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Home My WebLink AboutResolution - 2004-R0239 - Contract For 2004 Summer Food Service Program - 05_25_2004Resolution No. 2004-RO239 May 25, 2004 Item No. 24 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock BE and is hereby authorized and directed to sign for and on behalf of the City of Lubbock, a Contract by and between the City of Lubbock and Texas Department of Human Services, for the 2004 Summer Food Service Program for children, and all related documents. Said Contract is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the City Council this 25th ATTEST: Rebec Garza, City Secretary APPROVED AS TO Corbin Pemberton Parks and Recreation Director APPROVED AS TO FORM: M1 wm�y Sim �S'Attorney gs:/ccdocs/DHS Summer Food Program.res May 4, 2004 Texas Department Resolution No. 2004—RO239 Form 1506/March 2001 of Human Services SUMMER FOOD SERVICE PROGRAM I FOR DHS STAFF ONLY APPLICATION FOR PARTICIPATION lContract No. I TX No. Give as much information as possible. Attach Eff. Date FY additional sheets if needed; identify each attachment with the name of the contracting Approved For organization. ❑ Breakfast ❑ A.M. Supp. ❑ Lunch ❑ P.M. Supp. ❑ Supper ❑ All SECTION I — SPONSOR INFORMATION Contracting Organization Name -7 Texas ID No. Telephone No. Hotline No. City of Lubbock Parks & Recreation 1756000590-6000 806-775-2678 806-775-2673 Mailing Address (Street or P.O. Box, City, State, ZIP) PO Box 2000 Lubbock, Texas 79457 Street Address (if different) E-mail Address 1010 9th Street Lubbock, Texas 79401 ljmciellan@mail.cl.lubbock.b(.us Name of Administrator Title Johnny McLellan Indoor Recreation Supervisor Name of SFSP Contact Person Telephone of Contact Person (include Area Code) Alicia Gray (806) 775-2688 A. Contractor Classification (Check all that apply): ❑ National Youth Sports Program ❑ School Food Authority ❑Residential/Nonresidential Summer Camp ❑Continuous Calendar School Year ® Unit of Government -Contractor certifies that all food service sites are operated directly by the contractor. ❑ Private Nonprofit B. Is your program a year-round program?........................................................................................................................... ❑ Yes ® No C. Type of Contractor: ® Public Entity Is your agency considered to be state owned/operated?............................................................................................. ❑ Yes ® No Do you deposit your program reimbursement directly into the State Treasury? ........................................ ❑ N/A ❑ Yes ® No Do you deposit your program reimbursement into a local bank?............................................................... ❑ NIA ® Yes ❑ No If yes, is it direct deposit?...................................................................................................................................... ❑ Yes ® No ❑ Private Nonprofit Organization -Tax-exempt status established. Attach letter of determination (IRS 501-30) of tax-exempt status from IRS. Do you deposit your program reimbursement into a local bank?............................................................... ❑ NIA ❑ Yes ❑ No If yes, is it direct deposit?........................................................................ ..... ❑ Yes ❑ No ......................................................... D. Does the organization provide an ongoing year-round service to the community that is to be served by the Summer Food Service Program(SFSP)?................................................................................................................... Yes ❑ No If no, which of the following circumstances applies? ❑ Residential Camp ❑ Failure to operate would deny program to a poor area ❑ Serves Migrant Children ❑ Failure to operate would deny a significant number of children access to program E. Does the organization expend $300,000 or more in federal funds yearly?....................................................................... ® Yes ❑ No Attach a copy of the audit covering last year's program operation or documentation that an audit conforming with SFSP policy will be conducted, including the date it will be conducted. Form 1506 Page 2 SECTION II — BUDGET A. Estimate all SFSP costs which will be claimed for reimbursement for the program year: 1. ESTIMATED OPERATIONAL COSTS PROGRAM YEAR COSTS Program Labor Fringe Benefits Food $48,729.30 Non-food Supplies Utilities Rent Equipment Use Fee Rental of Equipment Rate per mile Transportation Other (specify); Coolers $500.00 Other (specify); Other (specify); TOTAL 1: $49,229.30 2. PROGRAM YEAR ESTIMATED ADMINISTRATIVE COSTS COSTS Administrative Labor $5,097.36 (Management, Monitor, Clerical) Fringe Benefits $749.81 Rental of Office Space Utilities Office Supplies $100.00 Office Building Maintenance Equipment Use Fee Audit Fees Legal Fees Rate per mile 0 $1,260.00 Transportation .36*3500 Other (specify); Advertising $500.00 Other (specify); TOTAL 2: $7,707.17 B. Indicate projected income to the food service from all sources other than SFSP reimbursement. Identify exactly the costs this income will cover. (Do not include state or federal funds.) Source of Income Amount Will be used for: NIA $ Source of Income Amount Will be used for: NIA $ SECTION III — MANAGEMENT PLAN A. List administrative level personnel who will be responsible for management and monitoring of the SFSP. (Do not include site supervisors, cooks, janitors or other personnel involved in on -site food service.) TITLE OF POSITION NUMBER IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Indoor Supervisor 1 Director of SFSP Program Manager 1 Assist Program Director & Monitor Administrative Assistant 1 Manage Records Monitor 1 Manage Records & Personnel Form 1506 Page 3 B. Are children charged separately for meals?..................................................................................................................... ❑ Yes ® No If yes, complete Form 1506, Attachment A (page 2), and submit with this application. C. Do you want to receive advance payments? For Operational Costs? ❑Yes ®No For Administrative Costs? ❑ Yes ® No D. If meal service is self -preparation, do you want to receive commodities?........................................................................ ❑ Yes ® No If yes, Form 1608, Application and Agreement for Commodities, must be completed and returned with your SFSP application. SECTION IV — PROGRAM OPERATION A.T. Beginning and Ending Dates of Meal Service A.2. Number of Sites FROM: June 1, 2004 TO: August 6, 2004 0 7 B. List dates and topics of SFSP training: DATES TOPICS May 26, 2004 Summer Satelite Staff Training June 2, 2004 SFSP Training LISD Monitors C. Is the organization currently contracting with a year-round food service management company? ................................... ❑ Yes ® No If yes, submit a copy of your procurement procedures, bid, contract, and all amendments; skip Item D. If no, complete Item D. D. Is the organization planning to contract with a food service management company?...................................................... ® Yes ❑ 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 March 22, 2004 Lubbock Avalanche Journal April 6, 2004 10:OOAM Is bid expected to be $100,000 or more? If yes, give place of bid opening: ❑ Yes ® No 0 Also, attach a copy of a minimum 11-day-cycle menu including all specific menus to be used. 