HomeMy WebLinkAboutResolution - 2002-R0198 - Contract For Summer Lunch Program - Department Of Human Services - 05_23_2002Resolution No. 2002-RO198
Nay 23, 2002
Item No. 31
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to execute for and on behalf of the City of Lubbock, a contract for a summer
lunch program, by and between the City of Lubbock and the Department of Human
Services, and all related documents. Said Contract is attached hereto and incorporated
in this resolution as if fully set forth herein and shall be included in the minutes of the
City Council.
Passed by the City Council this 23rd day of May , 2002.
ATTEST:
-Qd:�o 4 "C , 1�—� 5-
Rebecca Garza, City Secretary
APPROV CONTENT:
Ran4 Tru dell
Director of Parks and Recreation
APPROVED AS TO FORM:
William de Haas
Contract Manager/Attorney
BDHIO/Summer Lunch Program.2002.res
May 14. 2002
Resolution No. 2002-RO198
TEXAS DEPARTMENT OF HUMAN SERVICES May 23, 2002
SPECIAL NUTRITION PROGRAMS Item No. 31
AGREEMENT
STATE OF TEXAS §
COUNTY OF TRAVIS §
The Texas Department of Human Services, hereinafter referred to as TDHS,
010-01,
City of Lubbock
hereinafter referred to as the Contractor, do hereby make and enter into this contract, as required by the National School Lunch
Act and the Child Nutrition Act, as amended, and the following program regulations: the National School Lunch Program
(NSLP), 7 Code of Federal Regulations (CFR) fart 210; the Special Milk Program (SMP), 7 CFR Part 215; the School
Breakfast Program (SBP), 7 CFR Part 220; the Summer Food Service Program (SFSP), 7 CFR Part 225; and the Child and
Adult Care Food Program (CACFP) 7 CFR Part 226.
This agreement establishes or continues the rights and responsibilities of TDHS and the Contractor pursuant to the Contractor's
participation in one or more of the above named programs as stipulated herein. If this agreement continues an existing
agreement, all existing terms, conditions, liabilities and obligations of the parties under the prior agreement remain in full force
and effect, except to the extent that those terms, conditions, liabilities and obligations conflict with this agreement, in which
case this agreement takes precedence.
By signing this agreement, both parties are bound by its terms and conditions from its beginning effective date, or the beginning
effective date of any prior agreement/s continued by this agreement, until terminated in accordance with this agreement.
I.
MUTUAL AGREEMENTS
The Parties mutually agree:
A. Ifthe Contractor fails to provide services in accordance with the provisions of this contract, TDHS may, upon written notice
of default to the Contractor, immediately terminate the whole or any part of this contract, including refusal to pay claims
for reimbursement, and such termination shall not be an exclusive remedy but shall be in addition to any other rights and
remedies provided by law or under this contract. -
B. If federal or state laws or other requirements are amended or judicially interpreted so that the continued fulfillment of this
contract, on the part of either party, is substantially unreasonable or impossible, or if the parties are unable to agree upon
any amendment which would therefore be needed to enable the substantial continuation of the services contemplated by
this contract then, the parties shall be discharged from any further obligations created under the terms of this contract,
except for the equitable settlement of the respective accrued interest or obligations, including audit findings, incurred up
to the date of termination.
C. This contract may be canceled by mutual consent. However, if such mutual consent cannot be attained, then and in that
event, eitherparty to this contract may consider it to be canceled without cause by giving thirty `(30) days notice in writing
to the other party and this contract shall thereupon be canceled upon the expiration of such thirty (30) day period. Nothing
in this paragraph shall be construed to prohibit immediate cancellation pursuant above paragraphs A and/or B.
F.,,,...... ...n.jM
H.
CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT
A. The Contractor will comply with the applicable regulations for its designated program, as well as 7 CFR Parts 245 and 250,
as amended, the Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), Audits of State, Local
Governments, and Non -Profit Organizations (7 CFR 3052, as amended)and state policies and procedures as issued and
amended by TDHS. The Contractor further agrees to perform as described in its application (including its Policy statement
and supporting documents, and approved amendments tp the application) for participation in the designated program.
B. The Contractor accepts final administrative and financial responsibility for food service operations in each school, summer
feeding site, and child and/or adult care facility, hereinafter referred to as a site, operated or sponsored by the Contractor.
The responsibility includes any audit exceptions or payment deficiency in the program covered by this contract, and all
subcontracts hereunder, which are found after monitoring or auditing by TDHS or USDA and will be responsible for the
collections and payback of any amount paid in excess of the proper claim amount.
C. The Contractor submits for TDHS approval only those applications for sites which have delegated the authority for the
administration of food service operations to the Contractor or which have executed subagreements with the Contractor for
the administration of food services operations.
