just before meal time. The tickets are coded for accounting purposes. COLLECTION PROCEDURE 2 Each day, children pay for their meals in an office. A list with the names of all children who paid or are eligible for free meals is prepared and sent to the meal service area. A staff member who knows the children checks the names as children pass through the line or otherwise receive their meal. After the service of the meal, the list is returned to the office for accounting purposes. This method works only in a small site where the staff member knows all the children. COLLECTION PROCEDURE 3 The site supervisor gives each child an envelope for daily, weekly, session or monthly payments. Children return the envel- opes with the payments enclosed, or empty if eligible for free meals. The envelopes are collected in the office and coded tickets are issued to each child. COLLECTION PROCEDURE 4 Parents pay in advance by the month or session. Each site supervisor receives a list of those children who have paid. The site supervisor marks the list as paid for children who receive free meals. Only the bookkeeper knows which children receive a free meal. The site supervisor keeps daily records of each child served and sends the records to the office for ac- counting purposes. COLLECTION PROCEDURE 5 Meal payments are collected in the office. Payments can be made by children or parents on a daily, weekly, session or monthly basis. The secretary records payments and knows which children qualify for free meals. At the sites, the secretary distributes identical tickets labeled only with the children's names. Since the parents may make payments, even children who receive free meals may not know whether their meals are free or paid. COLLECTION PROCEDURE 6 Parents are billed monthly or by session for paid meals their children are served. Parents mail in all payments.. All participa- ting children receive a coded ticket each month, which is punched at each meal service. At the end of the month, the tic- kets are collected and a clerk calculates the amount to be billed. COLLECTION PROCEDURE 7 Other: Explain in detail (attach a sheet if more space is required). The contractor must ensure that this method prevents the overt identification of children receiving free meals. Texas Department of Human Services Form 1506, Attachment C February 1991 SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CRIMINAL PROVISIONS AND PENALTIES 1. Whoever, in connection with any application, procurement, record keeping entry, claim for reimbursement, or other document or statement made in connection with the program, knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or whoever in connection with the program knowingly makes an opportunity for any person to defraud the United States or does or omits to do any act with intent to enable any person to defraud the United States, shall be fined not more than $10,000 or imprisoned not more than five years. 2. Whoever being a partner, officer, director, or managing agent connected in any capacity with any partner- ship, association, cooperation, business, or organization, either public or private, embezzles, misapplies, steals, or obtains by fraud, false statement or forgery, any benefits provided by the program, or any money, funds, assets, or property derived from benefits provided by this program, shall be fines not more than $10,000 or imprisoned for not more than five years or both. If the benefits, money, funds, assets, or property involved is not over $200, then the penalty shall be a fine of not more than $1,000 or imprisonment for not more than one year, or both. 3. If two or more persons conspire or collude to accomplish any act made unlawful under this subsection, and one or more such person commit any act to effect the object of conspiracy or collusion, each shall be fined not more than $10,000 or imprisoned for not more than five years, or both. TERMINATION PROCEDURES The following list of deficiencies are grounds for termination. Grounds for termination, however, are not limited to this list: 1. Non-compliance with applicable bid procedures and contract requirements of Federal Child Nutrition regu- lations. 2. The submission of false information to the Texas Department of Human Services (DHS). 3. Program violations at a significant proportion of the sponsors' sites. Such violations include but are not limited to the following: A. Non-compliance with the meal service time restrictions. B. Failure to maintain accurate records. C. Failures to adjust meal orders to conform to the variations in the number of participating childrem. D. The simultaneous service of more than one meal to any child. E. Service of a significant number of meals which do not include required quantities of all meal components. F. The claiming of program payments for meals not served to participating children. G. Excessive instances of off -site meal consumption. H. Continued use of food service management companies that are in violation of health codes. Form 150612.91 Texas Department of Human Services 1 SUMMER FOOD SERVICE PROGRAM APPLICATION FOR PARTICIPATION NOTE: Give as much information as possible. Attach additional sheets if needed; please identify each attachment with the name of the contracting organization. SECTION I —SPONSOR INFORMATION FOR DHS STAFF ONLY TX No. Eff. Date FY Approved For ❑ Breakfast ❑ A.M. Supp. L Lunch ❑ P.M. Supp. ❑ Supper ❑ All Contracting Organization Name Vendor ID No. Telephone No. (include A/C) City of Lubbock 117560005906000 (806) 767-2691 Mailing Address (Street or PIO. Box, City, State, ZIP) P.O. Box 2000 Street Address if different) 916 (Texas Avenue, Lubbock,Texas 79401 Name of Administrator B.C. McMinn Title Mayor A. Contractor Classification: ❑ School Food Authority ❑ Residential/Nonresidential Summer Camp -,A ❑ Private Non-profit Unit of Government —Contractor certifies that all food service sites are operated directly by the contractor. B. IType of Contractor: tX.XlPublic Entity (explain): Municipal government organization Is your agency considered to be state owned/operated?................:............................. ❑ Yes UvJ No Do you deposit your program reimbursement directly into the State Treasury? .................... ❑ N/A ❑ Yes 1`^ t No Do you deposit your program reimbursement directly into a local bank? .......................... ❑ N/A EN Yes ❑ No ❑ Private Nonprofit Organization —Tax-exempt status established. Attach letter of determination (IRS 501-30) of tax-exempt status from IRS C. 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 ❑ Serves migrant children ❑ Failure to operate would deny program to a poor area ❑ Failure to operate would deny a significant number of children access to program D.1. Does the organization receive $100,000 or more in federal funds yearly? ........................ ... ... ® Yes ❑ No 2. Does the organization receive more than $25,000 but less than $100,000 in federal funds yearly? .............. ❑ Yes No 3. Attach a copy of the audit covering last year's program operation or documentation that an audit conforming with SFSP policy will be conducted, including the date it will be conducted. L Form 1506 Page 2 �ECTION II —Budget A. Estimate all SFSP costs which will be claimed for reimbursement 1. ESTIMATED OPERATIONAL COSTS MONTHLY COSTS Program Labor $ 18,328 Fringe Benefits 2,263 Food 79,788 Non-food Supplies 1,956 Utilities 0 Rent 0 Equipment Use Fee 0 Rental of Equipment 0 Rate per mile Transportation 0.25t x 2,592 mi. 1,306 Other (specify): Other (specify): Other (specify): TOTAL 1: [103,641 for the month with the most operating days: 2. ESTIMATED ADMINISTRATIVE COSTS MONTHLY COSTS Administrative Labor (management, monitor, clerical) 6 939 $ s Fringe Benefits 1,332 Rental of Office Space 0 Utilities 0 (postage for Office Supplies Flyers) 2,550 Office Building Maintenance 0 Equipment Use Fee 0 Audit fees 800 Legal Fees 0 Rate per mile Transportation .25t x 1,700 425 Other (specify): Other (specify): TOTAL 2: 12,046 B. Indicate projected income to the food service from all sources other than SFSP reimbursement. Identify exactly the costs this income will cover: Source of Income Amount Will be used for: N/A $ Source of Income Amount Will be used for: N/A $ SECTION III —MANAGEMENT PLAN A. List administrative level personnel who will be responsible for management and monitoring of the SFSP. (Do not include site super- visors, cooks, ianitors or other personnel involved in on -site food service.) TITLE OF POSITION NUMBER IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES 1. Indoor Recreation Outreach Coordinator 1 Director of City of Lubbock SFSP 2. Recreation Supervisor (F) 1 Asst: Director of City of Lubbock SFSP 3. Senior Cit'z. dtr. Supv. (FT) 1 Bookkeeper 06ervice 4. .Monitor (Contract) 1 Personnel Training, Manage Food Service Personnel. Records 5. Indoor Rec. Supv. (FT) 1 Developing Budget, Grant Application, Attending Training. Etc. Form 1506 Page 3 B. Are children charged separately for meals. (not, d camp ) , , , , , , : ❑Yes l No 9 P Y ........................... If yes, see Form 1508, Attachment B. C. Do you want to receive advance payments?............................................................ ❑ Yes H No If yes, 1. For Operational Costs?..................................................................... ❑ Yes E0 No 2. For Administrative Costs?................................................................... ❑ Yes ® No D. If meals service is self -preparation, do you want to receive commodities? .................................... ❑ Yes 0 No If yes, Form 1608, Application and Agreement for Commodities must be completed. SECTION IV —PROGRAM OPERATION A.1. Beginning and Ending Dates of Meal Service: From June 3, 1991 through August 16, 1991 2. Number of sites: ............................................................................... B. List dates and topics of SFSP training: 12 DATES TOPICS May 29 1991 Explanation of Program, Site Management, Record Keeping, Meal Requirements/Inventory, Nondiscrimination, Eligibility, Guidelines. C. Is the organization planning to contract with a food service management company for the ❑ Yes X preparation of unitized meals?....................................................................... No If yes, and the contract will exceed $10,000, attach a copy of the invitation to bid. Also give: Date of Bid Publication Place of Publication Date of Bid Opening Time of Bid Opening Is bid expected to be $100,000 or more? +If yes, give place of bid opening: El Yes ❑ No 7 Also, attach a copy of an 11-day-cycle menu including all specific menus to be used. D. Is organization contracting with a year-round food service management company? .......................... ❑ Yes ko 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, handicap, age, sex, or national origin. No separate charge will be made for any meal except in accordance with attachment B of this application. 2. The contracting organization assures DHS that, if it is sponsoring camps or other enrollment programs,: • The contracting organization has or will obtain family size and income data about all children whose meals will be reported as free or reduced -price; and • The children claimed as free or reduced -price meet the current family size and income standards set by the United States Department of Agriculture, DHS Form 4504, Standards for determining Free and Reduced -price Eligibility. II. CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT A The contractor will comply with the SFSP Federal Regulations (7 CFR, Part 225, as amended), Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), and state policies and procedures as issued and amended by DHS. The contractor further agrees to perform as described in its application (including supporting documents and approved amendments to the application) for participation in the SFSP. B. The contractor accepts final administrative and financial responsibility for food service operations at each site sponsored by the contractor. This responsibility includes the performance of the conditions of settlement of any audit exceptions or payment deficiency in the program and the collection and repayment of any amount paid in excess of the proper claim amount which are found after monitoring or auditing by DHS or the United States Department of Agriculture (USDA). This responsibility applies to this contract, and all subcontracts hereunder. C. The contractor will apply to DHS for approval of changes to its original application and for prior authorization for field trips if meals served on the field trips will be claimed for reimbursement. Requests for changes and field trip authorization must be received by DHS at least five (5) calendar days before the requested effective date for the change or the field trip. Contractors will notify DHS within five (5) days of the termination of an approved food service site. SFSP RECORD KEEPING A The contractor will keep financial and supporting documents, statistical records, and any other records pertaining to the services for which a claim is submitted. The records and documents will be kept for at least three (3) years and ninety (90) days after the termination of the contract period If any litigation, claim, or audit involving these records begins before the stipulated time period expires, the contractor will keep the records and documents for not less than three (3) years and ninety (90) days after the termination of the contract period and until all litigation, claims or audit findings are resolved. The case is considered resolved when a final order is issued in litigation or a written agreement is signed by DHS and the contractor. Extensions are considered as separate contract periods. B. The contractor and its subcontractors will allow DHS and USDA officials and other appropriate officials determined by DHS to inspect facilities and records and to audit, examine, and copy records at any reasonable time. This includes access to all records of costs paid, even in part, by DHS. IV. CTv9L RIGHTS POLICY COMPLIANCE A The contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (P.L 88-352), as amended, and all requirements imposed by the regulations of the Department of Agriculture (7 CFR, Parts 15, 15a and 15b) Department of Justice (28 CFR, Parts 42 and 50) and USDA and DHS directives or regulations issued pursuant to that Act or the regulations to the effect that, no person in the United States shall, on the grounds of race, color, national origin, sex, age, or handicap, be excluded from participation in, be denied the benefits of, or be otherwise subject to discrimination under any program or activity for which the contractor receives federal financial assistance from the DHS and USDA: and hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement. 11 SUMMER FOOD SERVICE PROGRAM AGRI3E%4ENT STATE OF TEXAS § COUNTY OF TRAVIS § The Texas Department of Human Services, hereinafter referred to as DHS, The 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 (7 Code of Federal Regulations [CFR], Part 225). L 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 cancelled 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 cancelled without cause by giving thirty (30) days notice in writing to the other party and this contract shall thereupon be cancelled 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. Form 1506 Page 4 3. If 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 the DHS that all requirements have been or will be met. B. Public Release (SFSP Handbook, Chapter 11, page 22) 1. The contracting organization will make efforts to ensure that the local news media will make a public announcement of the program and will supply them with a news release: )f the contracting organization is sponsoring a camp or other enrollment program, this release must contain, at a minimum, a list of all approved sites, a list of the current standards for determining free and reduced price eligibility, and the following statement: "The (Name of the contracting organization) announces the sponsorship of the Summer Food Service Program for Children. Free meals will be offered to all eligible children in attendance with no physical segregation of, or other discrimination against any child because of race, color, handicap, sex, age, or national origin. Eligibility will be based on family size and income using the Standards for Determining Free and Reduced -Price Eligibility, provided by the United States Department of Agriculture. Meals will be provided at the site(s) listed." For all other programs the announcement must contain, at a minimum, a list of all approved sites and the following statement: "The (Name of the contracting organization) announces the sponsorship of the Summer Food Service Program for Children. All children in attendance will be offered the same free meals with no physical segregation of, or other discrimination against any child because of race, color, handicap, sex, age, or national origin. Meals will be provided at the site(s) listed." 