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Resolution - 3359 - Grant Application - TDHS - Summer Food Program - 04_26_1990
Resolution # 3359 April 26, 1990 Item #19 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 Summer Food Service Program Application and related documents with the Texas Department of Human Services, attached hereto, 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 e uoya, ry APPROV AS TO C ENT: Lee Osborn, Direct -or of Parks & Recreation APPROVED AS TO FORM: a o Willard, Assistant City Attorney 26th day of April , 1990. /'B. C. MCMINN, MAYOR 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 28, 1990 - August 31, 1990 MONTH/DATE/YEAR TO MONTH/DATE/YEAR 1 CITY DEPARTMENT/INDIVIDUAL PREPARING GRANT: Kay Sti.ner, Indoor Recreation Superintendent (Whom to contact in case of questions) - APPROVAL . DE THE T HEAD ASSISTANT CITY MANAGER OR CHIEF OF POLICE BUDCET & RESEARCH DIRECTOR DEPUTY CITY MANAGER Upon completion of approvals, return to: Page 1 of 8 , - % /�� - / DATE DATE -/-///0/9,0 DATE DATE Kay Stiner / park R ReL•-rQitinn by INDIVIDUAL CITY DEPARTMENT OR SECTION DEADLINE DATE (IF APPLICABLE) A25-1 Texas department of Hunan Services f � SUMMER FOOD SERVICE PROGRAM APPLICATION FOR PARTICIPATION SSSR Form 1so6I1-g FOR DNS STAFF ONLY TX No. I Eft. Date I FY Ij NOTE: Please follow the SFSP Handbook references providecil Give as much infor. mation as possible. Attach additional sheets If needed; please Identify each attachment with the name of the contracting organization. Approved For ❑ Breakfast ❑ A.M. Supp. ❑ Lunch ❑ P.M. Supp. ❑ Supper ❑ All SECTION I —SPONSOR INFORMATION contracting Organization Name Vendor ID No. Telephone No. (include A/C) City of Lubbock 117560005906000 (806) 767-2680 Mailing Address (Street or P10. Box. City, State, ZIP) P.O. Box 2000 Street Address (if different) 916 Texas Avenue, Lubbock, Texas 79401 Name of Administrator Title B.C. McMinn Mayor A. Contractor Classification: (SFSP Handbook, Chapter II, page 1) ❑ School Food Authority ❑ Residential Summer Camp ❑ Private Non-profit ® Unit of Government —Contractor certifies that all food service sites are operated directly by the contractor (SFSP) handbook, Chap. II, pg. 17). B. Type of Contractor. (SFSP Handbook, Chapter II, pages 1 and 22) El Public Entity (explain): Munici pal goverr meet organi zati on Is your agency considered to be state owned/operated?.............................................. ❑ Yes ® No Do you deposit your program reimbursement directly into the State Treasury9 .................... ❑ N/A ❑ Yes ® No Do you deposit your program reimbursement directly into a local bank?......... .............. ❑ N/A ® Yes ❑ No ❑ Private Nonprofit Organization —Tax-exempt status established (attach letter of determination 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)? (SFSP Handbook, Chapter II, page 1) ................... ® 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? (SFSP Handbook, Chapter III, pages 31 and 32)...................................................................... El Yes ❑ No 2. Does the organization. receive more than $25,000 but less than $100,000 in federal funds yearly? (SFSP Handbook, Chapter iII, pages 31 and 32) ............. ...... ............. ❑ Yes 0 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. (SFSP Handbook, Chapter Ill). Form 1. W Page 2 SECTION II —Budget (SFSP Handbook, Chapter III, pages 15 through 27) A. Estimate all SFSP costs which will be claimed for reimbursement: • 1. ESTIMATED OPERATIONAL COSTS MONTHLY COSTS Program Labor $ 15,865 Fringe Benefits 1,908 Food 51,759 Non-food Supplies 1,756 Utilities 0 Rent 0 Equipment Use Fee 0 Rental of Equipment 0 Rate per We Transportation 0.2.5¢ x 2 592 mi . 1,306 Omer (specify) Omer (specify): Other (sper,ify): TOTAL 1: 72,594 2. ESTIMATED ADMINISTRATIVE COSTS MONTHLY COSTS Administrative Labor (management, monitor, clerical) $ 6,694 Fringe Benefits 996 Rental of Office Space 0 Utilities 0 Office Supplies 500 Office Building Maintenance 0 Equipment Use Fee 0 Audit fees 750 Legal Fees 0 Rate per mile Transportation . 2 5 t x 1, 700 425 other (specify): other (specify): TOTAL 2: 9 3 65 B. Indicate projected income to the food service from all sources other than SFSP reimbursement. Identify exactly the costs this income will cover: (SFSP Handbook, Chapter 111, page 26) Source of Income Amount Wit be used for. n/a $ Source of Income Amount Wit 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. (SFSP Handbook, Chapter II, pages 19, 20, and 22) (Do not include site supervisors, cooks, janitors or other personnel involved in on -Me food service.). TITLE OF POSITION NUMBER IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES I. Supt. Indoor Rec. (FT) 1 Director of City of Lubbock SFSP 1 2. Senior Citz. Ctr. Supv. (F ) 1 Bookkeeper 3. Food Service Monitor 1 Personnel Training, Manage Food Service Personnel (Contract) Records r Form Isoe Page B. Are children charged separately for meals? (SFSP Handbook; Chapter V, page 1) ... not, a, camp,), , . , , , , . , , ❑ Yes 0 No If yes, see Form 1508, Attachment B. C. Do you want to receive advance payments? (SFSP Handbook, Chapter V, page 1) ............................ ❑ Yes El No If yes, 1. For Operational Costs? .................................................................. ❑ Yes FX] No 2. For Administrative Costs? ............................................ ..................... ❑ Yes M No D. If meals service is self -preparation, do you want to receive commodities? (SFSP Handbook, Chapter II, page 8) .... ❑ Yes 0 No If yes, Form 1608, Application and Agreement for Commodities must be completed. n/a SECTION IV —PROGRAM OPERATION A.1. Beginning and Ending Dates of Meal Service: From June 4, 1990 through August 17, 1990 2. Number of sites:.............................................................................. 12 B. List dates and topics of SFSP training as required in SFSP Handbook, Chapter III, pages 1 through 7. DATES TOPICS May 30, 1990 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 preparation of unitized meals? (SFSP Handbook, Chapter IV) .............................................. ❑ Yes 0 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? N yes, give place of bid opening: ❑ Yes ❑ No 0 Also, attach a copy of an 11- day -cycle menu including all specific menus to be used. (SFSP Handbook, Chapter iV, page 12) D. is organization contracting with a year-round food service management company? (SFSP Handbook, Chapter11, page 17)............................................................................... ❑ Yes ❑ No if yes, submit a copy of your procurement procedures, bid, contract, and all amendments E. Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department notifying them of intent to operate a Food Service Program at the site(s) indicated on the attached Site Information sheet (Form 1507). (SFSP Handbook, Chapter II, page 17). SECTION V—ASSURANCES A. Free Meal Policy Statement (SFSP Handbook, Chapter III, page 12) 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 DNS 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 meats will be reported as tree 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, DNS Form 4504, Standards for determining Free and Reduced -price Eligibility. Form 1 FOG Pape 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 It, page 22) 1. The contracting organization assures the Texas Department of Human Services that the local news media will make a public announce- ment of the program: 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 Mare of the contesting 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 fist of all approved sites and the following statement: "The (Nam or 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 PUBLICATION Parks and Recreation Summer Leisure Guide May 20 1990 Week of Avalanche -Journal ay 26 1990 Week of Southwest Digest May 26 1990 NAME OF MEDIA OUTLET DATE OF PUBLICATION Week of E1 Editor May 26 1990 Week of Radio May 26 1990 Week of Television May 26 1990 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 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. c2 7 Signature-14 cial o Contracting Organization r Date Name (please type or p=Q Title B.C. McMinn Mayor - City of Lubbock FOR DHS USE ONLY ❑APPROVED ❑DENIED If denied, reason: Approved Ior Food Distribution Date ❑ Yes ❑ No 0 If yes, give date Form 1608 sent to FDD: Signature—DHS Representative Title Date Form 1507 / Pa" 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, page 13) ❑ Cafeteria.style Meat Service S Children Line Up and Pick Up Meals ❑ Children are Seated and are Given Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook. Chapter 11, page 21): 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 il, page 13) ❑ Indoor Meal Service L'._i Meal Service Will 8e Cancelled I ❑ Other: 10. Are meals delivered to the site?.................