D. Contractors participating in the NSLP agree
1. that the official signing the Claim for Reimbursement will be responsible for reviewing and analyzing meal
counts to ensure accuracy and compliance with federal regulations
2. to enter into an agreement to receive donated foods as required by federal regulations, and
3. to price lunch as a unit
E. Contractors participating in the CACFP provide or accept responsibility for the provision of organized, non-residential child
day care and will immediately report to The Texas Department of Protective and Regulatory Services (TDPRS) Licensing
or Child Protective Services staff, any suspected violations of TDPRS Licensing standards or suspected abuse of children
in sponsored centers or day homes.
M.
RECORD KEEPING
A. The Contractor will keep financial and supporting documents, statistical records, and any other records pertinent to the
services for which a claim was submitted in the manner and detail prescribed by TDHS. The records and documents will
be kept for a minimum of 3 years and 90 days after the termination of the federal fiscal year for the relevant program. If
any litigation, claim, or audit involving these records begins before such period expires, the Contractor will keep the records
and documents for not less than 3 years and 90 days and until all litigation, claims or audit findings are resolved. The case
is considered resolved when there is a final order issued in litigation, or a written agreement is entered into between TDHS
and the Contractor. The Contractor will keep records of non -expendable property acquired under the contract for 3 years
and 90 days after final disposition of the property.
B. The Contractor and its subcontractors will allow TDHS and USDA officials and other appropriate officials determined by
TDHS to inspect facilities and records and to audit, examine, and copy records at any reasonable time. This includes access
tb all records of costs paid, even in part, by TDHS.
C. The Contractor and its subcontractors will establish a method to secure the confidentiality of records and other information
relating to clients in accordance with the applicable federal law, rules, and regulations, as well as the applicable state law .
and regulations. The provision shall not be construed as limiting the Department's right of access to recipient case records
or other information relating to clients served under this contract.
D The Contractor certifies that the goods and/or service(s) covered by this contract are designated to be used prior to, during,
and after calendar year 2000 AD. The goods and/or service(s) will be operated during such time periods without error
relating to date which represents different centuries or more than one century.
IV.
CIVIL RIGHTS POLICY COiMPLLk CE
A. T nn e Contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (Public Law 88-352) and all requircments
imposed by the regulations of the Department of Agriculture (7 CFR Part I5), Department of Justice (28 CFR Pars 42 and
50) and FNS directives or regulations issued pursuant to that act and the regulations. Section 504 of the Rehabilitation Act
of 1973 (Public Law 93-112), the Americans with Disabilities Act of 1990 (Public Law 101-336), Title IX of the Education
Amendments of 1972 (7 CFR Part 15a), the Age Discrimination Act of 1975 (Public Law 94-135), and all amendments
to each, and all requirements imposed by the regulations issued pursuant to these acts. In addition the contractor agrees
to comply with Title 40, Chapter 73, of the Texas Administrative Code. These provide in part that no person in the United
States shaII, on the ground of race, color, national origin, sex, age, disability, political beliefs, or religion be excluded from
participation in, or denied any aid, care, service or other benefits provided by federal and/or state funding, or otherwise be
subjected to discrimination. The contractor also agrees to comply with Health and Safety Code Section 85.113 (relating
to workplace and confidentiality guidelines regarding AIDS and HIV).
The contractor 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 funds, reimbursable expenditures, grant or donation of federal property and interest in 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 fumishing
of services to the recipient, or any improvements made with federal financial assistance extended to the program applicant
by the TDHS. This includes any federal agreement, arrangement, or other contract which has as one of its purposes the
provision of cash assistance for the purchase of food, and cash assistance for purchase or rental of food service equipment
or any other financial assistance extended in reliance on the representation and agreements made in this assurance.
C. Th,2 Contractor agrees to compile data, maintain records, and submit reports as required, to permit effective enforcement
of the above Acts and permit authorized TDHS, USDA and FNS personnel during normal working hours to review such
records, books, and accounts as needed to ascertain compliance with the above Acts. If there are any violations of this
assurance, TDHS, USDA and INS have the right to seek judicial enforcement of this assurance. 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 the department. The person whose signature appears on this contract is authorized to sign this assurance
on the behalf of the Contractor.
D. A religious or charitable organization is eligible to be a contractor on the same basis as any other private organization. The
contractor retains its independence from State and local governments, including the contractor's control over the definition,
development, practice, and expression of its charitable or religious beliefs. Except as provided by federal law, TDHS shall
not interpret this contract to require a charitable or religious organization to alter its form of internal governance or remove
religious art, icons, scripture, or other symbols. Furthermore, if a religious or charitable organization segregates the
government funds provided under the contract, then only the financial assistance provided by these funds will be subject
to audit. However, neither TDHS's selection of a charitable or faith -based contractor of services nor the expenditure of
funds under this contract is an endorsement of the contractor's charitable or religious character, practices, or expression.