2. This public release was or will be published in the following news media outlet(s): NAME OF MEDIA OUTLET DATE OF RELEASE Parks and Recreation Summer Leisure Guide May 19, 1991 Week of Avalanche -Journal - Ma 27, 1991 Week of Southwest Digest May 27, 1991 NAME OF MEDIA OUTLET DATE OF RELEASE e e o -. E1 Editor 1ay 27, 1991 ee o Radio ay 27, 1991 eek o Television ay 27, 1991 3. Attach a copy of the contracting organization's public release statement as submitted to the news media and any other materials used . to publicize the program's availability and nondiscrimination requirements. SECTION VI —CERTIFICATION (see Form 1506, Attachment C) certify that the information on this application is true and correct to the best of my knowledge. 1 certify that reimbursement will 3e claimed only for approved meals served to eligible children during the hours they are in attendance at approved sites. I know :hat deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. C� May 9, 1991 Signature—Offifia(df Contracting Organization Date Name (please type or print) in -OR DHS USE ONLY ❑ APPROVED ❑ DENIED If denied, reason: Title Approved for Food Distribution Date ❑ Yes ❑ No � If yes, give date Form 1608 sent to FDD: Title r - City of Lubbock Signature—DHS Representative Date -11L EFFECTIVE DATE AND SIGNATURES For the faithful performance of the terms of this contract, the parties hereto in their capacities stated, affix their signatures and bind themselves. City of Lubbock Name of the Contracting Organization (Please Print or Type) Original signature -of the authorized representative of the contracting organization B.C. McMinn Name Mayor Please print or type, in the spaces provided above, the name and title of the authorized represc:=::-tive signing this agreement on behalf of the contracting organization. Effective Dates: B TEXAS DEPARTMENT OF HUMAN SERVICES through Date: A v B. This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, .grants and loans of federal fund, reimbursable expenditures, grant or donation of federal property or interest in such property, the detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease or furnishing of services to the recipient, or any improvements made with federal financial assistance extended to the contractor by DHS. This includes any federal agreement, arrangement, or other contract which has as one of its purposes the provision of assistance such as food, cash assistance for the purchase of food, rental of food service equipment or any other financial assistance extended in reliance on the representation and agreements made in this assurance. C. This assurance is binding on the contractor, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from DHS or USDA The person whose signature appears on this contract is authorized to make this assurance on behalf of the contractor. V. DHS CLAIMS PAYMENT DHS will, subject to the federal appropriation and availability to DHS of sufficient funds for the SFSP, make program payments to the contractor in accordance with the terms of this contract. No reimbursement shall be made for performance under this contract occurring prior to (a) the beginning effective date of this contract or (b) a later date established by DHS based on the date of receipt of a fully executed copy of this contract. :���I a CKUCO) ZI The contractor agrees to comply with the requirements of the Immigration Reform and Control Act of 1986 regarding employment verification and retention of verification forms for any individuals hired after November 6, 1986, who will perform any labor or services under this contract. 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. ' Texas Department of Human Services Form 4508 July 1990 CERTIFICATE OF AUTHORITY This is to certify that Name of Authorized Official (please type or print) Title Lee Osborn Director, Parks and Recreation Signature —Authorized Official is designated as the authorized representative of Name of Contracting Organization City of Lubbock Address (Street, City, State, ZIP) P.O. Box 2000 Lubbock, Texas 79457 The 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. C' May 9, 1991 Signature—Offic I of Contracting Agency Date Name of Official (please type or print) Title 8 C. McMinn IMayor FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: Agreement No. Received By Date TX- 'rexas Da�artment Form 450e of Human Services July 1990 CERTIFICATE OF AUTHORITY This is to certify that Name of -Authorized Official (please type or print) Title Bob Goodwin I Recreation Supervisor Signature —Authorized Official is designated as the authorized representative of Name of CI ty Or��LU DrDOC Kion Address (Street, City, State, ZIP) P.O. Box 2000 Lubbock, Texas 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. C 4�e � .(yMay 9, 1991 Signatur of Contracting Agency Date Name of Official (please type or print) Title B.C. McMinn payor FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: Agreement No. Received By Date TX- 'Texas Department Form 4508 of Human Services July 1990 CERTIFICATE OF AUTHORITY This is to certify that Name of Authorized Official (please type or print) Title Susan Bailey Indoor Recreation Outreach Signature —Authorized Official is designated as the authorized representative of Name of Contracting Organization City of Lubbock Address (Street, City, State, ZIP) P.O. Box 2000 Lubbock, Texas 79457 The 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. c • C f �' May 9, 1991 Signature--OfficiA of Contracting Agency Date Name of Official (please type or print) Title . . B.C. McMinn Mayor FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: Agreement No. Tc eived By Date TX- I xas Department Form 1507 l February 1991 Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY SITE INFORMATION TX I ❑ R C U Name of Food Service Site Telephone No. (inc. A/C) Hollins Park N/A Park Site Address of Site (Street. City, State, ZIP) 1st: and Temple Lubbock, Tx. Perind of Operation of Food Service (mo/daylyr—molday/yr) Number of Op- May 0 �Jun�o July 22 Aug. 12 #Sept.O From: 6/3/91 through 8/16/91 erating Days: ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp Site Serving Primarily Migrant Children Other Site ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) ❑ E. (serving one to two meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving -one to two meals) 2. Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) .............................................................. 100 % A. If non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Jackson Elementary B. For enrolled sites, Form 1531 will be used to document eligibility. 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, II) .............................. ❑ Yes 0 No If Yes, give name of contracting organization: 4. Monitoring Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: A. First Week of Operation 6/3/91 - 6/7/91 B. First Four Weeks of Operation 1 6/3/91 - 6/28/91 C. Additional Reviews 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED* MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 58 12 :00 2 :00 P.M. Supplement Supper i nls inrormation is considerea by utis when setting the approved meal service level. (SFSP Handbook, Chapter tt) 6. Method of Food Preoaration by Contracting Organization (SFSP Handbook. Chanter III Self -Preparation lVended [:]On Site ❑ Central Kitchen I ® Using School Food Authority ❑ Food Service Management Company (Includes All Year Contracts) Form 15071Page 2 �7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) 1 Cafeteria -style Children are Seated ak Children Line Up ❑ Meal Service ❑ and are Given Meals and Pick Up Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter ll): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal. Service ummer Recreation Worker 2 Help to Serve Meals .T.P.A. Worker 2 Help to Serve Meal 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service ❑ Service ® Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site? ..................................... ...... .. ........... ® Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II): Site Personnel Will Contact Administrative Site Personnel Will Communicate 0 Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) .................... ❑ Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): Stored in Refrigerator � Thrown Away Returned to Vendor ❑ and Served the Next Day El at the Site ❑ for Disposal ❑ Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. `tr • Name of Contracting Agency • _Mai 9, 1991 City of Lubbock Signature—Offi ' I of Contracting Organization Date Name of Official (please type or print) Title B.C. "Peck" McMinn I Mayor FOR DHS ❑ Approved ❑ Denied; reason: USE ONLY Title Signature—DHS Representative Date Ix as Department Form 1507 / February 1991 Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY SITE INFORMATION JTX OR CLu Name of Food Service Site Telephone No. (inc. A/C) Pioneer Park 1(806) N/A Park Site Address of Site (Street, City, State, ZIP) 6t.h and Ave, T Lubbock Tx. Period of Operation of Food Service (mo/dayl r-mo/day/yr) Number of Op. May 0 June 20 July 22 Aug. 12 Sept. 0 From: 6/3/91 through g/ 1 5 / 91 erating Days: ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp Site Serving Primarily Migrant Children Other Site ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) ® E. (serving one to two meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ 0. (serving -one to two meals) 2. Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals 79.3 0� for the site (SFSP Handbook, Chapter II).............................................................. A. If non enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Ramirez Elementary B. For enrolled sites, Form 1531 will be used to document eligibility. 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, ll) .............................. ❑ Yes , No If Yes, give name of contracting organization: City of Lu bbo c k 4. Monitoring Plan (SFSP Handbook, Chapter 111): Enter date of monitoring review to be conducted within: A. First Week of Operation B- First Four Weeks of Operation C. Additional Reviews 6/3/91 - 6/7/91 1 6/3/91 - 6/28/91 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter 11): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 108 12 :00 2 :00 P.M. Supplement Supper rots imormauon is considerea oy UHS wnen setting the approvea meal service level. (SFSP' Handbook. Cnapter 11) 6. Method of Food Preparation by Contractino Oroanization (SFSP Handbook. Chanter III Self -Preparation Vended ❑ On Site ❑ Central Kitchen I Busing School Food Authority ❑ Food Service Management Company (Includes All Year Contracts) -10 Form 15071Page 2 7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals � and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Redreation WorkEr 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service Service ❑ Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site?..................................................................... 0 Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II): 0 Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ..................... � Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): Stored in Refrigerator nn Thrown Away Returned to Vendor ❑ and Served the Next Day LXI at the Site ❑ for Disposal ❑ Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. C Name of Contracting Agency May 9, 1991City of Lubbock S gnature—Offic'ial-&fContracting Organization Date Name of Official (please type or print) Title B.C. "Peck" McMinn I Mayor FOR DHS ❑Approved ❑Denied; reason: USE ONLY Title Signature—DHS Representative Date I xas Department Form 1507 / February 1991 Human Services — SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY _ SITE INFORMATION jTX ❑R �JU Name of Food Service Site Telephone No. (inc. A/C) Carter Park N/A Park Site Address of Site (Street, Gil , State, ZIP) Globe and Nort�i Loop 289/ Lubbock, Tx Period of Operation of Food Service (mo/day/yr$ To/ aj Number of Op- May O June 0 July Z 2 Aug. 12 �5ept. O From: 6/3/91 through / 1�% erating Days:111 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp Site Serving Primarily Migrant Children Other Site ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) E. (serving one to two meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to two meals) 2. Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II)............................................................. A. If non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Arnett Elementary B. For enrolled sites, Form 1531 will be used to document eligibility. 93 0/0 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, II) .............................. ❑ Yes ❑ No If Yes, give name of contracting organization: 4. Monitoring Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: A. First Week of Operation 6/3/91 p� r � 91 B. First Four Weeks of Operation 6/3/91 - 6/28/91 C. Additional Reviews 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter Il): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED* MEAL SERVICE TIME BEGINNING ENDING Breakfast - A.M. Supplement Lunch 58 12 :00 2 :00 P.M. Supplement Supper - i nos oniormaLOn is Considered by DH5 when setting the approved meat Service level. (bt-SY Hanobook, chapter tt) 6. Method of Food Preoaratinn by Contractinn Oroanization (SFSP Handbook. Chapter III Self -Preparation Vended ❑ On Site ❑ Central Kitchen I ® Using School Food Authority []Food Service Management Company (Includes All Year Contracts) Form 1507/Page 2 7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) "afeteria•style .hildren are Seated Children Line Up El 'Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Worke^ 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) ❑Indoor Meal Fv-1 Meal Service Service `t^J Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site? ..................................... .............................. U Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II): Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ................... ❑ Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): Stored 'in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day XX at the Site ❑ for Disposal ❑ Other: 1 CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of Contracting Agency May 9, 1991 City of Lubbock Signature —Official of Contracting organization Date Name of Official (please type or print) Title B.C. "Peck" McMinn I Mayor FOR DHS USE ONLY ❑Approved ❑ Denied; reason: Title Date Signature—DHS Representative f xas Department Form 1507 / February 1991 Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY SITE INFORMATION TX FE:1 R LJu Name of Food Service Site Telephone No. (inc. A/C) Burns Park1(806)N/A Park Site Address of Site (Street, City, State, ZIP) 23rd. and Ave. L Lubbock,. Tx Period of Operation of Food Service (mo/day/yr—mo/day/yr) Number of Op. Mayo �Ju e �July22 �Aug.12 Sept. 0 From: 6/3/91 through 8 / 16 / 91 erating Days: ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp Site Serving Primarily Migrant Children Other Site ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) ® E. (serving one to two meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving -one to two meals) 2. Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II)............................................................. 93.9 A. If non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Bean Elementary B. For enrolled sites, Form 1531 will be used to document eligibility. 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, if) .............................. ❑ Yes 0 No If Yes, give name of contracting organization: City of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter HI): Enter date of monitoring review to be conducted within: A. First Week of Operation 6/3/91 - 6/7/91 B. First Four Weeks of Operation 1 6/3/91 - 6/28/91 C. Additional Reviews 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 91 12 :00 _. 