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). F. Are you implementing the option to allow off -site consumption of food? ................... ❑ All Sites ❑ Some Sites ® No Sites SECTION V —ASSURANCES A. Free Meal Policy Statement 1. The contracting organization assures the Texas Department of Human Services (DHS) that all children at the sites described on the Site(s) Information Sheets for the Summer Food Service Program will be offered the same meals with no physical segregation of, or other discrimination against, any child because of race, color, disability, age, sex, national origin, religion, or political beliefs. No separate charge will be made for any meal except in accordance with attachment A of this application. 2. The contracting organization assures DHS that, if it is sponsoring camps or other enrollment programs: • The contracting organization has or will obtain family size and income data about all children whose meals will be reported as free or reduced -price; and • The children claimed as free or reduced -price meet the current family size and income standards set by the United States Department of Agriculture, DHS Form 4504, Standards for Determining Free and Reduced -Price Eligibility. 3. If the contracting organization is sponsoring a camp or other enrollment program that charges separately for meals, the contracting organization has read Attachment A to this application, "Additional Assurances for Camps and Other Enrollment Programs that Charge Separately for Meals," and assures DHS that all requirements have been or will be met. Form 1506 Page 4 B. Public Release The contracting organization will make efforts to ensure that the local news media will make a public announcement of the program and will supply them with a news release. If the contracting organization is sponsoring a camp or other enrollment program, this release must contain, at a minimum, a list of all approved sites, a list of the current standards for determining free and reduced price eligibility, and the following statement: "The (Name of the organization) announces the sponsorship of the Summer Food Service Program. Income eligibility will be based on family size and income using the Standards for Determining Free and Reduced -Price Eligibility, provided by the United States Department of Agriculture. Meals will be provided at the site(s) listed. People who are eligible to participate in the program must not be discriminated against because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who believes that they have been discriminated against should write immediately to: Director, Civil Rights Division, MC W-206, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington, D.C. 20250. NOTE: Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services." For all other programs, the announcement must contain, at a minimum, a list of all approved sites and the following statement: "The (Name of the organization) announces the sponsorship of the Summer Food Service Program. Meals will be provided at the site(s) listed. People who are eligible to participate in the program must not be discriminated against because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who believes that they have been discriminated against should write immediately to: Director, Civil Rights Division, MC W-206, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington, D.C. 20250. NOTE: Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services." This public release was or will be published in the following news media outlet(s): NAME OF MEDIA OUTLET DATE OF RELEASE NAME OF MEDIA OUTLET DATE OF RELEASE Lubbock AJ Activity Guide April 18, 2004 Lubbock AJ May 30, 2004 3. Attach a copy of the contracting organization's public release statement as submitted to the news media and any other materials used to publicize the program's availability and nondiscrimination requirements. SECTION VI — WAIVER REQUESTS (Check all for which you are applying, submit appropriate waiver request form and documentation.) ❑ Waiver to operate more than 25 sites (Nonprofit organizations only.) ❑ Waiver of the time restrictions for meal service at migrant sites. ❑ Waiver of the 15 consecutive school day requirement for year-round school program sites. ❑ Waiver of the first -week site visit requirement (School Food Authorities only). SECTION VI — CERTIFICATION (see Form 1506, Attachment B) I certify that the information on this application is true and correct to the best of my knowledge. I certify that reimbursement will be claimed only for approved meals served to eligible children during the hours they are in attendance at approved sites. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. jo —r o 1 `2-1'0y 41 Sk§nature-Official of Contracting Organization Date Name (please type or print) Title T0HA1VP1'AVeL-,5L6,4-/t% I NPOO/k RFeX94-, row FOR DHS USE ONLY ❑ APPROVED ❑ DENIED (reason): Title Signature -Official of Contracting Organization Date Texas Department Form 1506, Attachment 9 of Human Services January 1999 SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CRIMINAL PROVISIONS AND PENALTIES I. 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 S10,000 or imprisoned not more than five years. 2. Whoever being a partner, officer, director, or managing agent connected in' any capacity with any partnership, association, cooperation, business. or organization, either public or private, embezzles, misapplies, steals, or obtains by fraud, false statement or forgery, any benefit provided by the program, or any money, funds, assets, or property derived from benefits provided by this program, shall be fined 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 is a list of deficiencies that are grounds for termination. Grounds for termination, however, are not limited to this list. 1. Non-compliance with applicable bid procedures and contract requirements of Federal. Child Nutrition regulations. 2. The submission of false information to the Texas Department of Human Services. 3. Program violations at a significant proportion of the sponsor's sites. Such violations include, but are not limited to the following: At 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 children. 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. ATTACHMENT SUMMER FOOD SERVICE PROGRAM (SFSP) APPLICATION OUTREACH PLAN FOR OPEN AND RESTRICTED OPEN SITES If you operate open sites or restricted open sitesindicate your plans for conducting outreach to inform persons about the operation of the SFSP at your sites and promote participation at your sites. Check all that apply. ❑ Make television announcements. ❑ Send letters to potential participants. ❑ Make radio announcements. ❑ Distribute flyers to potential participants. ® Display posters at locations visited by potential participants. ® Offer activities other than meals at sites. ❑ Partner with other organizations to advertise and promote the program. ® Other. Explain. Send out Press Releases to the local newspapers. Information in the Summer distributed through Lubbock Avalanche Journal. January, 2002 Texas Department Form 1507/ March 2001 of Human Services SUMMER FOOD SERVICE PROGRAM FOR DHS USE ONLY SITE INFORMATION TX JOR ❑ U Name of Food Service Site Telephone No. (inc. A/C) Bean Elementary (806) 766-1666 Address of Site (Street, City, State, ZIP) 3001 Avenue N Lubbock, Texas 79405 Period of Operation of Food Service (modday/yr.-rno./day/yr.) Number of Op- May June July Aug. Sept. From: June 3, 2004 through: June 25, 2004 erating Days: 0 019 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: ❑ Residential Camp ❑ Site Serving Primarily Migrant Children (serving one to three meals) (serving one to three meals) ❑ Nonresidential Camp ® Other Site (serving one to three meals) (serving one or two meals) 2. List ALL counties served by this site: Lubbock 3. A. Is your site an open or restricted open site?.................................................................................................................. ® Yes ❑ No B. Is your site enrolled?..................................................................................................................................................... ❑ Yes ®No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the site (SFSP Handbook, Section 2)..................................................................................... 