The purpose of this contract is the provision of services; no State expenditures have as their objective the funding of
sectarian worship, instructions, or proselytization.
A charitable or fa ith-based provider of services under this contract shall reasonably apprise all assisted individuals of the
following: "Neither TDHS's selection of a charitable or faith -based provider of services nor the expenditure of funds under
this contract is an endorsement of the provider's charitable or religious character, practices, or expression. No provider of
services may discriminate against you on the basis of religion, a religious belief, or your refusal to participate in a religious
practice. If you object to a particular provider because of its -religious character, you may request assignment to a different
provider. If you believe that your rights have been violated, please discuss the complaint with your provider or notify your
local TDHS Special Nutrition Programs office. -
Section 104 of The Personal Responsibility and Work OpportUnity Ro-onciliation Act of 1996. 42 U.S.C. § 604a, sets forth
certain additional rights and responsibilities for charitable and liaith-based providers of services, certain additional rights
of assisted individuals, and certain additional responsibilities of TDHS to these providers and assisted individuals. This
contract is subject to those additional rights and responsibilities.
M
TDHS CLAIMS PAYMENT
A. TDHS will, subject to the federal appropriation and availability to TDHS of sufficient funds for the applicable
program, make program payment to the Contractor in accordance with the terms of this agreement. No reimbursement
shall be made for performance under this agreement occurring prior to (a) the beginning effective date of this
agreement or (b) a later date established by TDHS based on the date of receipt of a fully executed copy of this
agreement.
B. In accordance with Section 403.055(h) of the Government Code, as added by Act of May 19, 1999, 76th Leg. R.S., ch.
583, Sec. 1, 1999 Tex. Sess. Law Ser. 3125 (Vernon), any payments owing to the contractor under this contract will be
applied toward elimination of the contractor's indebtedness to the state, delinquency in payment of taxes to the state, or
delinquency in payment of taxes that the comptroller administers or collects until the indebtedness or delinquency is
paid in full. This clause does not apply if federal law requires payment to be made to the contractor for goods and
services provided in support of any of the USDA child and adult nutrition programs, and may not apply if federal law
conditions the receipt of the money for these goods or services to the state on the basis of payment being made to the
contractor.
VI.
IMMIGRATION
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.
VH.
CERTIFICATION
A. Regarding Debarment, Suspension, Ineligibility, or Voluntary Exclusion For Covered Contracts -The contractor
certifies, by execution of this agreement, that neither it nor its principals is presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participating in this contract by any federal department or
agency or by the State of Texas. By making this certification the contractor agrees to the following terms:
1. The above certification is a material representation of fact upon which reliance was based when this contract was
entered into. If it is later determined that the contractor knowingly rendered an erroneous certification, in addition
to other remedies available to the federal government, the Department of Health and Human Services, United State
Department of Agriculture or other federal department of agency, or the Texas Department of Human Services may
pursue available remedies, including suspension and/or debarment. .
2. The contractor shall provide immediate written notice to the person to which this certification is submitted if at any
time the contractor learns that the certification was erroneous when submitted or has become erroneous by reason
of changed circumstances.
3. The words "covered contract," "debarred," suspended," "ineligible," "participant," "person," "principal,"
"proposal," and voluntarily excluded," as used in this certification have meanings based upon materials in the
- Definitions and Coverage sections of federal rules implementing Executive Order 12549. Usage is defined in the
attachment.
4. The contractor agrees by submitting this certification that, should the proposed covered contract be entered into, it
shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or
voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health
and Human Services, United States Department of Agriculture or other federal department or agency, and/or the
Texas Department of Human Services, as applicable.
VUI.
EFFECTIVE DATE AND SIGNATURES
The parties hereto in their capacities stated, affix their signatures and bind themselves for the faithful performance of the
terms of this contract pursuant to participation in the following program or programs:
National School Lunch Program
School Breakfast Program
Special Milk Program
. City of LUbbock
Name of Contracting Organization
(Please print or type)
Attest To: _
_
roar 6 Pvc p0a qez /
Name of Official Signing
(Please print or type)
Approved as Form:
• Child and Adult Care Food Program
Summer Food Service Program
Sijnature of c ifman of the board of directors
or other offs al who has been authorized to sign
contracts behalf of the contracting organization.
Mayor
Title of Official
(Please print or type)
kRTMENT OF HUMAN SERVICES
until terminated.