2 :00 P.M. Supplement - Supper This information is considered by OHS when setting the approved meal service level. (SFSP Handbook, Chapter II) 6. Method of Food Preparation by Contractino Oroanization (SFSP Handbook_ Chanter III Self -Preparation Vended 0 On Site [:]Central Kitchen I [ ] Using School Food Authority ❑ Food Service Management Company (Includes All Year Contracts) 371 Form 1507/Page 2 7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Cafeteria -style Children are Seated Children Line Up ElMeal Service ❑ and are Given Meals � and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter ll): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service ummer Recreation Worker 2 Help to Serve Meals .T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) EjIndoor Meal Meal Service Service Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site? .......... .......... ....................................... © Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. Il): ®Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) .................. � Yes FIND If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day C`_^J at the Site ❑ for Disposal ❑ Other: CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of Contracting Agency May 9, 199 City of Lubbock Signature —Official of eontfacli6g Organization Date Name of Official (please type or print) Title B.C. "Peck McMinn Mayor FOR DHS Approved ❑ Denied; reason: USE ONLY Signature —OHS Representative Date Title exas Department Form 15071 February 1991 Human Services FOR DHS USE ONLY SUMMER FOOD SERVICE PROGRAM FOR CHILDREN _ SITE INFORMATION TX 1, ❑ R ❑ If Name of Food Service Site Telephone No. (inc. A/C) Carlisle Park 1(806) N/A Park Site Address of Site (Street, City, State, ZIP) 26th and Ave. W Lubbock, Tx Period of Operation of Food Service (mo/daylyr—mo/daylyr) Number of Op May June July Aug. Sept. From:6/3/91 through 8/1�/91 erating Days: 0 20 22 12 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp Site Serving Primarily Migrant Children ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving -one to two meals) 2. Site Eligibility Other Site E. (serving one to two meals) Enter the percentage of children eligible for free and/or reduced price meals 90.5 for the site (SFSP Handbook, Chapter II)............................................................. . A. If non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Dupree Elementary B. For enrolled sites, Form 1531 will be used to document eligibility. % 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, II) .............................. ❑ Yes ® No If Yes, give name of contracting organization: City of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter 111): Enter date of monitoring review to be conducted within: A. First Week of Operation 6/3/91 - 6/7/91 B. First Four Weeks of Operation . 6/3/91 - 6/28/91 C. Additional Reviews 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 65 12 : 00 2 :'00 P.M. Supplement Supper - rnis imormanon is considered by UH5 when setting the approved meal service level. (SFSP Handbook, Chapter II) 6. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) Self -Preparation Vended [:]On Site ❑ Central Kitchen 1 0 Using School Food Authority ❑ Food Service Management Company (Includes All Year Contracts) Form 1507/Page 2 7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals 0 and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Worke 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve.Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) EjIndoor Meal Meal Service Service ❑X Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site?...................................................................... I Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11): Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ................... 0 Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): ❑ Stored in Refrigerator Thrown Away Returned to Vendor and Served the Next Day ❑X at the Site ❑ for Disposal ❑ Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. C Name of Contracting Agency May 91 1991 City of Lubbock Signature —Official Contra ting Organization Date Name of Official (please type or print) Title R r "Park" McMinn I Mavor FOR DHs ❑ Approved ❑ Denied; reason: USE ONLY Title Signature—DHS Representative Date Imas Department Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Form 1507 1 February 1991 FOR OHS USE ONLY ITX ❑ R U Name of Food Service Site Telephone No. (inc. AIC) Chatman Park N/A Park Site Address of Site (Street, City, State, ZIP) 27th and Ivory Lubbock, Tx, Period of Operation of Food Service (mo/daylyr—molds r) Number of Op- �M 0 20 July Aug. Sept. From: 6/3/91 through 8/16/y�l erating Days: 22 12 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp ❑ A. (serving one to four meals) Nonresidential Camp ❑ 0. (serving one to four meals) 2. Site Eligibility Site Serving Primarily Migrant Children ❑ C. (serving one to four meals) Site Serving Primarily Homeless Children ❑ D. (serving -one to two meals) Other Site ® E. (serving one to two meats) Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II).............................................................. 59.5 % A. if non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Wheatley Elementary B. For enrolled sites, Form 1531 will be used to document eligibility. 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, II) .............................. ❑ Yes V1 No If Yes, give name of contracting organization: City of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter II1): Enter date of monitorinq review to be conducted within: A. First Week of Operation B_ First Four Weeks of Operation C. Additional Reviews 6/3/91 - 6/7/91 6/3/91 - 6/28/91 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 45 12:00 - "2.00 P.M. Supplement Supper i ms inrormauon is constdered by uMb when setting the approved meal service level. (SFSP' Handbook, chapter it) 6. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter Iq self -Preparation Vended ❑ On Site ❑Central Kitchen Using School Food Authority []Food Service Management Company (Includes All Year Contracts) 111127 Form 1507/Page 2 7. Indicate the system to be used for the serving of meals and the supervision of children during meal service. period (SFSP Handbook, Chapter II) 1 Cafeteria -style Children are Seated Fv--4 Children Line Up ❑ Meal Service ❑ and are Given Meals I" and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor I Help Supervisor Meal Service Summer Recreation Worker 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service ❑ Service ® Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site? ....... .... ........ ... .............. ...... .......... FlYes ❑ NO IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II): 0 Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11) ......... ❑ Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day ® at the Site ❑ for Disposal ❑ Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. 1 certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. �+ •I Name of Contracting Agency C May 9, 1991 City of Lubbock Signature —Official of Contracting Organization Date Name of Official (please type or print) Title B.C. "Peck McMinn Mayor FOR DHS Approved ❑ Denied; reason: _ USE ONLY Signature—DHS Representative Date Title exas Department Form 1507 1 February 1991 i Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN _ FOR DHS USE ONLY SITE INFORMATION TX ❑ R _j U Name of Food Service Site Telephone No. (inc. AIC) Mahon Elementary Park N/A Park Site Address of Site (Street. City, State, ZIP) 2010 Cornell Lubbock Texas 79415 Period of Operation of Food Service (mo/daylyr—mo/daylyr) Number of Op- May June July Aug. Sept. From: 6 3 91 through 8 16 91 erating Days: 0 20 22 12 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp Site Serving Primarily Migrant Children Other Site ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) 0 E. (serving one to two meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving -one to two meals) 2. Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II)........................................................... 51.5 % A. If non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Mahon Elementary B. For enrolled sites, Form 1531 will be used to document eligibility. 