96.8 % D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced -price children. Bean E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program — refer to SFSP Handbook, Section 2.) F. What is the percentage of free and reduced -price meals for the site?.......................................................................... % 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2).......................................................... ® Yes ❑ No 61 If yes, give name of contracting organization: City of Lubbock Monitoring Plan (SFSP Handbook, Section 4) — Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews June 3-4, 2004 June 3-25, 2004 June 3-25, 2004 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A. M. Supplement Lunch 80 11:30 12:30 P.M. Supplement Supper 'This information is considered by DHS when setting the approved meal service level. (SFSP Handbook, Section 2) 7. Do you plan to feed children under one (1) year old?......................................................................................................... ❑ Yes ®No EA Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2): Self -Preparation vended Using School Using Food Service Management Company Using Private Nonprofit ❑ On -Site ❑ Central Kitchen ❑ Food Authority ® (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep Form 1507 Page 2 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. ❑ Yes ❑ No serve?............................................................................................................................................................................ 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Site Supervisor 1 Monitor Daily Operations, Daily Meal Service 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2): Indoor Meal Meal Service ® Service ❑ Will Be Cancelled ❑ Other: 12. Is this site implementing the option to allow off -site consumption of food?......................................................................... ❑ Yes ® No 13. Are meals delivered to the site?.......................................................................................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate ® Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)............................................... ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor ® and Served the Next Day ❑ 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 Organization City of Lubbock C451gnature fficial of Contracting Organization Date Name of Official (please type or print) Title Johnny McLellan Indoor Recreation Supervisor FOR ❑ Approved ❑ Denied, reason: DHS USE Title ONLY Signature — DHS Representative Date Texas Department Form 15071 March 2001 of Human Services SUMMER FOOD SERVICE PROGRAM FOR DHS USE ONLY SITE INFORMATION TX ❑ R ❑ U Name of Food Service Site Telephone No. (Inc. A/C) Guadalupe Neighborhood Center (806) 765-9713 Address of Site (Street, City, State, ZIP) 102 Avenue P Lubbock, Texas 79407 Period of Operation of Food Service (mo./day/yr.-mo./day/yr.) Number of Op- May June July Aug. Sept. From: June 7, 2004 through: July 23, 2004 erating Days: 18 16 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: ❑ Residential Camp ❑ Site Serving Primarily Migrant Children (serving one to three meals) (serving one to three meals) ❑Nonresidential Camp Other Site (serving one to three meals) ® (serving one or two meals) 2. List ALL counties served by this site: Lubbock 3. A. Is your site an open or restricted open site?.................................................................................................................. ® Yes ❑ No B. Is your site enrolled?..................................................................................................................................................... ❑ Yes ® No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the site (SFSP Handbook, Section 2)..................................................................................... 92.2 % D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced -price children. Guadalupe E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program — refer to SFSP Handbook, Section 2.) F. What is the percentage of free and reduced -price meals for the site?.......................................................................... % 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2).......................................................... ® Yes ❑ No 5. If yes, give name of contracting organization: City of Lubbock 4onitoring Plan (SFSP Handbook, Section 4) — Enter date of monitoring review to be conducted within: 4. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews June 7-11, 2004 June 7-July 5, 2004 June 7-July 23, 2004 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A. M. Supplement Lunch 80 12:10 1:10 P.M. Supplement Supper "This information is considered by OHS when setting the approved meal service level. (SFSP Handbook, Section 2) 7. Do you plan to feed children under one (1) year old?......................................................................................................... ❑ Yes ®No i:1 Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2): Self -Preparation vended Using School Using Food Service Management Company Using Private Nonprofit ❑ On -Site ❑ Central Kitchen ❑ Food Authority ® (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep Form 1507 Page 2 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. ❑ Yes ❑ No serve?............................................................................................................................................................................ 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Monitor Daily Operations, Site Supervisor Center Assistant Daily Meal Service 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2): Indoor Meal Meal Service ® Service ❑ Will Be Cancelled ❑Other: 12. Is this site implementing the option to allow off -site consumption of food?......................................................................... ❑ Yes ® No 13. Are meals delivered to the site?.......................................................................................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate ® Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)............................................... ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day ® 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 Organization City of Lubbock Signature IVOfficial of Contracting Organization Date Name of Official (please type or print) Title Johnny McLellan I Indoor Recreation Supervisor FOR I ❑ Approved ❑ Denied, reason: DHS USE Title ONLY Signature — DHS Representative Date Texas Department Form 15071 March 2001 of Human Services SUMMER FOOD SERVICE PROGRAM FOR DHS USE ONLY SITE INFORMATION TX JEIR ❑ U Name of Food Service Site Telephone No. (Inc. A/C) Parkway Neighborhood Center (806) 763-3969 Address of Site (Street, City, State, ZIP) 405 North MLK Blvd. Lubbock, Texas 79407 Period of Operation of Food Service (mo./daytyr.