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 11, 12, do 13. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11, pg. 21): ® Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly With Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II, page 13) ............ R Yes ❑ No it no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 13. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III, page 13): ❑ Stored In a Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to the Vendor 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. l know that deliberate misrepresentation or withholding of Information may result In prosecution under applicable state and federal statutes. C Name of Contracting Agency City Of Lubbock S+gnature—Otficiat of Contracting Orpatuzation Da]e Name of Official (please t/pe or print) Title B.C. "Peck" McMinn Mayor of Lubbock D►ts ❑ Approved Denied; reason: USE ONLYFOR TO Signature—DHS Representative Dade ra.�. t�nmant Form 15071 January 1900 of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY TX I El ❑U SITE INFORMATION Narne of Food Service Site Telephone No. (inc. A/C) Mahon Elementary Park N/A Park sitp Address of Site (Street. City, State, ZIP) 79415 Period of Operation of Food Service (m)/daylyr— Wday" Number of Op- May June Juy Aug. Sept. OQ From: 6-04-90 through 8-17-90 orating Days: 0 20 21 13 Describe the geographical area served by the site: I-27 (East) Clovis Rd. (South) Erskine (North) --See Map 1. Indicate Type of Site: ❑ A. Residential Camp (serving one to four meals) ❑ C. Site serving primarily migrant children (serving one to four meals) El B. Nonresidential Camp (serving one to four meals) � D. Other site (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 11, pages 1 through 6) ............................................. 51.5 °h A. It 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, II, page 6) ...................... ❑ Yes a No If Yes, give name of contracting organization: 4. Monitoring Plan (SFSP Handbook, Chapter III, pages 8 through 10): Enter date of monitoring review to be conducted within: A. First week of operation B. First Four weeks of Operation C. Additional Reviews 6-04-90 6-04-90/ 6-27-90 1 6-04-90/8-17-90 5. Meal Service Period Information (SFSP Handbook, Chapter II, page 13): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 65 12:00 1:30 P.M. Supplement Supper - Tn,s inloanauon is cons,aered Dy UK5 when setting the approved meal servrce level. t wok- Hanc=ok C.74ip(er it, page 17) 6. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11, pages 7 and 8) Self -Preparation I Vended ❑ On Slte ❑ Central Kltchen I [X 3Using School Food Authority ❑ Food Service Management Company (Includes All Year Contracts) Texas Department Form 1507 / January 1990 of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OHS USE ONLY TX I ❑R ❑u SITE INFORMATION Name of Food Service Site Telephone No. (inc. A/C) Yellow House Canyon Park (Washington American 1pqjon Hill) AWess of Site (Street, City, State, ZIP) Period of Operation of Food Service (mo/day/yr—molday/yr) Number of Op- May June Juy Aug. Sept. From: 6-04-90 through 8-17-90 erating Days: 0 20 21 13 0 Describe the geographical area served by the site: E. 60th (North) E. 65th (South) Olive Ave. (West) Sumac (East) --See Ma 1. Indicate Type of She: ❑ A. Residential Camp (serving one to four meals) ❑ C. Site serving primarily migrant children (serving one to four meals) ❑ B. Nonresidential Camp (serving one to four meals) F D. Other site (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 11, pages 1 through 6)............................................ . 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. 50.5 % 3. Did the site participate in previous years' SFSP? (SFSP Handbook. Chapter, II, page 6) ...................... ❑ Yes LA No It Yes, give name of contracting organization: 4. Monitoring Plan (SFSP Handbook, Chapter 111, pages 8 through 10): Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Revievrs 6-04-90/6-29-90 1 6-04-90/8-17-90 5. Meal Service Period Information (SFSP Handbook, Chapter II, page 13): 6. TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 35 12:00 1:30 P.M. Supplement Supper - ints rniormatron rs comciereo try DHs when setting the approved meal servroe K"t_ t,0-5F Hanobook, cnap(er n, page 1 ) iethod of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11, pages 7 and 8) iel f -Pre pa ra bon vented 0 On Site ❑ Contral Kitchen I Q using School Food Authority ❑ Food Service Manaoermnt Company (Includes All Year Contracts) 0 Form 15071 P*96 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, page 13) ❑ cafeteria -style Meal service ❑ Children are Seated and are Given Meals ® Children Une Up and Pick Up Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11, page 21): 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 11, page 13) 9 Indoor Meal Service ❑ Meal Service Will Be Cancelled ❑ Other: 10. Are meals delivered to the site?.................................................................... A l Yes ❑ No iF YES, COMPLETE ITEMS 11, 12, & 13. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11, pg. 21): ® Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly With Vendor 12. Will deWery be within one hour of the food service period? (SFSP Handbook, Chapter 11, page 13) ............ ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until tiros of service: 13. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter Ill, page 13): ❑ Stored in a Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to the Vendor for Dlsposal ❑ 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. 4 Nartts of Contracting Agency e, •�_,Z 'Y'o City of Lubbock 4,, 6ffaraj of contracting Organization Date Name of Official (please type or print) Title �•C• ��PPrk" McMinn Mayor of Lubbock , FOR DNS ❑ Approved ❑ Denied; reason: USE ONLY Tnla sbnawre—DHS Representative Die Texas Department Form IU7IJanuary 1990 of Hunan Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY TX I ❑ R ❑ u SITE INFORMATION Name of Food Service Site Telephone No. (inc. AIC) Carter Park N/A Park Site Address of Site (Street. City, State, ZIP) Globe and North Loop 289 .Lubbock Tx. Period of Operation of Food Service (mo/daytyr— no/daylyr) TNrUmber of Op- May June Juy Aup. Sept. ti From: 6-04-90 through--17-90 ting Days: 0 20 21 13 0 Describe the geographical area se by the E: N. Loop 289(South7 I -27 (Jest) Ursuline St. (North) Quirt Ave. (East) --See Map 1. Indicate Type of Site: ❑ A. Residential Camp (serving one to four meals) ❑ C. Site serving primarily migrant children (serving one to four meals) ❑ B. Nonresidential Camp (serving one to four meals) ® D. Other site (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 11, pages 1 through 6)............................................ 93 gb 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. 3. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter, II, page 6) ...................... ❑ Yes 0 No If Yes, give name of contracting organization: 4. Monitoring Plan (SFSP Handbook, Chapter III, pages 8 through 10): Enter date of monhorinq review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews 6-04-90 16-04-90/6-27-90 6-04-90 8-17-90 5. Meal Service Period Information (SFSP Handbook, Chapter 11, page 13): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 35 12:00 1:30 P.M. Supplement Supper This information is cormdered by OHS whop setting the approved rr" servuoe rewet. (5r iF Handbook. Ctlap(er Il, page 17) 6. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11. oaaes 7 and 8) self-P re pa neon Vended 1 0 On Slte ❑ Central Kitchen Using School Food Authority [:]Food Service Management Company (Includes All Year Contracts) , Form 1 SOT I Pa" 2 7. Indicate the system to be used for the serving of meals and the supervision of children during meat service period (SFSP Handbook, Chapter 11, page 13) ��-77 ElCafateria•style meal Service tX Xl Children Une Up and Pick Up Meals ❑ Children am Seated and are Given Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11, page 21): 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 11, page 13) ❑ Indoor Meal Service ER Meal Service Will Be Cancelled ❑ Other: 10. Are meals delivered to the site? .................................................................. � Yes ❑ No iF YES, COMPLETE ITEMS 11, 12, do 13. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II, pg. 21): ® Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly With Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II, page 13) ............ ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 13. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 111, page 13): ❑ Stored in a Refrigerator and Served the Next Day ❑ Returned to the Vendor for Disposal Thrown Away at the Site ❑ 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. d Name of Contracting Age-y 11.,74/ City of Lubbock S4i.aiure- o-ficial of c6niracting Organization Cate Name of Official (please type or print) Title .C. Peck McMinn IMay(yr of It,bbnck FO R DNS USE ONLY ❑ Approved ❑ Denied; reason: Title SP9nature—DHS Repre ntati" Mie Texas Department Form 1507 / January 1990 of Horton Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY TX ❑R El SiTE INFORMATION Name of Food Service Site Telephone No. (inc. A/C) Holins Park N/A Park Site Address of Site (Street, City, Stale, ZIP) 1st. and Temple Lubbock Tx. Period of operation of Food Service (mo/daylyr—mo/day/yr) Number of Op- May June � Joy Aug. Sept. From: _ 4-90 through 8-17-90 erating Days: 0 20 21 13 0 Describe the geographical area served by the site: 4th St. South University Ave,We rAveE --S e M 1. Indicate Type of Site: ❑ A. Residential Camp (serving one to four meals) ❑ C. Site serving primarily migrant children (serving one to four meals) ❑ B. Nonresidential Camp (serving one to four meals) ® D. Other site (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 11, pages 1 through 6)............................................. 100 °b 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, page 6) ...................... ❑ Yes Q No If Yes, give name of contracting organization: 4. Monitoring Plan (SFSP Handbook, Chapter Ill, pages 8 through 10): Enter date of monitoring review to be conducted within: A_ First Week of Operation B. First Four Weep of Operation C. Additional Reviews 6-04-90 6-04-90/6-27-90 16-04-90/8-17-90 5. Meal Service Period Information (SFSP Handbook, Chapter 11, page 13): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 45 12 :00 1: 30 P.M. Supplement Supper ' This information is considered by DHS when setting the approved meal berv" level. (SrSP Handbook, Chapter 11, page 17) 6. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11, pages 7 and 8) Self -preparation Vended [:]On Site ❑ Untral Kitchen I ®Usino School Food Authority ❑ Food Service Management Company (includes All Year Contratiz) Form 15071 P" 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, page 13) ❑ Cafeteria style Meal Service Lnd Children Una Up and Pick Up Meals ❑ Children are Seated and are Given Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11, page 21): 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 i1, page 13) El Indoor Meal Service ❑ ideal Service Will Be Cancelled ❑ Other: 10. Are meals delivered to the site?.................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 11, 12, as 13. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11, pg. 21): ® Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly With Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11, page 13) ............ ® Yes ❑ No If no, describe arrangements within standards prescribed by focal health authorities for delivery and holding of meals until time of service: 13. if there is an excess of meals delivered, meats will be (SFSP Handbook, Chapter 111, page 13): ❑ Stored in a Refrigerator and Served the Next Day ❑ Returned to the Vendor for Disposal ® Thrown Away at the Site ❑ 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. 4 Flame of Contracting AQ-" F4d City of Lubbock SKan.ature—C;ffic al o Contracting OrGaruzation Date Name of Offcial (please type or print) Title B.C. "Peck" McMinn Mayor- City of Lubbock FOR DHs Approved ❑ Denied; reason: USE ONLY Thte Sinnature—DHS Representative Dale Texas CeI=rnent Form 1507 / January 1990 or Hyman Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHs USE ONLY TX --L❑R ❑U SITE INFORMATION Name of Food Service Site Telephone No. (inc. A/C) Mae Simmons1806-767-2700 Address of Site (Street, City, state, ZIP) 23rd and Oak Lubbock Tx Period of Operation of Food Service (moldaylyr—mWdaY 6-04-90 8-17- 0 Number of Op- May June July Aug. Sept. ili0 From: through orating Days: 0 20 21 13 Describe the geographical area served by the site: Idalou Rd. (South) Mackenzie Pk. (West) Parkway Dr.(North)--See Map 1. Indicate Type of Site: ❑ A. Residential Camp (serving one to four meals) ❑ C. She serving primarily migrant children (serving one to four meals) ❑ B. Nonresidential Camp (serving one to four meals) ® D. Other site (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 11, pages 1 through 6)............................................. 57.7 9t1 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, II, page 6) ...................... ❑ Yes 0 No it Yes, give name of contracting organization: Ci ty of 'Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter III, pages 8 through 10): Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weep of Operation C. Additional Reviews 6-0 5. Meal Service Period Information (SFSP Handbook, Chapter 11, page 13): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TiME BEGINNING ENDING Breakfast A.M. Supplement Lunch 100 12:00 1:30 P.M. Supplement Supper i nts intomiatbn is cons+oerec oy urts when setting file apprrnad meat earV— teveL torWr nanaooac, grapier It, page 17) 6. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter it, pages 7 and 8) Self -Preparation Vented []On Site 0 Central Kitchen I [Using School Food Authority ❑ Food Service Management Company (Includes All Year Conlracts) Forth I S07 / Pa" 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, page 13) ❑ Camerla•styie Deal Service ❑ Children are Seated and are Given Meals ® Children Una Up and Pick Up Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11, page 21): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Center Supervisor 1 Supervise Meal Service Asst. Center Supervisor 2 Hel-'- - - 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, page 13) ® indoor Meal Service ❑ Meal Service Will Be Cancelled ❑ Other: 10. Are meals delivered to the site? . .............................................................. ID Yes ❑ No iF YES, COMPLETE ITEMS 11, 12, & 13. IF NO, FORM iS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11, pg. 21): ® Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly With Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11, page 13) ............ El Yes ❑ No if no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 13. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter Ill. page 13): ❑ Stored in a Refrigerator and Served the Next Day ❑ Returned to the Vendor for Disposal �^J Thrown Away at the Site ❑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. Q Marne of Contracting Agency C , �� ��.24-19O City of Lubbock S4-=ure--L`fficial contracting Orgarrzation Dale Name of Otf4W (please type or print) Title R_r. "Peck" McMinn MBYor-City of luhhnnk FOR DHS AFproved USE ONLY ❑ Denied; reason:. Title SiPnature—DHS Representative Texas Department of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Form 1507 / Januwy I FOR DHS USE ONLY TX I El El Name of Food Service Site Tefepflom No. (Inc. A/C) Woods Community Center 806-767-2698 Address of Site (Street, City, State, ZIP) Zenith and Erskine Lubbock, Tx. Period of Operation of Food Service (mo/day/yr—mo/dayfr) Number of Op- May 0 Jtne }uy Aug. Sept. � � � From: 6-04-90 through 8-17-90 orating flays: 0 20 21 13 Describe the geographical area served by the site: Parkway Dr. (South) Loop 289 (North) Ash Ave./Mackenzie Park (West) --See Map 1. indicate Type of Site: ❑ A. Residential Camp (serving one to four meals) ❑ B. Nonresidential Camp (serving one to four meals) 2. Site Eligibility ❑ C. Site serving primarily migrant children (serving one to four meals) H 0. Other site (serving one to two meals) Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter il, pages 1 through 6)............................................. 87.25 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 1100%) B. For enrolled sites, Form 1531 will be used to document eligibility. 3. Did the site participate in previous years' SFSP? (SFSP Handbook. Chapter, il, page 6) ...................... 0 Yes 0 No If Yes, give name of contracting organization: City of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter III, pages 8 through 10): Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews 6-04-90 1 6-04-90 6-27-9 1 6-04-90 8-17-90 5. Meal Service Period information (SFSP Handbook, Chapter It, page 13): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 50 12:00 1:30 P.M. Supplement Supper This information is considered by DHS when tetbng the approved meal service level. (SFSP Handbook, Chapter 11, page 17) 6. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter li, pages 7 and 8) self -?reparation vended [:]On Site ❑ Central Kitchen I Pglfsing School Food Authority ❑ Food Service Management Company (includes Ail Year Contracts) Form 1507 / Pegs 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, page 13) ❑ Cateteria•styie Meal Service ❑ Children are Seated and are Given Meals ❑ Children Una Up and Pick Up Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11, page 21): 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 it, page 13) ® indoor Meal Service ❑ Meal Service Will Be Cancelled ❑ Other: 10. Are meals delivered to the site? ................................................................. F Yes ❑ No IF YES, COMPLETE ITEMS 11, 12, 8t 13. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11, pg. 21): ® Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly With Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11, page 13) ............ ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until tims of service: 13. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III, page 13): ❑ Stored in a Refrigerator and Served the Next Day ❑ Returned to the Vendor for Disposal 0 Thrown Away at the Site ❑ 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. 1 know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. C ZJ ;_a of Contracting -Z ,� p City of Lubboc :>.gnature—ctidal of Contracting Organization Date None of Official (please type or print) Title �.�C. "Peck" McMinn Mayor -City of Lubbock FOR FOR ApProved ❑ D3nled; reason: DHS USE ONLY Title-- - t Signature—DHS Representative D.te TaYnx nw.-i rtrrYint Form 1507 r Jamavy 1990 of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE iNFORMATION FOR DHS USE ONLY TX I EIR ❑U Name of Food Service Site Pionpp-r Park Telephone No. (inc. A/C) N/A Park Site Address of Site (Street. City, Sate, ZIP) 6th and Period of Operation of Food Service (moldaylyr—mo/dayfyr) From: through 8-17-90 Number of Op- May June erating Days: 0 Juy Aug. Sept. 20 21 13 O0 Describe the geographical area served by the site: Broadway South University 4th St. No Ave. --See Map 1. indicate Type of Site: ❑ A. Residential Camp (serving one to four meals) ❑ B. Nonresidential Camp (serving one to four meals) 2. Site Eligibility ❑ C. Site serving primarily migrant children (serving one to tour meals) ® D. Other site (serving one to two meals) Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter 11, pages 1 through 6)............................................. 79.3 dfi 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 Elementar 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, page 6) ...................... ❑ Yes EU No If Yes, give name of contracting organization: City Of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter 111, pages 8 through 10): Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews 6-04-90 1 6-04-90/6-27-90 1 6-04-90/8-17-90 5. Meal Service Period Inforrnation (SFSP Handbook, Chapter 11, page 13): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 35 12 : 00 1: 30 P.M. Supplement Supper Tnis information is considered Der DH5 when setting the approved rneal Service te'vet. (SFSP' Handbook, Chapter 11, page 17) 6. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II, pages 7 and 8) Self�reparaeort vended 7 On Site 0 Cantrzl Kitchen J [D(Using School Food Authority ❑ Food Service (Management Company Qncludes All Year Contracts) Form 150T t P" 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, page 13) ❑ Cafeteria -style areal Service ❑ Children are Seated and are Given Meals ® Children Line Up and Pick Up Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11, page 21): 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 11, page 13) ko indoor Meal Service ❑ deal Service Will Be Cancelled ❑ Other: 10. Are meals delivered to the site?.................................................................... 0 Yes ❑ No IF YES, COMPLETE ITEMS 11, 12, 8c 13. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which %riil be used to adjust meal deliveries. (SFSP Handbook, Chap. 11, pg. 21): ❑ Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly With Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II, page 13) ............ ❑ Yes ❑ No if no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 13. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 111, page 13): ❑ Stored In a Refrigerator and Served the Next Day ❑ Returned to the Vendor for Disposal ® Thrown Away at the Site ❑ 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. 1 know that deliberate misrepresentation or withholding of information may resutt In prosecution under applicable state and federal statutes. Cf Name of Gontrxting Agency /V Z f z� lCity of Lubbock S;gnature--cmcial of contracting organization Dale Name of Ot6caal (please typo or print) Title R r I'D—pl M,M, nn —7Mayor-Ci t�Z of I tjbbnck DHs Approved Denied; reason: USE OMLYr-0R Title Signaiure—OHS ReprL-iontatw Dxe Texas 0a-Arnent of Human services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Form 1507 / Janwvy 1990 FOR DHS USE ONLY Tx ❑R ❑u Name of Food Service Site Teiephone No. (inc. A/C) Copper 806-767-2704 Address of Site (Street, City, State. ZIP) 4 Period of Operation of Food Service (mWdaylyr—mo/day" Number of Op. May June Juy Aug. Sept. From: 6-04-90 through 8-17-90 erating Days: 0 2 0 Describe the geographical area served by the site: p 34th (North) Quirt (East) 50th (South) --See Map 1. Indicate Type of Site: ❑ A. Residential Camp (serving one to four meals) ❑ B. Nonresidential Camp (serving one to four meals) 2. Site Eligibility ❑ C. Site serving primarily migrant children (serving one to four meals) ® D. Dther site (serving one to two meals) Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter 11, pages 1 through 6)............................................ 95.6 A. If non -enrolled sties, submit documentation supporting this percentage figure. For sites using school data, list the schools used to document site eligibility, as applicable: Harwell Elementar B. For enrolled sites, Form 1531 will be used to document eligibility. �b 3. Did the site participate in previous years' SFSP? (SFSP Handbook. Chapter, 11, page 6) ...................... ❑ Yes 0 No If Yes, give name of contracting organization: City of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter III, pages 8 through 10): Enter date of monitorinq review to be conducted within: A First Week of Operation B. First Four Weep of Operation C. Additional Reviews 6-04-90 1 6-04-90/6-27-90 1 6-04-90/8-17-90 5. Meal Service Period Information (SFSP Handbook, Chapter 11, page 13): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED* MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 30 1 P.M. Supplement Supper This information is considered by DHS when setting the approved meal service lever- (SFSP Handbook, Chapter 11. page 17) 6. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11, pages 7 and 8) Self -Preparation vended [:]On Site [:]Contra[ Kitchen I [using School Food AuthorltY ❑ Food Service Management Company (Includes All Year Contracts) Form 1507 f P" 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, page 13) ❑ Cafeteria -style Meal Service ❑ Children are Seated and are Given Meals ® Children Line Up and Pick Up Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II, page 21): 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 i1, page 13) U Indoor Meal Service ❑ Meal Service Will Be Cancelled ❑ Other: 10. Are meals delivered to the site?.................................................................... FX] Yes ❑ No IF YES, COMPLETE ITEMS 11, 12, & 13. iF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11, pg. 21): ® Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly Wlth Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11, page 13) ............ ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 13. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III, page 13): ❑ Stored in a Refrigerator and Served the Next Day ❑ Returned to the Vendor for D1SpoSai ® Thrown Away at the Site ❑ 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. 1 kmw that deliberate misrepresentation or withholding of Information may result in prosecution under applicable state and federal statutes. C Name of Contracting Agency --Zlv-I City S,q atur cjarof con racting Omarization Date Name of Official (please type or pnnt) Title B.C. "Peck" McMinn Mavn� City of Iuhhnck FOR DHs Approved ❑ Denied; reason: USE ONLY Title S gnature—OHS Reprosontative Date Texas Deoartrnent Form 1507 i .larkxwy 1990 of Htrtvn Services ' SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY TX I ❑R ❑U SITE INFORMATION Name of Food Service Site Teleptx" No. (inc. A/C) Burns Park N/A Park Site Address of Site (Street, City. State. ZIP) 23rd and Ave. L Lubbock Tx. Period of Operation of Food Service (moldaytyr—mo/day" Number of Op. may �uu,e �ut,y Aug. �Sopt. From: 6-04-90 through _ erating Days: Describe the geographical area served by the site: 34th S 1. indicate Type of Site: ❑ A. Residential Camp (serving one to tour meals) ❑ C. She serving primarily migrant children (serving one to tour meals) ❑ B. Nonresidential Camp (serving one to four meals) D. Other site (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, pages 1 through 6)............................................. 93.9 A. if non -enrolled sites, submit documentation supporting this percentage figure. For sites using school data, list the schoots 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 .