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, 11) .............................. ❑ Yes E No If Yes, give name of contracting organization: 4. Monitoring Plan (SFSP Handbook, Chapter III): Enter date of monitorinq review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews 6 3 91 - 6/7/91 1 6/3/91-".6/28/91 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 39 12:00 - 2:00 P.M. Supplement Supper rnis Iniormatlon is considered by UNS when setting trio approved meat service level. (St -Se HandbOdk, unapler it) 6. Method of Food Preparation by Contracting Organization (SFSP Handbook. Chanter Ill Self -Preparation Vended [:]On Site [:]Central Kitchen 1 2 Using School Food Authority ❑ Food Service Management Company (Includes All Year Contracts) Form 15071Page 2 7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter 11) 1 Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ znd are Given Meals ® and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Help Supervise Meal Service Summer Recreation Worker 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) ❑Indoor Meal Meal Service Service 0 Will Be Cancelled ❑ Other. 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site? ........ ............................... ........................... 0 Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II): Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ..................... 0 Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 111): Stored in Refrigerator Thrown Away Returned to Vendor Eland Served the Next Day � at the Site ❑ for Disposal ❑ Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of Contracting Agency May 9. 1991 City of Cdbbock 9.9nature—officidTofidontracting 6rganization Date Name of Official (please type or print) Title B.C. "Peck"McMinn Mayor FOR DHS ❑ Approved ❑ Denied; reason: USE ONLY Title Signature—DHS Representative Date exas Department Form 1507 / February 1991 Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY SITE INFORMATION TX ❑ R Li. u Name o1 Food Service Site Telephone No. (inc. A/C) Yellow House Canyon Park (Washington American Legion Hall) N/A Park Site Address of Site (Street, City, State, ZIP) E 61 t and Olive Period of Operation of Food Service (mo/day/ mo/ y/yr) Number of Op 1May June July Aug. Sept. From: b/3/91 throughX/16I9y1 erating Days: T 0 0 20 0 22 12 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp Site Serving Primarily Migrant Children Other Site ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) © E. (serving one to two meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving -one to two meals) 2. Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals 50.5 for the site (SFSP Handbook, Chapter II).............................................................. A. If non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Wheatley Elementary B. For enrolled sites, Form 1531 will be used to document eligibility. % 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, II) .............................. ❑ Yes ❑ No If Yes, give name of contracting organization: 4. Monitoring Plan (SFSP Handbook, Chapter 111): Enter date of monitoring review to be conducted within: A. First Week of Operation W 61 B. First Four Weeks of Operation 6/3/91 - 6/28/91 C. Additional Reviews 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 30 12 :00 . 2 :00 P.M. Supplement Supper I nis information is considered by OHS when setting the approved meal service level. (SFSP Handbook, Chapter II) S. Method of Fond Prenaratinn by Cnntractinn nrnnni7atinn (SFSP Handhnok_ Chanter III Self -Preparation Vended ❑ On Site ❑ Central Kitchen I E Using School Food Authority ❑ Food Service Management Company (Includes All Year Contracts) Form 1507/Page 2 �7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter 11) Cafeteria -style Children are Seated Children Line Up ? ❑ Meal Service ❑ and are Given Meals Rand Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES . Center Supervisor 1 Help Supervise Meal Service Summer Recreation WorkEr 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service ® Service ❑ Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site? ... .............................................................. � Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11): Site Personnel Will Contact Administrative Site Personnel Will Communicate ® Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11) ..................... [!] Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): Stored 'in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day � at the Site ❑ for Disposal ❑ Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. 1 certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. IQ Name of Contracting Agency May 9, 1991 City of Lubbock Signature —Official of Q6ntracting Organization Date Name of Official (please type or rint) Title B.C. "Peck' McMinn Mayor FOR OHS USE ONLY ❑ Approved ❑ Denied; reason: Title Signature—DHS Representative Date -10 Form 1507/Page 2 . 7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter 11) ? ❑ Cafeteria -style Children are Seated Children Line Up Meal Service ❑ and are Given Meals � and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Supervise Meal Service Asst. Center Supervisor 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) EiIndoor Meal Meal Service Service ❑ Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site?........................................................... ........ ❑ Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II): ®Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) .................... ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meats delivered, meals will be (SFSP Handbook, Chapter III): Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day 0 at the Site ❑for Disposal ❑Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. t• Name of Contracting Agency May 9, 1991 City of Lubbock e& Signature —Official &f4tontracting Organization Date l Name of Official (please t��pe or riot) Title B.C. "Peck McMinn Mayor FOR ohs ❑Approved ❑Denied; reason: USE ONLY Signature—DHS Representative Title Date Form 1507/Page 2 7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter 11) ❑Cafeteria -style Children are Seated Children Line Up Meal Service ❑ and are Given Meals 0 and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Supervise Meal Service Asst. Center Supervisor 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service Service ❑ Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site? .................................................................. ❑ Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11): ®Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ..................... ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): Stored'in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day 0 at the Site ❑ for Disposal ❑ Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. y ft Name of Contracting Agency May 9, 1991 lCity of Lubbock Signature—Otficiat 6totontracting Organization Date Name of Official (please type or rint) Title Maor B.C. "Peck McMinn Y FOR DHS USE ONLY ❑ Approved ❑ Denied; reason: Title Signature—DHS Representative Date exas Department Form 15071 February 1991 r Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OHS USE ONLY SITE INFORMATION TX ❑ R ❑ U Name of Food Service Site T le hon ��06� Rodgers Community Center Address of Site (Street, City, State, ZIP) 3200 Amherst Lubbock, Texas Period of Operation of Food Service (moldaylyr—moldaylyr) Number of Op- may June �Jull �C �Aug'12 Sept. 0 From: 6/3/91 through 8/ 16 / 91 erating Days: ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp ❑ ❑ Site Serving Primarily Migrant Children Other Site � A. (serving one to four meals) C. (serving one to four meals) E. (serving one to two meals) Nonresidential Camp ❑ ❑ Site Serving Primarily Homeless Children B. (serving one to four meals) D. (serving -one to two meals) 2. Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals 69.15 for the site (SFSP Handbook, Chapter II)............................................................. . A. If non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: McWhorter Elementary (84.4%) Tubbs Elementary (52.9%) B. For enrolled sites, Form 1531 will be used to document eligibility. 