-mo./day/yr.) Number of Op- 0 May o June 0 July 0 Aug. Sept. From: June 7, 2004 through: July 23, 2004 erating Days: 18 16 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: ❑ Residential Camp ❑ Site Serving Primarily Migrant Children (serving one to three meals) (serving one to three meals) ❑Nonresidential Camp Other Site (serving one to three meals) ® (serving one or two meals) 2. List ALL counties served by this site: Lubbock 3. A. Is your site an open or restricted open site?.................................................................................................................. ® Yes ❑ No B. Is your site enrolled............................................................................................................. ❑ Yes ® No C. Site Eligibility: Enter the percentage of children eligible for free and/or 95.6 % reduced -price meals for the site (SFSP Handbook, Section 2)..................................................................................... D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced -price children. Alderson E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program — refer to SFSP Handbook, Section 2.) F. What is the percentage of free and reduced -price meals for the site?......................................................................... 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2).......................................................... ® Yes ❑ No 61 If yes, give name of contracting organization: City of Lubbock Monitoring Plan (SFSP Handbook, Section 4) — Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews June 7-11, 2004 June 7-July 5, 2004 June 7-July 23, 2004 6, Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A. M. Supplement Lunch 100 12:15 1:15 P.M. Supplement Supper 'This information is considered by DHS when setting the approved meat service level. (SFSP Handbook, Section 2) 7. Do you plan to feed children under one (1) year old?......................................................................................................... ❑ Yes ® No 0 Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2): Self -Preparation Vended Using School Using Food Service Management Company Using Private Nonprofit ❑ On -Site 0 Central Kitchen 0 Food Authority ® (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: Form 1507 Page 2 (SFSP Handbook, B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. ❑ Yes ❑ No serve?............................................................................................................................................................................ 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Monitor Daily Operations, Site Supervisor Center Assistant Daily Meal Service 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2): Indoor Meal Meal Service ® Service ❑ Will Be Cancelled ❑ Other: 12. Is this site implementing the option to allow off -site consumption of food?......................................................................... ❑ Yes ® No 13. Are meals delivered to the site?.......................................................................................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate ® Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)............................................... ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor Eland Served the Next Day ® 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 Organization City of Lubbock Signatur Official of Contracting Organization Date Name of Official (please type or print) Title Johnny McLellan I Indoor Recreation Supervisor FOR ❑ Approved ❑ Denied, reason: DHS USE Title ONLY Signature — DHS Representative Date Form 15071 March 2001 Texas Department of Human Services SUMMER FOOD SERVICE PROGRAM SITE INFORMATION Name of Food Service Site PHEA Boys & Girls Club Address of Site (Street, City, State, ZIP) 1801 24th Street Lubbock, Texas 79404 FOR DHS USE ONLY TX I ❑R ❑U Telephone No. (Inc. A/C) (806) 763-0204 Period of Operation of Food Service (mo./day/yr.-mo./day/yr.) INumber of Op- 0 May June July Aug. Sept. From: June 1, 2004 through: Aug. 6, 2004 1erating Days: 22 21 5 j ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: ❑ Residential Camp (serving one to three meals) ❑ Site Serving Primarily Migrant Children (serving one to three meals) ❑Nonresidential Camp (serving one to three meals) ® Other Site (serving one or two meals) 2. List ALL counties served by this site: Lubbock 3. A. Is your site an open or restricted open site?.................................................................................................................. ® Yes ❑ No B. Is your site enrolled?............................................................................................................................: ..... ❑ Yes ® No ................... C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the site (SFSP Handbook, Section 2)..................................................................................... 88.1 % D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced -price children. Dupre E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program — refer to SFSP Handbook, Section 2.) F. What is the percentage of free and reduced -price meals for the site?.......................................................................... % 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2).......................................................... ® Yes ❑ No 5. If yes, give name of contracting organization: City of Lubbock Monitoring Plan (SFSP Handbook, Section 4) — Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews June 1-4, 2004 June 1-29, 2004 June 1-August 6, 2004 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A. M. Supplement Lunch 100 12:00 1:00 P.M. Supplement Supper 'This information is considered by OHS when setting the approved meal service level. (SFSP Handbook, Section 2) 7. Do you plan to feed children under one (1) year old?......................................................................................................... ❑ Yes ® No 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2): Self -Preparation Vended Using School Using Food Service Management Company Using Private Nonprofit ❑ On -Site ❑Central Kitchen ❑ Food Authority ® (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep 9.A Form 1507 Page 2 Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. ❑ Yes ❑ No serve? ........................................... ................................................................................................................................. 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Site Supervisor 1 Monitor Daily Operations, Daily Meal Service 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2): Indoor Meal Meal Service ® Service ❑ Will Be Cancelled ❑ Other: 12. Is this site implementing the option to allow off -site consumption of food?......................................................................... ❑ Yes® No 13. Are meals delivered to the site?.......................................................................................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate ® Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)............................................... ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day ® 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 Organization ell,- Z / `� City of Lubbock ignature Official of Contracting Organization Date Name of Official (please type or print) Title Johnny McLellan Indoor Recreation Supervisor FOR DHS USE ONLY ❑ Approved ❑ Denied, reason: - DHS Date Title Texas Department Form 15071 March 2001 of Human Services SUMMER FOOD SERVICE PROGRAM FOR DHS USE ONLY SITE INFORMATION TX 1011 ❑ U Name of Food Service Site Telephone No. (Inc. A/C) Copper Rawlings/Harwell Gym (806) 767-2704 Address of Site (Street, City, State, ZIP) 213 401h Street Lubbock, Texas 79404 Period of Operation of Food Service (mo./day/yr.