Date: 2-
Approved for Form by OGC: ,Signature on file
Revised May 2001
1 iam a aas
Competiti.on"and.Contracts
Manager
Approved as to -Content.,
.,,
t- ,
,
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�EJ¢a`�' ii' a' -- �`��:[''^� •fLt`�'•�%`�..TZ�•:�s:J�`!�C•.7�yi;'��r.�w(�''Y�4'�j"F`�{�?"p Y�'rlit3tiC'��._�+ .� -
:array Trtae dell Parks i� R66c ..eatfn Hanaoer
VII.
CERTIFICATION
(Continued)
The contractor further agrees by submitting this certification that it will include TDHS Form 2045 titled
"Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts"
without modification, in all covered subcontracts and in all solicitation for aII covered subcontracts.
6. A contractor may rely upon a certification of a subcontractor that it is not debarred, suspended, ineligible, or
voluntarily excluded from the covered contract, unless it knows that the cenification is erroneous. A contractor
must, at a+minimum, obtain certificates from its covered subcontractor upon: each subcontractor's initiation and
upon each renewal.
i. Nothing contained in all the foregoing shall be construed to require establishment of a system of records in order t
render in rood faith the certification required by this certification document. The knowledge and information of a
contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course of
business dealings.
S. Except for contracts authorized under paragraph 4 of these terms, if a contractor in a covered contract knowingly
enters into a covered subcontract with a person who is suspended, debarred, ineligible, or voluntarily excluded
from participation in this transaction, in addition to other remedies available to the federal.government, Departrten
of Health and Human Services, United States Department of Agriculture, or other federal department or agency, as
applicable, and/or the Texas Department of Human Services may pursue available remedies, including suspension
and/or debarment.
B. Regarding Federal Lobbying - This certification applies only to this contract and is a material representation of fact
upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a
prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than Sl 0,000 and not mere than
$ i 00,000 for each such failure.
The contractor certifies, to the best of his or her knowledge and belief, that:
No fedcrally appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for
influencing or attempting to influence an officer or employee, of any agency, a member of Congress, an officer or
employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal
contract, the making of any federal grant, the making of any federal Ioan, the entering into of any cooperative
agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, Ioan, or
cooperative agreement.
If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of
Congress, or an employee of a member of Congress in connection with this federally funded contract, subcontract,
subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form
to Report Lobbying," in accordance with its instructions.
The contractor shall require that the language of this certification be included in the award documents for all covered
subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative
agreements) and that all covered subrecipients shall certify and disclose accordingly.
C. The contractor certifies that if it is a corporation, it is either a for -profit corporation that is not delinquent in its
franchise tax payments to the State of Texas, or is a non-profit corporation or is otherwise not subject to payment of
franchise taxes to the State of Texas. _ _ . _ _ .. _
D. 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.
E. Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in
this contract, bid, or application is not ineligible to receive'the specified grant, loan, or payment and acknowledges that
#u. ,.,,..+�+ rrinv i,P tPrm;nnfM sari navmPnt may I-.P w4li +-M rIFttrrC rPrtrfir•atinn ie irnar-rrrrrntP
Texas Department
or Human Services SUMMER FOOD SERVICE PROGRAM
APPLICATION FOR PARTICIPATION
r..
Form 1506IMarth 2001
FOR DHS STAFF ONLY
Contract No. TX No.
-�S"ee l / S E
Give as much information as possible. Attach Elf. Data
additional sheets If needed; identify each 5-2
attachment with the name of the contracting Approved For
organization. 1 ❑ Breakfast ❑ A.M. Supp.
sFr_naN I -SPONSOR INFORMATION
P.M.Sup;). U Supper U All
Contracting Organa."on Narne
_ )D No.
T"phane No.
No.
1
(Hotline
MaaZg Ad&4sS Street or P.O. Box. City. State. Zip]---
n o o
Street Adores (rf different) E-mail Address
Vie, S/7G Lei%ice a G . Cl. LilP�
Name of Aarpincstrator (1/� j
'
^ 1.-
Tine
1 r�
1 r r-
Nameof S SP Contact on -- - -- -._. _ ..
Telephone of Co^n}tact Person (induce Area Code)
__1
A. Contractor Classification (Check all that apply):
Reside ntiaUNonresidential Unit of Government -Contractor certifies that all food
❑ National Youth Sports Program ❑ Summer Camp service sites are operated directly by the contractor.
Continuous Calendar
❑ School Food Authority ❑ School Year ❑ Private Non-profit
B. Is your program a year-round program? ............................................. ............. . ........... [—]Yes o
C. Type of Contractor.
-0.Public Entity
is your agency considered to be state ownedloperated?.................................................. ❑Yes ® No
Do you deposit your program reimbursement directly into the State Treasury? ................................... ❑ WA ❑Yes E�No
Do you deposit your program reimbursement into a local bank? ................................................ ❑ WA E.Yes ❑ No
If yes, is it direct deposit?........................................................................................ []Yes �RNo
❑ Private Nonprofit Organization -Tax-exempt status established. Attach letter of determination (IRS 501-30) of tax-exempt status from IRS.