-_t Chapter, II, page 6) ...................... LYes 0 No If Yes, give name of contracting organization: Ci tx of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter III, pages 8 through 10): Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews 6-04-90 1 6-04-90/6-27-90 1 6-04-90/8-17-90 5. Meal Service Period Infom-tation (SFSP Handbook Chapter 11, page 13): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 100 P.M. Supplement Supper • This information is considered by OHS wtwn setting the appmved meal service level (SFSP Handbook. Chapter 11, page 17) 6. Method of Food Preparation by Contractina Omanization (SFSP Handbook. Chapter 11. paaes 7 and 8) SelfPreparanort vended [:]On Site ❑ Central Kitchen I E Using School Food Authority ❑ Food Service Management Company (Includes All Year Contracts) r Form 15071 Pe" 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, page 13) ❑ CaXlerfa-style Meal Service L^_a Children Line Up and Pick Up Meals ❑ Children are Seated and are Given Meals ❑ Othec 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11, page 21): TITLE OF POSITION NO. iN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES —Center Asst. Center Supervisor 2 Help To Serve.Meals J.T.P:A. Worker 2 Help To Serve Meals 9. Indicate what provisions will btte,, made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11, page 13) Elindoor meal service [DMeal Service Will Be Cancelled ❑ Other: 10. Are meals delivered to the site?.................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 11, 12, do 13. IF NO, FORM iS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II, pg. 21): ® Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor . ❑ Site Personnel Will Communicate Directly With Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II, page 13) ............ F Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meats until time of service: 13. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 111, page 13): ❑ Stored in a Refrigerator and Served the Next Day ❑ Returned to the Vendor for Disposal IX IQ thrown Away at the Site ❑ 01her. I CERTIFY that the information on this form Is true and correct to the best of my knowledge. 1 certify that this site has been visited and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of Contracting Agency City of --boc k Snrulum_of8cial of contracting Organization Dale Name of offiaal (ploase type or print) Title _C_ "PPck" McMinn Mayor -City of Lubbock FOR OHS Approved USE ONLY ❑ Denied; reason: Tdle SigruWre—DHS Representative Date Texas Department of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SiTE INFORMATION Form 1507 / January 19W FOR DHS USE ONLY TX ❑R ❑U Name of Food Service Site Telephone No. (inc. A/C) Ca,lp Park N/A Park Site - Address of Site (Street. City, Stale, ZIP) 26th and Ave W Lubbork Ix Period of Operation of Food Service (moldayiyr—mWday/yr) Number of Op- +Mao �J �Juy Aug�Se�O From: 6_ _ through 8-17-90 erating Days: 4 20 21 13 Descnbe the geographical area served by the site: 34th (South) University Ave (West) 19th (North) Ave Q. (East) --See Map 1. Indicate Type of Site: ❑ A. Residential Camp (serving one to four meals) ❑ B. Nonresidential Camp (serving one to four meals) 2. Site Eligibility ❑ C. Site serving primarily migrant children (serving one to four meals) ® D. Dther site (serving one to two meals) Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter 11, pages 1 through 6)............................................. 90.5 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: Dupre 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, page 6) ...................... ❑ Yes 0 No If Yes, give name of contracting organization: City of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter Ill, pages 8 through 10): Enter date of monitorinq review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews 6-04-90 1 6-04-90/6-27-90 1 6-04-90/8-17-90 5. Meal Service Period Information (SFSP Handbook, Chapter 11, page 13): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 100 1 P.M. Supplement FSupper Thrs rntormation rs considered try oKs wren senng the approved meal servroe revel. (Z I sP Handbook. Utkipfer 11, page 17) 6. Method of Food Preparation by Contractinq Organization (SFSP Handbook, Chapter it, pages 7 and 8) Self-Preparabon vended [:]on Site ❑ Contral kitchen I EUsing School Food AuthorltY ❑ Food Service Manage=nt Company (Inciudes All Year Contracts) Form 1 SOT / Peggy 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, page 13) ❑ Cafeteria•styie Meal Service ❑ Children are Seated and are Given Meals ® Children Una Up and Pick Up Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11, page 21): 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 it, page 13) ❑ Indoor Meal Service ® Meal Service WIII Be Cancelled ❑ Other: 10. Are meals delivered to the site?.................................................................... ❑ Yes ❑ No IF YES, COMPLETE ITEMS 11, 12, dr 13. iF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11, pg. 21): ® Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly With Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11, page 13) ............ ❑i( Yes ❑ No if no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 13. if there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter Ill, page 13): ❑ Stored In a Refrigerator and Served the Next Day ❑ Returned to the Vendor for Disposal R Thrown Away at the Site ❑ Other. t 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. 1 know that deliberate misrepresentation or withholding of Information may result in prosecution under applicable state and federal statutes. C Name of Contracting Agen • C . &/ `� cy _.Zlo- D Ci t of Lubbock Signature—c-mcial of Contracting Organization Care Name of Officja{ (please type or print) Title _R-C. "Puck" McMinn Mayor -City of Lubbock , r-0fl Fro ApPmved ❑ Denlod; reason: USE ONLY Title i Sgnature—DHS Representative Date Texas Deoariment Form 1507 I January 1990 of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY TX I ❑ R ❑ u SiTE INFORMATION Name of Food Service Site Teiephone No. (inc. A/C) Rodgers Community Center 806-767-2702 Address of Site (Street, city, State, ZIP) 3200 Amherst Lubbock, Tx. Period of Operation of Food Service (molday/yr—molday/yr) Number of Op- fray June Juy Aug. Sept. Frorr16-04-90 through 8-17-90 orating Days: 0 20 21 13 0 Describe the geographical area served by the site: W ' "N r h University (Fa,;t)_ See Ma 1. indicate Type of Site: ❑ A. Residential Camp (serving one to four meals) ❑ B. Nonresidential Camp (serving one to four meals) 2. Site Eligibility ❑ C. Site serving primarily migrant children (serving one to four meals) 51 D. Other site (serving one to two meals) Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II, pages 1 through 6)............................................. 69.15 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 (85.4%) Tubbs Elementar= e(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, page 6) ............ . ......... �J Yes 0 No If Yes, give name of contracting organization: City of Lubbock 4. Monitoring Plan (SFSP Handbook, Chapter 111, pages 8 through 10): Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weeks of Operation C. Additional Reviews 6-04-90/6-27-90 1 6-04-90/6-27-90 5. Meal Service Period Information (SFSP Handbook, Chapter II, page 13): TYPES OF ?.TEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVILE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch .75 12:00 1:30 P.M. Supplement Supper - This rntomzation is cons dered Dy UH5 when BetUng the approved meal 9emce revel. (JFSF Handbook chapter 11, page 17) 6. Method of Food Preparation by Contractinq Orqanization (SFSP Handbook, Chapter 11, pages 7 and 8) Self-P re pa rnton Vended [:]on Site []Contra] Kitchen I [Dl!sing School Food Authorlty ❑ Food Service Managernent Company (Includes All Year Contracts) Form 1 SOT I Pam 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, page 13) ❑ Cateleria.style Meal Service ❑ Children Une Up and Pick Up Meals ❑ Children are Seated and are 61ven Meals ❑ Mer. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11, page 21): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGR" DUTIES Center Sdpery isor 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 11, page 13) ® Indoor Meal Service ❑ Meal Service WIN Be Cancelled ❑ Other: 10. Are meals delivered to the site?.................................................................... FX1 Yes ❑ No iF YES, COMPLETE ITEMS 11, 12, & 13. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11, pg. 21): 2 Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly With Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11, page 13) ............ ® Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service: 13. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter ill, page 13): ❑ Stored in a Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to the Vendor for Disposal ❑ Other. 1 CERTIFY that the Information on this form is true and correct to the best of my knowledge. t 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. Q Name of Contracting Agency Signature—omdal of contracting Organization Dale Name of Official (please type or print) Title kl- PA;- Mavnr_(ity of I iihhnrk FOR DHS 0Approver ❑Denied; reason: USE ONLY Title i Signature —OHS Representative Date Texas Department of Hurnan Servicee Form 1507 / Jartuxry 1990 0"2221rD IT CrDCr1D r`Uir nnam F(Xi n}IC [Mr r3N1 V ' SITE INFORMATION TXr� R 0U Name of Food Service Site Tetephom No. (inc. A/C) N/A Park Site Address of Site (Street, Gty, State, ZIP) 27th and I Tx Period of Operation of Food Service (mWdayryr—mo/day" Number of Op- May June July Aug. Sept. From: 6-04-90 through 8-17-90 erating Days: 20 2, Describe the geographical area served by the site: 34th South Ave. A West Southeast Drive (East) --See Ma 1. Indicate Type of Site: ❑ A. Res►dential Camp (serving one to four meals) ❑ C. Site serving primarily migrant children (serving one to four meals) MV ❑ B. Nonresidential Camp (serving one to four meals) Ina D. Other site (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 11, pages 1 through 6)............................................. 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: 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, page 6) ...................... ❑ Yes 0 No If Yes, give name of contracting organization: Ci ty of I uhhnck 4. Monitoring Plan (SFSP Handbook, Chapter 111, pages 8 through 10): Enter date of monitoring review to be conducted within: A. First Week of Operation B. First Four Weep of Operation C. Additional Reviews 6-04-90 1 6-4-90/6-27-90 1 6-04-90/8-17-90 5. Meal Service Period Information (SFSP Handbook, Chapter 11, page 13): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 40 1 1:30 P.M. Supplement Supper - i nis intorrnation is consioweo oy uHts wnon setting the approvea meat service eawr. for -St✓ Hanatwok, c nap(er tt. page 17) 6. Method of Food Preparation by Contractinq Organization (SFSP Handbook, Chapter 11, pages 7 and 8) Self -Preparation Veenoed 0 On Site ❑ Central Kitchen i EaUsing School Food Authority ❑ Food Service Managerrsant Company (Includes All Year Contrarzs) r Form 1507 1 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, page 13) ❑ Cawerla-style Meal Service ❑ Children Una Up and Pick Up Meals ❑ Children are Seated and are Given Meals ❑ Other. 8. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter 11, page 21): TITLE OF POSITION NO. IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES 'Center Suppryispr 1 Supervisor 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 11, page 13) ❑ Indoor Meal Service Q Meal Service Will Be Cancelled ❑ Other: 10. Are meals delivered to the site?.................................................................... ® Yes ❑ No IF YES, COMPLETE ITEMS 11, 12, & 13. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 11. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. 11, pg. 21): 9 Site Personnel Will Contact Admin. Staff, Who Will Contact Vendor ❑ Site Personnel Will Communicate Directly With Vendor 12. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II, page 13) ............ ❑ Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until tims of service: 13. if there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter Ill, page 13): ❑ Stored in a Refrigerator and Served the Next Day ❑ Returned to the Vendor for Disposal © Thrown Away at the Site ❑ other. 1 CERTIFY that the Information on this form is true and correct to the best of my knowledge. 1 certify that this site has been visited and that It has the capability and facilities for the meal service planned for the number of children anticipated. 1 know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. C — Name of Contracting Agency ,� ,alp— a City of -ubbock s;pnature—c!ficia7 of 6ontracting oFgan nation Dale Name of Official (please type or print) Title _B.C. "Perk" McMinn Mayor- City of Lubbock FOR OHS Approved ❑Denied; 'Eason: USE ONLY Title Signature—I)HS Reprosentaliw D:de Texas Department Form 45 of Human Services September 19 CERTIFICATE OF AUTHORITY This is to certify that Name of Authorized Official (please type or print) Title Kav Stiner Superintendent of Indoor Recreation V nature —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 agreements with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agree- ments, and to present claims for reimbursement, when appropriate, to the department. 190 Signature—Officlai of Contracting Agency Date Name of Official (please type or print) Title R. C. McMinn I Mayor FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: Agreement No. Received By: Date TX- FORM 4508 Instructions PURPOSE To identify the official designated by con- tracting organization staff to act on behalf of the organization and to record the representa- tive's signature. PROCEDURE When to Prepare Contracting organization staff completes Form 4508 when applying for participation in a food program and when designating a new authorized representative. Number of Copies Contracting organization staff prepares an original and one copy. Transmittal Contracting organization staff sends both copies to Food Services Division, P.O. Box 2960 (mail code 520-W), Austin, Texas 78769. When approved, Food Services Divi- sion staff returns one copy to the contracting organization. How to Obtain Copies Order copies of Form 4508 from Food Ser- vices Division in DHS. Form Retention Contracting organizations must keep Form 4508 for three years and 90 days from the end of the contract period. DHS staff must retain records for three years and 90 days from the date of submission of the final Financial Status Report (Standard Form 269). Exception: If audit findings, claims, or litiga- tion have not been resolved, all forms and records must be retained beyond the required time period until all issues are resolved. DETAILED INSTRUCTIONS Name of Authorized Official/Title — Type or print the name of the official who will rep- resent the contracting organization by signing correspondence and filing reports and claims CERTIFICATE OF AUTHORITY for reimbursement with DHS. Type or print the person's title, such as executive director, principal, center director, or food director. Three officials may be authorized to repre- sent the contracting organization. A separate Form 4508 is required for each official autho- rized. Note: If the official is replacing some- one already authorized, contracting organization staff must notify Food Services Division staff of the name to be deleted. Signature — The person being authorized to represent the contracting organization must sign this form exactly as he will sign the doc- uments and claims for reimbursement. Name of Contracting Organization/ Address — Type or print the name of the contracting organization that holds the tax- exempt status and has the ultimate legal responsibility for the agreement with DHS. Include the address (street, P.O. box, city, state, and ZIP code). This name and address must be identical to those on the Application for Vendor Identification Number filed with the Texas Comptroller of Public Accounts. Signature — Official of Contracting Agency/Title — The official of the contract- ing organization must sign the form. This offi- cial must be the chief officer of the governing body such as chairman of the board of direc- tors, mayor, owner, pastor, etc. He may des- ignate himself as the authorized representative. Type or print the name and title of this official in the spaces below the signature. For Texas Department of Human Services Use Only — The Food Services Division staff • enters the agreement number assigned to the contracting organization, and • signs and dates the form after reviewing the information. Ia SUMMER FOOD SERVICE PROGRAM AGREEMENT - I STATE OF TEXAS § COUNTY OF TRAVIS § The Texas Department of Human Services, hereinafter referred to as -DHS, AND The City of Lubbock P.O. Box 2000 Lubbock, Texas 79457 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. II. CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT i 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 andto audit, examine, and copy records at any reasonable time. This includes access to all records of costs paid, even in part, by DHS. IV. CIVIL 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 LUIM 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,o.r,Type) Original signature of the authorized representative of the contracting organization B. C. McMinn Name Mayor Title Please print or type, in the spaces provided above, the name. and title of the authorized representative signing this agreement on behalf of the contracting organization. TEXAS DEPARTMENT OF HUMAN SERVICES. Effective Dates: .through_. By: r - assistance from the DHS and USDA: and hereby gives assurance that it will immediately take ! any measures necessary to effectuate this agreement. 