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, II) .............................. ❑ Yes No If Yes, give name of contracting organization: City of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews 6/3/91 - 6/7/91 1 6/3/91-6./28) 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 108 12 :00 ,2 : 00 P.M. Supplement Supper - inrs mrormation is consiaerea by umi when setting the approved meal service level. (SFSP Handbook, Chapter 11) 6. Method of Food Preparation by Cnntractino Ornanization (SFSP Handbook_ Chanter III Sell -Preparation Vended [:]On Site [:]Central Kitchen I 0 Using School Food Authority ❑ Food Service Management Company (Includes All Year Contracts) n � Form 1507/Page 2 7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter ll) J Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals 0 and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor Z Supervise Meal Service Asst. Center Supervisor 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service Service ❑ Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site? ... ....................... ....................... ........... FX1 Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. ll): Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ..................... 0 Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day ® at the Site ❑ for Disposal ❑ Other. 1 CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of Contracting Agency 4 May 9 1991City of Lubbock Signature—Olfic al of Contracting Organization Date Name at Official (please type or print) Title B.C. "Peck" McMinn I Mayor - City of Lubbock FOR DHS ❑ Approved []Denied; reason: USE ONLY Title Signature—DHS Representative Date jxas Department Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Form 1507 / February 1991 FOR OHS USE ONLY TX I ❑R ❑u Name of Food Service Site Telephone No. (inc. A/C) Mae Simmons Community Center 806 767-2700 Address of Site (Street, City, State, ZIP) 23rd and Oak Lubbock Texas Period of Operation of Food Service (mo/day/yr—mo/day/yr) Number of Op- May +June +July Aug. +Sept. From: through erating Days: 0 7 20 T 2 7 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp Site Serving Primarily Migrant Children Other Site ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) ® E. (serving one to two meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving -one to two meals) 2. Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II).............................................................. 57.7 0/0 A. If non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Posey Elementary B. For enrolled sites, Form 1531 will be used to document eligibility. 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, ll) .............................. ❑ Yes 10 No If Yes, give name of contracting organization: City of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: A. First Week of Operation 6/3/91 - 6/7/91 B. First Four Weeks of O eration 6/3/91 - 6/28791 C. Additional Reviews 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter 11): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 137 12 :00 2:00 P.M. Supplement Supper - t his inlormation is considered by DHS when selling the approved meal service level. (SFSP Handbook, Chapter II) 6. Method of Food Preparation by Contractina Oroanization (SFSP Handbook. Chapter III Self -Preparation Vended 0 On Site 0 Central Kitchen I ® Using School Food Authority [:]Food Service Management Company (Includes All Year Contracts) Form 1507/Page 2 .7. Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter 11) ? Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Su ervise Meal Service Asst.' Center Supervis r 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service ® Service ❑ Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site? ........................................ ......... ® Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II): Site Personnel Will Contact Administrative Site Personnel Will Communicate ® Staff, Who Will Contact Vendor ❑ Directly With Vendor _ 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ..................... 0 Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): Stored in Refrigerator Thrown Away. Returned to Vendor ❑ and Served the Next Day I A I at the Site ❑ for Disposal ❑ Other: 1 CERTIFY that the information on this form is true and correct to the best of my knowledge.I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. 1 know that deliberate misrepresentation or withholding of informatiori may result in prosecution under applicable state and federal statutes. e l • Name of Contractin A ency .//�K May 9, 1991 City of Lu�bock Signature—Officiai ofttontracting Organization Date Name of Official (please type or print) Title R r "Pack" McMinn Mayor FOR DHS El Approved ❑Denied; reason: USE ONLY Title Signature—DHS Representative Date exas Department Form 1507 1 February 1991 � Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY SITE INFORMATION TX ❑ R ❑ U Name of Food Service Site Telephone No. (inc. A/C) Woods Community Center (806) 767-2698 Address of Site (Street, City. State, ZIP) Zenith and Erskine Lubbock, Texas Period of Operation of Food Service (mo/daylyr—moldaytyr) NUmber of Op May June July Aug. Sept. From: through 8 16 91 eratir Oays:. 0 20 22 12 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: Residential Camp Site Serving Primarily Migrant Children Other Site ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) ® E. (serving one to two meats) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving -one to two meals) 2. Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals 87.25 for the site (SFSP Handbook, Chapter 11).......................................................... . . A. If non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Hunt Elementary (74.5/) Parkway Elementary (100%) B. For enrolled sites, Form 1531 will be used to document eligibility. % 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, II) .............................. ❑ Yes ' ❑ No If Yes, give name of contracting organization: City of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews 6/3/91 - 6/7/91 1 6/3/91 - 6/28/91 6/3/91 - 8/16/91 5. Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement ` Lunch 96 12 :00 2 :06 . P.M. Supplement Supper - ims mrormauon is considered by DHS when selling the approved meal service level. (brSP Handbook, Ghapler 11) _ 6. Method of Food Preparation by Contractina Oraani72tion (SFSP Handbook. Chanter III Self -Preparation lVended ❑ On Site ❑ Central Kitchen I ® Using School Food Authority ❑ Food Service Management Company (includes All Year Contracts) TForm 1507/Page 2 7. Indicate the system to be used for the serving of. meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) } Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Supervise Meal Service Asst. Center Supervisor 2 Help to Serve Meals J.T.P.A. Worker 2 Help to Serve Meals 9. Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service Service ❑ Will Be Cancelled ❑ Other: 10. If the site feeds primarily homelwss children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? 11. Are meals delivered to the site? ........... .......................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 12, 13, & 14. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 12. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II): Site Personnel Will Contact Administrative Site Personnel Will Communicate © Staff, Who Will Contact Vendor ❑ Directly With Vendor 13. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ................... ® Yes ❑ NO If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 14. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III): Stored 'in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day at the Site ❑ for Disposal ❑ Other: I CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of Contracting Agency e , is May 9, 1991 City of Lubbock Signature—OfFiciijgfof Con acting Organization Date Name of Official (please type or print) Title B.C. "Peck" McMinn Mayor FOR FOR ❑Approved El Denied; reason: DHS USE ONLY Title Signature—DHS Representative Date 3 6 ": AGREEMENT TO FURNISH FOOD SERVICE (SPONSOR/SCHOOL) THIS AGREEMENT is made and entered into by and between LUBBOCK IND. SCHOOL DIST. (LISD) and CITY OF LUBBOCK: LISD agrees to supply unitized meals (inclusive) of milk and juice to CITY OF LUBBOCK with and for the rates herein listed: Breakfasts . . . $ N/A each Lunches . . . $ 1.55 each Snacks . . . . . $ N/A each Supper . . . $ N/A each It is further agreed that LISD, pursuant to the provisions of the Summer Food Service Program Regulations, the attached copy of which is part of this agreement, will assure that said meals meet the minimum requirements as to nutritive value and content, and will maintain full and accurate records that the institution will need to meet its responsibility including the following: 1. Menu Records, including amount of food prepared. 