Do you deposit your program reimbursement into a local bank? ................................................ ❑ WA ❑Yes ❑ No
If yes, is it direct deposit?_._.....................•-------.......--•-----............................•........... ❑Yes [I No
D. Does the organization provide an ongoing year-round service to the community that is to be served by
the Summer Food Service Program (SFSP)?............. ........................................................Yes []No
If no, which of the following circumstances applies?
❑ Residential Camp ❑ Failure to operate would deny program to a poor area
❑ Serves Migrant Children ❑ Failure to operate would deny a significant number of children access to program
E. Does the organization expend $300,000 or more in federal funds yearly? ..........................................Yes El No
Attach a copy of the audit covering last year's program operation or documentation that an audit conforming with SF policy will
be conducted, including the date it will be conducted. '
}G
2
SECTION II --BUDGET t;4i
Estimate all SFSP costs which will be claimed for reimbursement 1
1.
ESTIMATED OPERATIONAL COSTS
PROGRAM YEAR
COSTS
Program Labor
Fringe Benefits
Food
1p� 67/:7.
Non-food Supplies
Utilities
Rent
Equipment Use Fee
Rental of Equipment
Rate per mile
Transportation
Other (specrty):
Other (specify):
Other (specify):
1 OTAL 1:
�(9%0
Form 1506
Page 2
`or the program year.
2
ESTIMATED ADMINISTRATIVE COSTS
PROGRAM YEAR
TCOSTS
Administrative Labor
(Management, Monitor, Clerical)
O� q O
6 F. 3
Fringe Benefits
-79 7. 09
Rental of Office Space
Utilities
Office Supplies
Do
Office Building Maintenance
—
Equipment Use Fee
Audit Fees
Legal Fees .
Rate per rule
Transportation Z (0X DCQ
00
Other (specify):
A U
Other (sw-ify):
TOTAL 2:
B. Indicate projected income to the food service from all sources other than SFSP reimbursement. Identify exactly the costs this income
will cover. (Do not include state or federal funds.)
Source of Income
Amount
wig be used for.
$
Sou= of Income
Amount
$
wig oe used for.
SECTION III —MANAGEMENT PLAN
A. List administrative level personnel who will be responsible for management and monitoring of the SFSP. (Do not include site
supervisors, cooks, janitors or other personnel involved in on -site food service.)
TITLE OF POSITION
NUMBER N
POSITION
SPECIFIC FOOD SERVICE PROGRAM DUTIES
S
i; ok S FS P
!Z)
1
KO r,, r
h Pt•r
Form 1506
Page 3
B. Are children charged separately for meals?........................................................................... ❑Yes --rV/:]-No
if yes, complete Form 1506, Attachment A (page 2), and submit with this application.
C. Do you want to receive advance payments?
For Operational Costs? ❑Yes
For Administrative Costs? ❑Yes'" to
D. If meal service is self -preparation, do you want to receive commodities? ............................................. ❑Yes jf.�j No
If yes, Form 1608, Application and Agreement for Commodities, must be completed and returned with your SFSP application.
SECTION IV —PROGRAM OPERATION
A.1. Beginning and Ending Dates of Meal Service �A.2. Number of Sites
FROM: �Z ✓ f? - -- 70: AyX 2002
B. List dates and topics of SFSP training:
DATES
TOPICS
C. Is the organization currently contracting with a year-round food service management company?.......................OYes [%o
If yes, submit a copy of your procurement procedures, bid, contract, and all amendments; skip Item D. if no, complete Item D.
D. Is the organization planning to contract with a food service management company? ...................................Yes ❑ No
If yes, and the contrail will exceed a10,000, attach a copy of the invitation to bid. Also
'aff 2 Y, zz/2[ '.d
led to be S 1 OQ,OOo or more? i !r yes.
Yes INJ No
bid
Also, attach a copy of a minimum 11-day-cycle menu including all speck menus to be used.
E. Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department notifying them of intent to
operate a Food Service Program at the sites) indicated on the attached Site Information sheet (Form 1507).
j
/ F. Are you implementing the option to allow off -site consumption of food? .............. [I All Sites [:]Some Sites �Nci Sites
SECTION V—ASSURANCES
A. Free Meal Policy Statement
1.The contracting organization assures the Texas Department of Human Services (DHS) that all children at the sites described on the
Site(s) Information Sheets for the Sumner Food Service Program, will be offered the same meals with no physical segregation of, or
other discrimination against, any child because of race, color, disability, age, sex, national origin, religion, or political beliefs. No
separate charge will be made for any meal except in accordance with attachment A of this application.