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. W CERTIFICATION The contractor agrees to comply with the requirements of the Immigration Reform and Control Act of 1986 regarding employment verification and retention of verification forms for any-individuals'hired after November 6, 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. D Ham Sandwich A Orange Juice Y Fruit Cocktail Vanilla Wafers 1 Milk D Poor Boy Sandwich A Lettuce/Tomato Y Orange Cookie 2 Milk D Peanut Butter & Jelly A Cheese Stick Y Carrot & Celery Sticks Applesauce 3 Milk D Turkey Sandwich A Cole Slaw Y Jello w/ Peaches 4 Milk D Bologna and Cheese A Fruit Drink Y Pineapple Chunks Brownie 5 Milk D Tuna Fish Sandwich A Macaroni Salad Y Diced Pears Cookie 6 Milk D A Y 7 Submarine Sandwich Lettuce/Tomato Jello w/ fruit Apple Milk D Ham and Cheese Sandwich A Potato Salad Y Fruit Cocktail Sliced Pickles 8 Milk D Roast Beef Sanwich A Carrot Sticks Y Diced Peaches Cookie 9 Milk D Salami and Cheese Sandwich A Cole Slaw Y Orange Cookie 10 Milk D Turkey and Cheese Sandwich A Celery Sticks Y Pineapple Chunks Brownie 11 Milk Texas Department Form I-rWAttachmant A of Haman senxes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN Jamw' 19% 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 camp sessions, specify the projected number of children by site and date of session: SITE (name of site, school, camp, eto.y AMERICAN INDIAN ALASKAN NATIVE ASIAw ISU1N ED FIC BLACK HISPANIC WHITE Rodgers,Community Center #5 5 - 21 63 1,329 1,624 Rawlings Community Center #39 3 - 3 34 814 699 Simmon Community Center #116 #80 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 (.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 � 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 � No If yes, give details including dates, names, and results: 11. REHABILITATION ACT OF 1973 (Section 504) A. Does the contracting organization have any policies, practices, or architectural barriers that limit, deny, or discourage participation in the program or employment by the contracting organization because of disability?........ U Yes ❑ No Ityes, explain: Some park/playground sites are not handicap accessible. At these sites, staff will assist handicap participants. Form 1506 1 Attachmwit A Pape 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 T itte Scott Snider, 504 Coordinator Golf Supervisor 767-2442 2. Has the organization established grievance procedures that incorporate appropriate due processstandards?.....................................................................� Yes ❑ No If yes, do these procedures provide for the prompt and equitable resolution of complaints that allege an action prohibited by Section S(A of the Rehabilitation Act of 1973? ................. ® Yes ❑ No 3. Has the contracting organization infommd 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. 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? ........... 0 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 ofdisability?.................................................................................� 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 noncompliance 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. Non-discrimination has not been found within the City of Lubbock. Texas Department Forth 15MAttschnient A of Human seneces SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CIVIL RIGHTS QUESTIONNAIRE I. CIVIL RIGHTS ACT OF 1964 A. 1. Estimate, by racial/ethnic group, the number of children that will participate in the program at each site. If the program consists of several camp sessions, specify the projected number of children by site and date of session: SITE (nartr of *Its, school, camp, ate.) AMERICAN INDIAN ALASKAN NATIVE ASiAw PACIFIC ACT ISLANDER BLACK HISPANIC WHRE Yellowhouse Canyon Neighborhood #118 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 (.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 � 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 newspapeIE 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 FD No If yes, give details including dates, names, and results: Il. REHABILITATION ACT OF 1973 (Section 504) A. Does the contracting organization have any policies, practices, or architectural barriers that limit, deny, or discourage participation in the program or employment by the contracting organization because of disability? ........ 0 Yes ❑ No If yes, explain: Some park/playground sites are not handicap accessible. At these sites, staff will assist handicap participants. Form 15061 Attachmem A Pape 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 Scott Snider, 504 Coordinator Golf Supervisor 767-2442 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 i nformation is 6 b 1 ished in the Parks and Recreation Leisure three times annually. 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? ........... El 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?.......................................................E]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. Non-discrimination has not been found within the City of Lubbock. Texas Deparlff*M Forth 15=Att*ctwmnt A of Hurnan Serfces SUMMER FOOD SERVICE PROGRAM FOR CHILDREN JaJ"uwy 19W CIVIL RIGHTS QUESTIONNAIRE I. CIVIL RIGHTS ACT OF 1964 A. 1. Estimate, by racial/ethnic group, the number of children that will participate in the program at each site. If the program consists of several camp sessions, specify the projected number of children by site and date of session: SITE (nary» of site, school, camp, 91c.) AMERICAN INDIAN ALASKAN NATIVE ASIAW PAaFlC ISLANDER BLACK HISPANIC WHrTE Mahon School #54 3 - 1 140 915 652 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. 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 M 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 newspaper 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 El No If yes, give details including dates, names, and results: Ill. REHABILITATION ACT OF 1973 (Section 504) A. Does the contracting organization have any policies, practices, or architectural barriers that limit, deny, or a ❑ 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 1506 / Attachment A Pape 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 Scott Snider, 504 Coordinator Golf Supervisor 767-2442 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 0No 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: She Sec ti on 504 i nformati on i s pub1 i shed in the Parks and Recreation Leisure three times annually. 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? ........... LJ 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 ofdisability?...................................................................................'Al 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 Nyes,explain: There is no policy in this regard; however the Personnel Department would work to correct any problems. Non-discrimination has not been found within the City of Lubbock. Page 2 of CITY OF LUBBOCK GRANT PROPOSAL EVALUATION FORM INSTRUCTIONS: 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 the 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 4 through August 17 in four community center sites (Rodgers, 3200 Amherst; Rawlings, 40 & Ave B; Simmons, 23 & Oak; Woods, Zenith & Erskine) and eight CDBG funded playground sites (Burns, 23 & Ave K; Carlisle, 28 & X; Pioneer, 6 & Ave T; Hollins, 1 & Temple; Chatman, E. 29 & Juniper; Carter, Globe & N. Loop 289; Yellowhouse Canyon, E. 61 & Olive; Mahon Elementary, 2010 Cornell) Monday through Friday. The program will provide an alter-. native meal opportunity for low income and latch key children in identified City neighborhoods. It is anticipated that an average of 710 meals will be (continue on attached sheet) A. Is this the fulfillment of an identifiable community (Lubbock) goal? If so,'list the source -of the identified goal. Council Goals - 1990/Top Priority-1.