-mo./day/yr.) Number of Op- a May 0 June July Aug. Sept. From: June 1, 2004 through: Aug. 6, 2004 erating Days: 22 21 5 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: ❑ Residential Camp ❑Site Serving Primarily Migrant Children (serving one to three meals) (serving one to three meals) ❑Nonresidential Camp ® Other Site (serving one to three meals) (serving one or two meals) 2. List ALL counties served by this site: Lubbock 3. A. Is your site an open or restricted open site?.................................................................................................................. ® Yes ❑ No B. Is your site enrolled?..................................................................................................................................................... ❑ Yes ® No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the site (SFSP Handbook, Section 2)..................................................................................... 94.2 % D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced -price children. Harwell E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program — refer to SFSP Handbook, Section 2.) F• What is the percentage of free and reduced -price meals for the site? .......................... ......................................... 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2)......................................................... 5. If yes, give name of contracting organization: City of Lubbock Monitoring Plan (SFSP Handbook, Section 4) — Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews June 1-4, 2004 iJunel-29,2004 June 1-August 6, 2004 6. Meal Service Period Information (SFSP Handbook, Section 2): ® Yes ❑ No TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A. M. Supplement Lunch 135 11:30 12:30 P.M. Supplement Supper 'This information is considered by OHS when setting the approved meal service level. (SFSP Handbook, Section 2) 7. Do you plan to feed children under one (1) year old?......................................................................................................... ❑ Yes ® No IN Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2): Self -Preparation vended Using School Using Food Service Management Company Using Private Nonprofit ❑ On -Site ❑ Central Kitchen 0 Food Authority ® (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep Form 1507 Page 2 A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. ❑ Yes ❑ No serve?............................................................................................................................................................................ 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Monitor Daily Operations, Site Supervisor Center Assistant Daily Meal Service 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2): Indoor Meal Meal Service ® Service ❑ Will Be Cancelled ❑Other: 12. Is this site implementing the option to allow off -site consumption of food?......................................................................... ❑ Yes ® No 13. Are meals delivered to the site?.......................................................................................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate ® Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)............................................... ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day ® 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 Organization City of Lubbock ignature cial o ontracting Organization Date Name of Official (please type or print) Title Johnny McLellan Indoor Recreation Supervisor FOR ❑ Approved ❑ Denied, reason: DHS USE ONLY — DHS Date Title Texas Department Form 1507/ March 2001 of Human Services SUMMER FOOD SERVICE PROGRAM FOR DHS USE ONLY SITE INFORMATION TX IF] 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) 2004 Oak Avenue Lubbock, Texas 79404 Period of Operation of Food Service (mo./day/yr.-mo./day/yr.) Number of Op- a May 0 June 0 July Aug. Sept. From: June 1, 2004 through: Aug. 6, 2004 erating Days: 22 21 5 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: ❑ Residential Camp ❑ Site Serving Primarily Migrant Children (serving one to three meals) (serving one to three meals) ❑Nonresidential Camp ® Other Site (serving one to three meals) (serving one or two meals) 2. List ALL counties served by this site: Lubbock 3. A. Is your site an open or restricted open site?.................................................................................................................. ® Yes ❑ No B. Is your site enrolled?..................................................................................................................................................... ❑ Yes ® No C. Site Eligibility: Enter the percentage of children eligible for free and/or 89 5 % reduced -price meals for the site (SFSP Handbook, Section 2)..................................................................................... D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced -price children. Iles E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program — refer to SFSP Handbook, Section 2.) F• What is the percentage of free and reduced -price meals for the site?.......................................................................... % 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2).......................................................... ® Yes ❑ No If yes, give name of contracting organization: City of Lubbock 5. Monitorinq Plan (SFSP Handbook, Section 4) — Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews June 1-4, 2004 June 1-29, 2004 June 1-August 6, 2004 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A. M. Supplement Lunch 130 11:45 12:45 P.M. Supplement Supper 'This information is considered by DHS when setting the approved meal service level. (SFSP Handbook, Section 2) 7. Do you plan to feed children under one (1) year old?......................................................................................................... ❑ Yes ® No fE Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2): Self -Preparation Vended Using School Using Food Service Management Company Using Private Nonprofit ❑ On -Site ❑Central Kitchen ❑ Food Authority ® (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep Form 1501 Page 2 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. ❑ Yes ❑ No serve?............................................................................................................................................................................ 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Monitor Daily Operations, Site Supervisor Center Assistant Daily Meal Service Camp Monitor 1 Monitor and Daily Operations 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2): Indoor Meal Meal Service ® Service ❑ Will Be Cancelled ❑ Other: 12. Is this site implementing the option to allow off -site consumption of food?......................................................................... ❑ Yes ® No 13. Are meals delivered to the site?.......................................................................................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate ® Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)............................................... ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day ® 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 Organization 2 / -0 � City of Lubbock 4gnatur Official of Contracting Organization Date Name of Official (please type or print) Title Johnny McLellan Indoor Recreation Supervisor FOR 1 ❑ Approved ❑ Denied, reason: DHS USE Title ONLY Signature - DHS Representative Date Texas Department Form 15071 March 2001 of Human Services SUMMER FOOD SERVICE PROGRAM FOR DHS USE ONLY SITE INFORMATION TX TOR ❑ U Name of Food Service Site Telephone No. (inc. A/C) Maggie Trejo Community Center (806) 767-2703 Address of Site (Street, City, State, ZIP) 3200 Amherst Lubbock, Texas 79415 Period of Operation of Food Service (mo./day/yr.-mo./day/yr.) Number of Op- a May a June July Aug. a Sept. From: June 1, 2004 through: Aug. 6, 2004 erating Days: 22 21 5 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1. Indicate Type of Site: ❑ Residential Camp (serving one to three meals) ❑ Site Serving Primarily Migrant Children (serving one to three meals) ❑Nonresidential Camp (serving one to three meals) ® Other Site (serving one or two meals) 2. List ALL counties served by this site: Lubbock 3. A. Is your site an open or restricted open site?.................................................................................................................. ® Yes ❑ No B. Is your site enrolled?..................................................................................................................................................... ❑ Yes ® No C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the site (SFSP Handbook, Section 2)..................................................................................... 92.7 % D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free & reduced -price children. McWhorter E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program - refer to SFSP Handbook, Section 2.) F. What is the percentage of free and reduced -price meals for the site?.......................................................................... % 4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2).......................................................... ® Yes ❑ No 5. If yes, give name of contracting organization: City of Lubbock Monitoring Plan (SFSP Handbook, Section 4) - Enter date of monitoring review to be conducted within: A. First Week of Operation TBUFirst Four Weeks of Operation CAdditional Reviews June1-4,2004 ne 1-29, 2004 jJune 1-August 6, 2004 6. Meal Service Period Information (SFSP Handbook, Section 2): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED MEAL SERVICE TIME BEGINNING ENDING Breakfast A. M. Supplement Lunch 140 12:00 1:00 P.M. Supplement Supper 'This information is considered by OHS when setting the approved meal service level. (SFSP Handbook, Section 2) 7. Do you plan to feed children under one (1) year old?............................................................................ ❑ Yes ® No ............................. 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2): Self -Preparation vended Using School Using Food Service Management Company Using Private Nonprofit ❑ On -Site ❑ Central Kitchen I ❑ Food Authority ® (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep Form 15W Page: 9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2) Cafeteria -style Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other: B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. ❑ Yes ❑ No serve?............................................................................................................................................................................ 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2): TITLE OF POSITION I NO. IN POSITION I SPECIFIC FOOD SERVICE PROGRAM DUTIES (Center Supervisor 1 (Monitor Daily Operations, Site Supervisor Center Assistant Imeai Service 11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2): Indoor Meal Meal Service ® Service ❑ Will Be Cancelled ❑ Other: 12. Is this site implementing the option to allow off -site consumption of food?......................................................................... ❑ Yes ® No 13. Are meals delivered to the site?.......................................................................................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6) Site Personnel Will Contact Administrative Site Personnel Will Communicate ® Staff, Who Will Contact Vendor ❑ Directly With Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)............................................... ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) Stored in Refrigerator Thrown Away Returned to Vendor ❑ and Served the Next Day ® 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 Organization L City of Lubbock 6naturejZ Official of Contracting Organization Date Name of Official (please type or print) Title Johnny McLellan Indoor Recreation Supervisor FOR ❑ Approved ❑ Denied, reason: DHS USE ONLY — DHS Date Title Texas Department SPECIAL NUTRITION PROGRAMS Form 156i of Human Services SINGLE AUDIT IDENTIFICATION DATA March 2001 For Program Year (SNP Use Only) Contractor Name Contact Person City of Lubbock Johnny McLellan Address (Street or P.O. Box. City, State, ZIP) PO Box 2000 Lubbock, Texas 79457 Telephone No. Texas ID No. (Payee ID No.) Contract No. (806) 775-2678 1-75-6000590-6000 175- J5001 Contractor Fiscal Year End (mm/dd/yyyy) Type of Contract 09/30/2004 ❑ For Profit ❑ Non -Profit ® Governmental Check the appropriate box(es) to indicate the type(s) of program(s) in which you currently participate or for which you are applying: COMMODITY ASSISTANCE PROGRAMS PROGRAM NOS. CASH REIMBURSEMENT PROGRAMS PROGRAM NOS. ❑ A — National School Lunch ❑ AD — Adult Day Care TX - ❑ B — Charitable Institutions ❑ BL— National School Lunch/Breakfast TX - ❑ C — Area Agency on Aging ❑ CC — CACFP Center TX - ❑ G —Summer Camps ❑ DH — CACFP Day Home TX - ❑ H — Summer Food Service ® SF —Summer Food TX — 152-1004 ❑ J —Jails ❑ SM — Special Milk TX - ❑ I — TEXCAP ❑ TE — TEXCAP TX - ❑ CS — Commodity Supplemental Food Prog. ❑ CS — Commodity Supplemental Food Prog. TX - Give the source and amount of any federal funds that your agency expends other than from those programs listed above: SOURCE AMOUNT Community Development Block Grants $3,776,993.00 South Plains Association of Governments $112,000.00 SINGLE AUDIT EXEMPTION — I certify that I am not required to submit an audit under the Single Audit Act for the following reason(s): L❑ I am a for -profit organization. ❑ I expend less than $300,000 annually in total federal funding. I SINGLE AUDIT ASSURANCE — I understand that if 1 meet the requirements of the Single Audit Act, I will agree to submit an audit as a condition of eligibility to participate in the Special Nutrition Programs, and that failure to do so as required could result in adverse action, including the withholding of my claim for reimbursement payments and termination of my contract. I also understand that if I am a private non-profit organization subject to the requirements of the Single Audit Act and have a financial audit performed annually, I must also obtain a sinale audit on an annual basis. Zl— 2/-V-11 Signature —Authorized Representative Date Name (please type or print) Title Johnny McLellan Indoor Recreation Supervisor Office of Accounting P.O. Box 2000 • 1625 13th Street Lubbock, Texas 79457 (806) 775-2156 • Fax (806) 775-3273 April 20, 2004 Texas Department of Human Services Special Nutrition Programs, Operation Division 2109 Avenue Q Lubbock, TX 79405 To whom it may concern, We are in the process of compiling information for the single audit report, which is performed in accordance with the Single Audit Act of 1984 and OMB Circular A-133. We anticipate that this will be completed and published by June 30, 2004. If you have any questions, please