2.The contracting organization assures DHS that, if it is sponsoring camps or other enrollment programs:
• The contracting organization has or will obtain family size and income data about all children whose meals will be reported as free
or reduced -price; and
• The children claimed as free or reduced -price meet the current family size and income standards set by the United States
Department of Agriculture, DHS Form 4504, Standards for Detemuning Free and Reducer -Pace E6gib►7ity.
3.If the contracting organization is sponsoring a-camp.or other enrollment program that charges separately for meals, the contracting
organization has read Attachment A to this application, •Addtional Assurances for Camps and Other Enrollmenit-Pro grams that
Charge Separately for Meals% and assures DHS that all requirements have been or will be met. _ _
Farm ISO$
Page 4
B. Public Release
1.The contracting organization will make efforts to ensure that the local news media will make a public announcement of the program
and will supply them with a news release:
if the contracting organization is sponsoring a camp or other enrollment program, this release must contain, at a minimum, a list of an
approved sites, a list of the current standards for determining free and reduced price eligibility, and the following statement:
'The (Name of the =Mrae5ng orgamtUbm.) announces the sponsorship of the Summer Food Service Program.
Income eligibility will be based on family sae and income using the Standards for Determining Free and Reduced -Price
Eligibility, provided by the United States Department of Agriculture. Meals will be provided at the site(s) listed. People who
are eligible to participate in the program must not be discriminated against because of race, color, national origin, sex, age,
disability, religion, or political belief. Anyone who believes that they have been discriminated against should write
immediately to: Director, Civil Rights Division, MC W-206, Texas Department of Human Services, P.O. Box 10030, Austin,
Texas 78714-9030 or the Secretary of Agriculture, Washington, D.C. 20250. NOTE: Discrimination complaints based on
religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services."
Fcr all other programs the announcement must contain, at a minimum, a list of all approved sites and the following statement:
"The (Name cf the aaniractng organ®tian) announces the sponsorship of the Summer Food Service Program.
Meals will be provided at the sites) listed. People who are eligible to participate in the program must not be discriminated
against because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who believes that
they have been discriminated against should write immediately to: Director, Civil Rights Division, MC W 206, Texas
Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington,
D.C. 20250. NOTE: Discrimination complaints based on religion or political beliefs must be referred only to the Director,
Civil Rights Division, Texas Department of Human Services."
This public release was or will be published in the following news media outlet(s):
NAME OF MEDIA OUTLET
DATE OF RELEASE
L �j1 A' (',
2l oz
L�,
NAME OF MEDIA OUTLET DATE OF RELEASE
3. Attach a copy of the contracting organization's pubrtc release statement as submitted to the news media and any other materials
used to publicize the program's availability and nondiscrimination requirements.
SECTION VI-- WAIVER REQUESTS (Check all for which you are applying, submit appropriate waiver request form and documentation.
❑ Waiver to operate more than 25 sites (Nonprofit organizations only.)
❑ Waiver of the time restrictions for meal service at migrant sites.
❑ Waiver of the 15 consecutive school day requirement for year-round school program sites.
❑ Waiver of the first -week site visit requirement (School Food Authorities only).
SECTION VII— CERTIFICATION (see Form 1506, Attachment B)
I certify that the information on this application is true and correct to the best of my knowledge. I certify that reimbursement will be
claimed only for approved meals served to eligible children during the hours they are in attendance at approved sites. I know that
deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes.
FOR DHS USE ONLY
[]APPROVED [—I DENIED (reason):
Tide
srgnatum—Olricial ar consf vv Organaatim late
1 ei
Office of Accounting
P.O. Box 2000 + 1625 13th Street
Lubbock, Texas 79457
(806) 775-2156 • Fax (806) 775-3273
April 29, 2001
Texas Department of Human Services
Special Nutrition Programs, Operation Division
2109 Avenue Q
Lubbock, TX 79405
RE: Single Audit Report for September 30, 2001
To whom it may concern,
We are in the process of compiling information for the single audit report, which is performed in accordance with the
Single Audit Act of 1984 and OMB Circular A-133. We anticipate that this will be completed and published by June 30,
2002.
If you have any questions, please feel free to contact me at (806) 775-2148.
Sincerely,
Dena Morris
Grant Accountant
M
Te.as Deoaitment Form 1506. Attar^.ment 6
of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN Januar't 1999
CRIMINAL PROVISIONS AND PENALTIES
1. Whoever, in connecticn with any application, procurement, record keeping entry, claim for reimbursement, or other
document or statement made in connection with the program, knowingly and willfully falsifies, conceals or covers up by
any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or whoever in
connection with the program knowingly makes an opportunity for any person to defraud the United States or does or
omits to do any act with intent to enable any person to defraud the United States, shall be fined not more than $10,000
or imprisioned not more than five years.