(D) Redevelopment of Overton Area - Pioneer Park is one of the selected sites. High priority - 6. (A,B,D) Expand recruitment and Outreach programs to Encourage Minorities in City dmployment, Create Programs to Encourage. Minority Management Capacity, Continue and Enhance all employee -and staff development - This program in association wity the CDBG Summer Satellite Program hires summer employees. Of the eight employees hires last summer, five were from minority groups. The implementation and administration of the program is handled by these minority employees, and their supervisors (three of four who are minority) and all facets of the program will enhance employee and staff development. �continued on attach d heelt) . Is this the ful il�ment 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 1980, during the last City of Lubbock sponsored Summer Lunch Program, the same four community centers identified for this program served 300 meals daily. Staff anticipates the same if not larger participation in their neighborhoods. At the -four Summer Satellite Playgrounds existing last summer, over seven thousand (7,000) children attended over the course of the summer. Staff expects a high percentage of those who participate in the playground program to also parti.cipate in the Summer Lunch Program. According to Lubbock I.S.D., over 5,300 of the children living in neighbor- hoods served by the lunch program, are receiving free and reduced lunches in school. The school lunch has the same goals relating to health, child- care, and public service, as the Summer Lunch Program. A25-2 Grant Proposal Evaluation Form City of Lubbock April 12, 1990 Page 2 of 8 continuation 1. 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. IA. Moderate Priority - 8(B) Finish and Continue Current Work Program - Last summer through the approval of the CDBG Summer Satellite Program, the Council supported more direct human service programming. With the approval of doubling this summer's program, the Council is reaffirming this direction. The Summer Lunch Program continues the work involved with this trend in providing direct human services for those children participating in the program. Alliance for the 90's - Lubbock Needs Assessment 1988 - Volume I Ranked third among the general population and key citizens was the protective services of children. (page 23) "By percentage, respondents indicating "Need More" services ranked protective services for children as highest with 74% of the General Population perceiving that increase in such services as needed. In the Key Citizen group, 70% listed after -school care as a program requireing more services, (page 24). Summer child care is to Parks and Recreation the same need as after school care, and this is the focus of the lunch program. The Needs Assessment broke down this perceived need along ethnic lines, 73% Black, 66% Hispanic, and 58% Anglo perceiving this need for more children and child related services. Likewise, 74% of the general population believed that this (child protection) was the number one need in terms of more programs. Page 3 of 2. List at 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 nutrious noon.meals to youth ages 1 - 18 years old, June 4 through August 17. (b) An average of 710 nutrious meals will be served daily. (c) Was a staff of twenty-four (24) supervisory staff with volunteer and JTPA personnel will be used to supervise and distribute the meals. 3. 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. 4. Are other agencies (other than the City of Lubbock) available to administer this program? If so, list the agencies: Yes, Lubbock I.S.D. is another capable agency which did administer 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 cafeteris setting. A25-3 Page 4 of E 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) for providing this program. The Texas Department of Human Services, which provides the grant, is encouraging the City of Lubbock to provide this program and is pledging its support. 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 A25-4 Page 5 of f 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 fundswill 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 operzting 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. No capital outlay will be funded through this grant. 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. In`1980, after over three years of providing this program, the decision was made to discontinue the program in Lubbock. normally this program is provided on an annual basis and the funds are available. A25-5 Page 6 of 8 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 expend 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 one time grant with an option to renew. The City of Lubbock has not participated since the summer of 1980, and 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, $.1475 is paid for administrative expenses - the more meals served, the more administrative costs recovered. All direct costs are reim- bursed. A25-6 Page 7 of E 11. Are grant audit costs reimbursed by the grant? Yes, audit costs are reimbursed by the grant, if enough administrative reimbursements are secured. 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. Administravie 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 .85 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 4.2 man years of employment if the scope of the program remains the same for its duration. A25-7 Page 8 of 8 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 1/2 time clerk, purchase desk, capital project construction, etc.). Attach additional sheets if necessary. FOR GRANT FISCAL YEAR (From 1989 to 1990 ): 19 90 19 91 19 92 19 93 1994 R e v e n u e s I,c tZt _tj u�-ty,419,,440 Federal Grant A��,35i State Grant (L'r }"` $77,351 Local MatchqVww`0�''�' Sq Other `120 -7u� du $77,351 $77,351 $77,351 $77,351 *Total Revenues $77,351 $77,351 $77,351 $773,351 $77,351 Operating Costs - $1.87 X 710 meals/day X 54 days = $71,695 Administrative costs - $.1475 X 710 meals/day X 54 days = $5,656 TOTAL $77,351 FOR GRANT FISCAL YEAR (From 1989 to 1990 ): 19 90 19 91 Expenditures Personnel $23,937 $23,937 Admin. Staff, Site Supervisors Supplies $2,256 $2,256 Maintenance 0 0 Other Charges $55,766 $55,766 LISD Food Caterer, Contractual Program Monitor Audit Capital Outlay 0 0 Fee Capital Project 0 0 19 92 19 93 19 94 $23,937 $23,937 $235937 $25256 $2,256 $2,256 0 0 0 $55,766 $55,766 $55,766 0 0 0 0 0 0 ** Total Expenditures $81,959 $81,959 $81,959 $81,959 $81,959 *Based on 710 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 per- A25-8 sonnel . This grant will reimburse all direct Avnnnco�ccnr atnrl ,i th tho nrnnram OPERATIONAL COSTS BUDGET Eight (8) Playground Sites Eight (8) sites X Two (2) s-ites X 1.5 hours/day X 54 days X $4.32 @ hour = $5,599 Playground Back-ups Staff 8 sites X 1 site X 1.5 hours/day X 54 days X $4.32 @ hour = $2,799 Training 8 sites X 2 sites X 2 hours X $4.32 @ hour = $138 12 miles a day X 4 supervisors X 54 days X $.25/mile = $1,306 Four (4) Community Center Staff Food Four (4) sites X 1.5 hours/day X 54 days X $5.04 @ hour = $1,633 One (1) site X 1.5 hours/day X 54 days X $13.16 (Olevia) = $1,066 One (1) site X 1.5 hours/day X 54 days X $12.07 (Doris) = $978 One (1) site X 1.5 hours/day X 54 days X $13.70 (Susie) = $1,110 One (1) site X 1.5 hours/day X 54 days X $9.53 (Larry) _ $772 Community Center Back-up Four (4) sites X 1.5 X 54 days X $5.04 @ hour = $1,633 Training 4 X 2 hours X $5.04 = $40 + hourly ($13.16 + $13.70 + $12.07 + 9.53) X 2 = $97/$137 Part -Time Fringe $ 111,842 X .076255 = 902 Full -Time Fringe $ 4,032 X .25 fringe = $1,006/$1,908 710 meals/day X $1.35/meal X 54 days = $51,759 Non -Food 2 card tables X $45/tables X 8 sites = $640 1 hose X 12 sites X $25 = $300 brooms X 12 sites X $10 = $120 dust pans X 12 sites X $14 = $48 plastic bags 2/day X 54 X 12 sites X $.50 = $648 1,756 ADMINISTRATION Food Monitor $6.00/hour X 8 hours/day X 59 days = $2,832 (no fringe contract) mileage .25 X 1,700 mi. = $425 Program Director (Kay) $18.89/hour X 2 hours/day X 59 days = $2,229 Bookkeeper (Paula) $7.77/hour X 2 hours/day X 59 days = $917 TOTAL $3,143 $3,143 X .25 for fringe = $787 $787 fringe X .2277 (Cost allocation) = $179 $3,143 X .2277 (cost allocation plan) = $716 LUBBOCK INDEPENDENT SCHOOL DISTRICT !`'larch 30, 1990 Ms. Kay Stlner City of Lubbock Parks and Recreation Department 'ubbock v TX 79408 Dear Ms. Stiner: In connection with the Summer Feeding Program for Children to be operated from various Community Centers and City Parks the following are the schools and their enrollments and :iLmtber of students approved for free and reduced price meals: Feeding Site Rawlings C.C. Mae Simmons C.C_ George Woods C.C. George Woods C.C. Rodgers C.C. Rodgers C.C. Chatman Park Yeilowhouse Canyon Neighborhood Pioneer Part: Burns Park: Carlisle Park :tarter Park. Mahon Playground Hollins Park %t4umber Approved Free & Reduced School Enrollment Price Meals Harwell Elem. 553 529 95_6 Posey Elem. 421 243 57.7 Hunt Elem. 400 298 74.5 Parkway Elem. 364 395 10k'J- McWhorter Elem. `�+.'� 504 e5.'4 Tubbs Elem. 542 2e7 52.9 !Wheatley Elem. 333 229 5'-; .5 Wheatley Elect. 412 20e 5FD.5 Ramirez Elem. 9112 649 79.._ Bean Elem. 761 715 Dupre Elem. 372 337 90.5 Arnett Elem. 246 229 93.0 Mahon Elem. 252 120 51.5 Jackson E1em. 54r�! 562 100 Please find enclosed a cop', Cif "Summer Feeding --'even Day Menu Scheduie1e. We trust this is the information needed. Darwin Hilliard Executive Director-Purchasing/Contract Services MIKE MOSES, ED.D., SUPERINTENDENT ADMINISTRATIVE OFFICES: 1628 19TH STREET, LUBBOCK, TEXAS 79401-4895 TELEPHONE 806/766-1000 (FAX 806/766-1037)