feel free to contact me at (806) 775-2148. Sincerely, Dena Morris Grant Accountant Texas Department NONGOVERNMENTAL CONTRACTOR CERTIFICATION Form 4732 of Human Services September 1994 The Texas Department of Human Services (DHS) has adopted rules pertaining to contracting with organizations in which a former board member or employee (whose last day of duty was within the past two years) has any ownership or control, or who is an employee or consultant of such organization. Also, Human Resources Code §22.0033 prohibits for one year after employment former DHS employees in pay grades equivalent to or above pay grade 17, Step 1, from helping (for pay) another entity obtain a contract with DHS in an area for which the former employee was directly concerned or had administrative responsibility. Additionally, DHS has adopted standards for contracting with contractors associated with current or former employees and board members, and their relatives. This form is necessary to help the Department determine compliance with those rules. All potential non -governmental contractors for any type of contract must complete this certification. The contract, if awarded, may be terminated for cause if (1) the contractor knowingly provides incorrect information in its certification; or (2) the contractor uses a subterfuge, such as a subcontract arrangement, to avoid the application of state laws or DHS rules. Does the potential contractor have an officer, director, employee, consultant, or owner (in whole or in part): 1. A person who is currently a DHS employee or DHS board member?.............................................................................. ❑ Yes ❑ No 2. A person who was a former DHS employee or board member whose last day of duty with DHS was withinthe past two years?................................................................................................................................................ ❑ Yes ❑ No 3. A person who is related (see Relationship key below) to a current DHS employee or DHS board member? .................. ❑ Yes ❑ No 4. A person who is related (see Relationship key below) to a former DHS employee or DHS board member whose last day of service to DHS was within the past two years?................................................................................... ❑ Yes ❑ No Wife Brother Stepdaughter Spouse's Sister RELATIONSHIP Husband Sister Stepson Spouse's Brother KEY Father Son Mother-in-law Mother Daughter Father-in-law IF YOU ANSWERED "YES" TO ANY OF THE ABOVE QUESTIONS, YOU MUST COMPLETE AND ATTACH FORM 4732-A. CERTIFICATION I certify that the information above is complete, true and correct to the best of my knowledge. I understand that lack of full, true and complete disclosure may be grounds for withholding payment for delivered services and may cause contract termination. Name of Potential Nongovernmental Contractor Contract No. Social Security No. or VIN Print or Type Name N/A Signature - Authorized Representative Date Texas Department Form 2041 of Human Services CERTIFICATION REGARDING FEDERAL LOBBYING October 1990 (Certification for Contracts, Grants, Loans, and Cooperative Agreements) PREAMBLE Federal legislation, Section 319 of Public Law 101-121 generally prohibits entities from using federally appropriated funds to lobby the executive or legislative branches of the federal govemment. Section 319 specifically requires disclosure of certain lobbying activities. A federal government -wide rule, "New Restrictions on Lobbying," published in the Federal Register, February 26,1990, requires certification and disclosure in specific instances and defines terms: Covered Awards and Subawards-Contracts, grants, and cooperative agreements over the $100,000 threshold need (1) certifications, and (2) disclosures, if required. (See certification term number 2 concerning disclosure.) Lobbying -To lobby means "to influence or attempt to influence an officer or employee of any agency (federal), a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with any of the following covered federal actions: • the awarding of any federal contract, • the making of any federal grant, • the making of any federal loan, • the entering into of any cooperative agreement, and • the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan or cooperative agreement." Limited Use of Appropriated Funds Not Prohibited -The prohibition on using appropriated funds does not apply to activities by one's own employees with respect to: liaison activities with federal agencies and Congress not directly related to a covered federal action; • providing any information specifically requested by a federal agency or Congress; • discussion and/or demonstration of products or services if not related to a specific solicitation for a covered action; or • professional and technical services in preparing, submitting or negotiating any bid, proposal or application for a federal contract, grant loan or cooperative agreement or for meeting legal requirements conditional to receipt of any federal contract, grant, loan or cooperative agreement. (The prohibition also does not apply to such services provided by nonemployees for the same purposes.) Professional and Technical Services -Professional and technical services shall be advice and analysis directly applying any professional or technical expertise. Note that the professional and technical services exemption is specifically limited to the merits of the matter. Other Allowable Activities -The prohibition on use of federally appropriated funds does not apply to influencing activities not in connection with a specific covered federal action. These activities include those related to legislation and regulations for a program versus a specific covered federal action. Funds Other Than Federal Appropriations -There is no federal restriction on the use of nonfederal funds to lobby the federal government for contracts, grants, and cooperative agreements. Applicability of Other State and Federal Requirements -Neither the govemment-wide rule nor the law affect either (1) the applicability of cost principles in OMB circulars A-87 and A-122, or (2) riders to the Texas State Appropriations Acts which disallow use of state funds for lobbying. TERMS OF CERTIFICATION This certification applies only to the instant federal action for which the certification is being obtained and is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. The undersigned certifies, to the best of his or her knowledge and belief, that: 1. No federally appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. 2. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federally funded contract, subcontract, subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (If needed, contact your Texas Department of Human Services procurement officer or contract manager to obtain a copy of Standard Form-LLL.) 3. The undersigned shall require that the language of this certification be included in the award documents for all covered subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all covered subrecipients shall certify and disclose accordingly. Do you have or do you anticipate having covered subawards under this transaction? ....................................... ❑ Yes ❑ No Name of Contractor/Potential Contractor r ndor ID No. or Social Security No. DHS Contract No. Name of Authorized Representative itfe N/A per DHS IT I Signature -Authorized Representative Date With a few exceptions, you have the right to request and be informed about the information that the Department of Human Services (DHS) obtains about you. You are entitled to receive and review the information upon request You also have the right to ask DHS to correct information that is determined to be incorrect. (Govemment Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please refer to the contact information in your application, procurement, or renewal packet. Bluefield St. , ,,,,, v*f,t nt I I I •00 Ltau - our t. uru. ItL: buo ioo IIIU P. UU2 LLIBSOCK ISD % of Eiarnentmy Economically Dlaadvanteged fall PEIMS Snapshot 20034M ELEMENTARN Total Disadvan % Alt~rsdt 493 473 95.6% AMOC ,: 218 207 96.0% 8alfetep� 317 313 98.7% 8t{ylMi 707 541 76.5% ear-, 493 477 96.8% Bowie 320 138 43.1 % Bagman 187 182 07.3% Brown' 460 381 84.7% 320 282 88.1% ` 218 201 92.2% Hardwick 582 235 40.4% i4ama ` 430 405 94.2% Haynes 393 89 22.6% "ado" 610 550 90.2% Honey 475 54 11.4% IIe1t"' 371 332 89.5% Jaakm 279 265 95.0% Maddpott 380 227 59.7% M8 281 272 96.8% Maw > 326 316 96.9% AAavIl arter 425 395 92.7% Murfee 347 22 6.3% Overbore 292 208 70.5% Pam 213 210 98.6% Parsing 673 297 51.8% R Welson 467 135 26.9% 9101it+9z 281 232 80.9% Rush 582 264 43.4% Smith 715 67 9.4% Stftart ` 455 313 68.5% Tubbs" 338 270 79.9% waters 640 205 32.0% MOW 429 294 68.5% W611111MY 262 239 94.8% VIItMN X* 357 273 76.5% Whiteside 747 107 14.3% Williams 446 147 33.0%. WciAartR 600 454 90.8% WrW 166 138 83.6% Total 10,057 10,208 63.6% News Release FOR UvIMEDIATE RELEASE: Contact: Johnny McLellan, 775-2678 The City Of Lubbock is pleased to announce the Summer Food Program for Children, sponsored by the Texas Department of Human Services. This program is provided through the City Of Lubbock Parks and Recreation Department, under direction of Civic Services. The Program will provide a nourishing noon meal to youngsters age one through eighteen. Meals will be served Monday through Friday, beginning June 1 st and ending August 6, 2004 noon in the following locations: Maggie Trejo Supercenter — 3200 Amherst Mae Simmons Community Center — 23`d & Oak Parkway Center — 405 N. MLK Guadalupe Center —102 Ave. P Beginning June 3`d and ending June 25th, meals will be served Monday through Friday, at 11:30am at the following locations: Bean Elementary — 3001 Ave N Rawlings Community Center/Harwell Gym — 4101 Ave D (Lunch will be served at Harwell Gym throughout the summer) Also participating in the program is the PHEA Branch of the Boys & Girls Club, located at 1801 24th. The program will run from June 1 — August 6, 2004. Service time for this site will begin at 12:00 noon. Children who are eligible to participate in this program must not be discriminated against on the basis of race, color, national origin, age, religion, sex, disability, or political beliefs. Anyone who believes he or she has been discriminated against, should write to: Director, Civil Rights Division, MC W-206, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030 or Secretary of Agriculture, Washington D.C. 20250. NOTE: Discrimination complaints based on religious or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services. CITY OF LUBBOCK MEMO TO: Bridget Faulkenberry, Environmental Inspection FROM: Johnny McLellan, Interim Indoor Recreation Supervisor DATE: 4l20l04 RE: Summer Lunch Program The City Of Lubbock will once again be participating in the Summer Lunch Program for children. This program will begin on Tuesday, June 1 and will end on Friday, August 6, 2004. Meals will be served at the following locations: Trejo Supercenter — 3200 Amherst Rawlings Community Center/Harwell Gym — 40th & Ave. B Simmons Community Center — 23ra & Oak Parkway Center — 405 N. MLK Guadalupe Center — 102 Ave. P In addition to these sites, LISD will be participating in the program from June 3ra through June 25th. Meals will be served at 11:30am in the following locations: Bean Elementary — 3001 Ave. N Rawlings Community Center/Harwell Gym — 40tb & Ave. B (lunch will be served at Harwell Gym throughout the summer) Also participating in the program is the PHEA Branch of the Boys & Girls Club, located at 1801 24th. The program will run from June 1 — August 6, 2004. Service time for this site will begin at 12:00 noon. Cave ovl-e 13 Summer Lunch Menu City of Lubbock Day 1 Poor Boy loz - bologna 1 oz - cheese 1/2 oz - Salami 1/4 cup - Lettuce/tomato 1 whole apple 1 cookie 1 cup — Milk (chocolate) Day 2 Peanut Butter/Jelly Sandwich 1 oz - Peanut Butter / Jelly 2 slices - Bread loz - American cheese 1/4 cup - Celery Sticks 1 whole apple 1 cup — Milk (chocolate) Day 3 Turkey Ham & Cheese Sandwich 1 oz - Turkey Ham 1 oz - American Cheese 2 slices - Bread 4 oz - Orange Juice - 100% 3/8 cup - mixed fruit 2 cookies 1 cup — Milk (chocolate) Day 4 Pastrami & Swiss Sandwich loz - Turkey Pastrami loz - Swiss Cheese 2 slices -Bread 1/4 cup - Potato salad 1 whole orange 1 cookie 1 cup - Milk (chocolate) Day 5 Ham & Cheese Sandwich 1 oz - Ham loz - American Cheese 2 slices - Bread 1/4 cup - lettuce, tomato, pickle chips 1/2 cup - peaches 2 cookies 1 cup — Milk (chocolate) Inq - "2 G Day 6 Bologna & Cheese Sandwich loz - Bologna 1 oz - Cheese 2 slices - Bread 4 oz Apples juice - 100% 3/8 cup - Pineapple chunks 1 brownie 1 cup — Milk (chocolate) Day 7 Turkey & Swiss Sandwich loz - Turkey 1 oz - Swiss cheese 2 slices bread 1/4 cup - Lettuce/tomato 1 whole - orange 1 cookie 1 cup — Milk (chocolate) Texas Department of Human Services Form 450E May 200( SPECIAL NUTRITION PROGRAM CERTIFICATION OF AUTHORITY This is to certify that the following erson s : Name of Authorized Representative (please type or print) Title Johnny McLellan I I Indoor Recreation Supervisor is (are) designated as an Authorized Representative of Name of Contracting Organization City of Lubbock Address (Street, City, State, ZIP) PO Box 2000 Lubbock, Texas 79457 The representative(s) designated above, and myself, acknowledge that each is individually authorized on behalf of the contracting organization to make written agreements with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to the department. By signing this document, we certify individually and collectively that to the best or our knowledge and belief, all documents submitted physically or electronically on behalf of the above named Contracting Organization pursuant to our participation in any and all programs administered by Special Nutrition Programs, TDHS, are/will be true and correct in all respects, that they are/will be completed according to the terms and conditions of existing agreements including amendments, that records aretwill be available to support any and all claims, and that we will not submit claims (excluding amended/adjusted claims) for goods or services for which we have already received payment. We recognize that we are fully responsible for any excess amounts which may result from errors made In relation to the completion and submission of claims. We are also aware that deliberate misrepresentation or withholding of Information may result in prosecution under applicable state and federal statutes. 1 Name of Official of Contracting Agency (please type or print) Marc McDougal /'Mayor n mm P c m mn . I X Signature Official of Contracting Agency City Secretary DELETED AUTHORIZED REPRESENTATIVES: A c ntracting organization may not have more than three (3) Authorized Representatives, including the Official of the Con acting Agency. If you are replacing or deleting an Authorized Representative, list the name(s) of the individual() to be removed as Authorized Representative(s) below: Name of Deleted Representative I [Name -of Deleted Representative Name of Deleted Representative APPROVED AS TO TENT; Corbin Pemberton Parks & Recreation Director FOR DHS USE ONLY Contract No. 75 - Received By APPRO AS TO FORM; my.L �' ims ass t t City Attorney Date Received