2. Whoever being a partner, officer, director, or managing agent connected in any capacity with any partnership,
association, cooperation, business, or organization, either public or private, embezzles, misapplies, steals, or obtains
by fraud, false statement or forgery, any benefit provided by the program, or any money, funds, assets, or property
derived from benefits provided by this program, shall be fined not more than $10,000 or imprisoned for not more than
five years or both. If the benefits, money, funds, assets, or property involved is not over $200, then the penalty shall be
a fine of not more than S1,000 or imprisonment for not more than one year, or both.
3. If two or more persons conspire or collude to accomplish any act made unlawful under this subsection, and one or
mori such person commit any act to effect the object of conspiracy or collusion, each shall be fined not more than
$10,000 or imprisoned for not more than five years, or both.
TERMINATION PROCEDURES
The following is a list of deficiencies that are grounds for termination. Grounds for termination, however, are not limited to this list.
1. Non-compliance with applicable bid procedures and contract requirements Federal Child Nutrition regulations.
2. The submission of false information to the Texas Department of Human Services.
3. Program violations at a significant proportion of the sponsor's sites. Such violations include, but are not limited to the following:
A. Non-compliance with the meal service time restrictions.
S. Failure to maintain accurate records.
C. Failures to adjust meal orders to conform to the variations in the number of participating children.
D. The simultaneous service of more than one meal to any child.
E. Service of a significant number of meals which do not include required quantities of all meal components.
F. The claiming of program payments for meals not served to participating children.
G.E:xcessive instances of off -site meal consumption.
H. Continued use of food service management companies that are in violation of health codes.
News Release
FOR IMMEDIATE RELEASE:
Contact: Johnny McLellan, 775-2678
The City Of Lubbock is pleased to announce the Summer Food Program for Children,
sponsored by the Texas Department of Human Services. This program is provided
through the City Of Lubbock Parks and Recreation Department, under direction of Civic
Services. The Program will provide a nourishing noon meal to youngsters age one
through eighteen. Meals will be served Monday through Friday, beginning May 281h and
ending August 9, 2002 noon in the following locations:
Maggie Trejo Supercenter — 3200 Amherst
Mae Simmons Community Center — 23rd & Oak
Parkway Center — 405 N. MLK
Guadalupe Center — 102 Ave. P
Rawlings Community Center/Harwell Gym — 4101 Ave D
Beginning June 3Td and ending June 28`h, meals will be served Monday through Friday, at
11:30am at the following locations:
Bean Elementary — 3001 Ave N
Jackson Elementary — 201 Vernon
McWhorter Elementary — 3202 Erskine
Rawlings Community Center/Harwell Gym — 4101 Ave D
Also participating in the program is Big Brothers Big Sisters of Lubbock, located at 1706
23rd. The program will run from July 15 — July 19, 2002. Service time for this site will
begin at 12:00 noon.
Children who are eligible to participate in this program must not be discriminated against
on the basis of race, color, national origin, age, religion, sex, disability, or political
beliefs. Anyone who believes he or she has been discriminated against, should write to:
Director, Civil Rights Division, MC W-206, Texas Department of Human Services, P.O.
Box 149030, Austin, Texas 78714-9030 or Secretary of Agriculture, Washington D.C.
20250. NOTE: Discrimination complaints based on religious or political beliefs must be
referred only to the Director, Civil Rights Division, Texas Department of Human
Services.
CITY OF LUBBOCK
MEMO
TO: Peter Kern, Environmental Inspection
FROM: Johnny McLellan, Interim Indoor Recreation Supervisor
DATE: 4/18/02
RE: Summer Lunch Program
The City Of Lubbock will once again be participating in the Summer Lunch Program for
children. This program will begin on Tuesday, May 28 and will end on Friday, August 9,
2002. Meals will be served in the following locations:
Trejo Supercenter — 3200 Amherst 12:30 — 1:30
Simmons Community Center — 23" & Oak 12:15 — 1:15
Parkway Center — 405 N. MLK 12:20 —1:20
Guadalupe Center — 102 Ave. P 12:30 — 1:30
In addition to these sites, LISD will be participating in the program from June 3ra through
June 28th. Meals will be served at 11:30am and last till 12:30pm in the following
locations:
Bean Elementary — 3001 Ave. N
McWhorter — 2711 lst
Jackson — 201 Vernon
Rawlings Community Center/Harwell Gym — 40th & Ave. B
Also participating in the program this year is Big Brothers Big Sisters of Lubbock,
located at 1706 23ra. The program will run from July 15 — July 19, 2002. Service time for
this site will begin at 12:00 noon.