2. Meals, including daily number of meals delivered by type. These records must be reported to the institution promptly at the end of each month. LISD agrees also to retain records required under the preceding clause for a period of 3 years after the end of the fiscal year to which they pertain ( or longer, if an audit is in progress); and upon request, to make all accounts and records pertaining to the program available to representatives of the U.S. Department of Agriculture and the General Accounting Office for audit or dministrative review at a reasonable time and place. This agreement shall be effective as of (date) June 3. 1991 It may be terminated by notice in writing given by any party hereto to the other parties at least 30 days prior to the date of termination. IN WITNESS WHEREOF, the parties hereto have executed this agreement as of the dates indicated below: 17 Agreed to this date '9% School officials —V Location of food preparation center: Coronado High School Cafeteria Sponsor official Title- Mayor MEAL PATTERN REQUIREMENTS (continued) C Or Bread Alternates (whole grain or enriched): — cornbread, biscuits, rolls, muffins, etc. 1 serving - or cooked pasta or noodle products 1/2 cup — or cooked cereal grains such as rice, corn grits, or bulgur 1/2 cup Or an equivalent quantity of any combina- tion of bread or bread alternate(s) Milk Fluid milk 1 cup (1/2 pint) Sponsors may serve food items that are not listed in the meal pattern requirements. They may also serve more than the mini- mum quantities required. Sponsors are not reimbursed for meals that do not meet the minimum meal pattern requirements. Meal Service In addition to serving meals that meet the meal pattern require - Requirements ments, sponsors must comply with the following rules: • Serve the same meal to all children. • Ensure that children eat all meals on -site. Site personnel must supervise all children on the site while they are eating meals. Only costs for meals that children eat on -site are reimbursable. • Serve meals during the times of meal serve submitted on the Site Information Sheet and approved by DHS. Sponsors must obtain DHS approval for any changes in these meal service times. • All children in attendance at the site must receive one meal before any child can be served a second meal. • Ensure that three hours elapse between meals. If nonresidential camp sites and sites serving primarily migrant children serve lunch and supper with no afternoon snack between the two meals, they must ensure that four hours elapse between the lunch and supper. These sites must begin serving supper no later than 7 p.m. and must end supper service by 8 p.m. None of these time restrictions applies to residential camps and homeless feed- ing sites. Homeless feeding sites are not limited to meal service at the times shown on Form 1507, Summer Food Service Pro- gram — Site Information. DHS must approve any other waivers to these restrictions. (Il —16) Texas Dept. of Human Services SFSP 91-1/February 1991 C MEAL PATTERN REQUIREMENTS (continued) Milk Fluid milk Lunch or Supper - Meat and Meat Alternates Lean meat or poultry or fish Or Meat Alternates — cheese — or eggs or cooked dry beans or peas — or peanut butter, soynut butter, other nut or seed butters ._.. or peanuts, soynuts, tree nuts or seeds (No more than 50% of the meat/meat alternate requirement may be met with nuts or seeds when nuts or seeds are used to fulfill part of the meat/meat alternate requirement. They must. be combined with another meat/meat alternate. Or an equivalent quantity of any combina- tion of meat or meat alternates) _ Vegetables and Fruits (Must include 2 or more selections for a total of 3/4 cup): Vegetables and/or fruits — or full-strength vegetables or fruit juice (may be counted to meet not more than V2 of this requirement) Bread and Bread Alternates Bread (whole grain or enriched) 11 Program Planning 1 cup (1J2 pint) 2 ounces (edible portion as served) 2 ounces 1 large egg V2 cup 4 tablespoons 1 ounce 3/4 cup total 1 slice (II —15) Texas Dept. of Human Services SFSP 91-1/February 1991 /Bay summer. 1991, Feeding Item Day -Cost---Cost--------------------------------------------------------------------- 't Poor Boy sandwich 1 oz. bologna {----- 0 090 1 oz_ cheese 0.080 1/2 oz. salami 0.045 hot dog bun 0.070 Lettuce/tomato 1/4 C. 0.060 R Apple 1 whole (1/2 C.) 0128 Cookie 2 ea. 0 067 Milk --------------------------------------------------------------------------------- 1 Cup 0.140 0.680 ------------------ Pizza 2 oz. meat & bread 0.377 Day Tossed salad 1/4 r_. 0.060 Pears 1/2 c. 6.190 ' 2 Milk 1 Cup 0.140 i 0.767 ---------------------------------------------------------------------------------t---------' Day Ham & Cheese Sandwich 1 oz. turkey ham ' 0 120 . -------- 1 oz. Amer. cheese 0080 ' bread, 2 slices 0.069 j 3 Orange juice 4 oz_ 100% juice 0.105 ' Mixed fruit 3/8 C. 0154 Cookie 2 ea. 0.067 ; Milk 1 Cup 0.140 t 0.735 ------------------------------ Day --------------------------------------------------- Hot Dog I --------- one 8:1 frank --------- 0.153 ` hot dog bun 0.070 4 Potato Salad 1/4 C. 0'127 Grapes 1/2 C. j 01=4 Cookie Leach 1 0.067 Milk 1 CUP 0.140 0.701 ------------ Day ------------------------------------------------------------------ Turkey Sandwich 3 oz. = 2 oz. meat req. ------- 0.215 -------- bread, 2 slices 0.069 5 Lettuce & Tomato 1/4 c. 0.060 Jello w/ peaches 1/2 C_ peaches 0 187 ' Mild: 1 C. r 0.140 � 0.705 --------------------------------------------------------------------------------- Day Peanut Butter & Jelly Sandwich --------- 1 oz. peanut butter --------- 0.119 ' bread, 2 slices 0069 6 Jelly, 1 Tbsp. 0.040 -- Cheese stick 1 oz. 0.080 Carrot & celery sticks 1/4 C. 0.150 Banana 1/2 C. 0130 ' Milk 1 C. 0.140 0.728 -------------------------------------------------------------------------------- Day Hamburger charpattie ------- 0.230 -------- hamburger bun i 0.070 catsup PC 0015 7 Lettuce/tomato/pickle chips 1/4 C. 0 065 Peaches 1/2 C. 0.177 Cookie 2 ea. 0 067 Milk 1 Cup --------- 0.140 0.764 -- ------------------------------------------------------------------------ Day Bologna & Cheese Sandwich 1 1/2 oz. bologna i-------- 0.135 � 1/2 oz. cheese 0 040 bread, 2 slices 0.069 8 APple juice 4 oz. 100% juice 0.090 Pineapple chunks 3/8 C. 0125 Brownie 1 each 0 080 f Milk 1 Cup 0.140 0.679 Day Roast beef sandwich 2 oz. roast beef bread, 2 slices 9 Carrot sticks 1/4 C. Watermelon 1/2 C. Cookie 2 ea. Milk 1 C. ------------- Day ---------------------------------------------------- Submarine sandwich 1 1/2 oz. ,bologna 1/2 oz. r_heese hot dog bun 10 Lettuce/tomato 1/4 C. Orange, whole leach (1/2 C.) Popcorn bag 1 ea. ---- Milk- 1 Cu Burrito 1 ea. Day Carrot sticks 1/4 c. Apple 1/2 c. 11 Fruit Freeze bar 1/4 c. Milk 1 Grip --------------------------------------------------------------------- Day Turkey Sandwich 3 oz. = 2 oz. meat req. bread, 2 slices 12 Lettuce/tomato 1/4 C. Applesauce 1/4 c. Orange juice 1/4 c. ------------Milk--- Day ------------------------- Ham & Cheese sandwich --1-CUP --------------------- 1 1/2 oz. ham 1/2 oz. cheese hamburger bun 13 Potato salad 1/4 C. Fruit cocktail 3/8 C. Pickle spear 1/8 C. Milk 1 Cup ----------------------------------------------btuz Day Hot Dog or Hamburger ------------------- frank or charpattie ALT mustard Baked beans 1/2 c.. Lettuce/tomato 1/4 e. Brownie 1 ea. Milk--- -----1-CUP ------------------- ------------ Average -------------=-------- times 10% All sandwiches include 2 oz. enriched white bread or 2 oz. enriched hamburger or hot dog bun. -; 0.360 ' 0.069 ' 1 0.142 i ' --0 032 ; 0 067 ------0_140-I----0-81- 0.135 I 0_040 i 0.070 t 0.060 1 0.128 0.125 1 -1 0 NO 0.698 1- I I 0.3 , ' 0.142 ; 0.128 ; ' 0.149 ; 0.14 0.859 ' 0.215 ' 0.069 ' 1 0 060 1 0:065 1 0.120 ' 0 140 0.669 ' 0.180 ' 0.040 ' 0 070 1 0 1n7 1 0:154 1 1 0027 1 0 140 0.738 ---11 ------- 1 -1 --------- -i O'01.017 I 1 001 1 06106 1 1 1 0,08 1 --_�----0'14-1--0_6555- 0.728 0.801