Summer Lunch Menu
City of Lubbock
Day 1
Poor Boy
loz — bologna
1 oz — cheese
'/zoz — Salami
'/4 cup — Lettuce/tomato
1 whole apple
1 cookie
1 cup — Chocolate Milk
Day 2
Peanut Butter/Jelly Sandwich
1 oz — Peanut Butter/Jelly
2 Slices — Bread
1 oz — American cheese
'/4 cup — Celery stick
1 whole apple
1 cup — Chocolate Milk
Day 3
Turkey Ham & Cheese Sandwich
1 oz — Turkey Ham
1 oz — American cheese
2 Slices — Bread
4oz —Orange Juice — 100%
3/8 cup — mixed fruit
2 — cookies
1 cup —Chocolate Milk
Day 4
Pastrami & Swiss Sandwich
1 oz — Turkey Pastrami
1 oz — Swiss cheese
2 Slices — Bread
1/4 cup — Potato Salad
1 whole orange
1 cookie
1 cup — Chocolate Milk
Day 5
Ham & Cheese Sandwich
1 oz - Ham
1 oz — American cheese
2 Slices — Bread
'/4 cup — lettuce, tomato, pickle chips
1/Z cup — peaches
2 cookies
1 cup — Chocolate Milk
Day 6 Bologna & Cheese Sandwich
1 oz — Bologna
loz — Cheese
2 Slices — Bread
4oz Apple juice — 100%
3/8 cup — Pineapple Chunks
1 brownie
1 cup —Chocolate Milk
Day 7 Turkey & Swiss Sandwich
1 oz — Turkey
loz — Swiss cheese
2 Slices — Bread
I/4 cup — Lettuce/Tomato
1 whole orange
1 cookie
1 cup — Chocolate Milk
Day 8 Poor Boy
loz — bologna
loz — cheese
%oz — Salami
1/4 cup — Lettuce/tomato
1 whole apple
1 cookie
1 cup — Chocolate Milk
Day 9 Peanut Butter/Jelly Sandwich
loz — Peanut Butter/Jelly
2 Slices —Bread
loz — American cheese
I/4 cup — Celery stick
1 whole apple
1 cup — Chocolate Milk
Day 10 Turkey Ham & Cheese Sandwich
loz — Turkey Ham
loz — American cheese
2 Slices — Bread
4oz — Orange Juice — 100%
3/8 cup — mixed fruit
2 — cookies
1 cup — Chocolate Milk
Day 11 Pastrami & Swiss Sandwich
loz — Turkey Pastrami
loz — Swiss cheese
2 Slices — Bread
1/4 cup — Potato Salad
1 whole orange
1 cookie
1 cup — Chocolate Milk
Texas Department
of Human Services Form 1507/Mares 2001
SUMMER FOOD SERVICE PROGRAM FOR OHS USE ONLY
SITE INFORMATION TX
❑ R U
Name of Fow Samoa Site Tetepnone No. (inc. A/C)
c ` �b
Address of S40 (street, City, state. )
�911 L
Period of Operation of Food Sept Ulday/yr-etoJday/yr.) Number of Op. May. A Juna A July Aug. A Sept
`
From: 3 gh'ArIJ 20o erating Days: ,r) p^( f]) 'r)
ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED
Residential Camp Site Serving Primar>7y Migrant Children
1. Indicate Type of Site: ❑ (serving one to three meats) ❑(serving one to three meals)
Nonresidential Camp Other Site
❑ (serving one to three malls) (serving one or two meals)
2. List ALL counties served by this site: Ll,► k--)00 r k
3. A. Is your site an open or restricted open site? ........................................................ .'Yes ❑ No
B. Is your site enrolled?.......................................................................... []Yes PNo
C. Site Eligibility: Enter the percentage of children eligible for free and/or
reduced price meals for the site (SFSP Handbook, Section 2).......................................... _ %
0. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For openlrestricted
open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percentage of free
& reduced price children.
E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced -price meals for the site? ..................................... %
4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ gYes ❑ No
n .
5.
If yes, give name of contracting organization:
donitoring Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within:
k First Week of Operation s. First Four Weeks of op♦rmon C. Additiorwt Renews
tom.,
6. Meal Service Period Information (SFSP Handbook. Section 2):
TYPES OF MEALS
NUMBER OF
ELIGIBLE CHILDREN
TO BE SERVED
MEAL SERVICE TIME
BEGINNING
ENDING
Breakfast
A.M. Supplement
Lunch
1 0 0
'. 3
, :.
P.M. Supplement
_.
Supper,
-ints ruormatwn is consaoerea cy txta wren "=9 vw avpruvw mom r♦rnrw raver. tarar ranc000x, becsoon zr -
7. Do you plan to feed children under one (1) year old?........:........................................................ Yes ❑No
S.
4ethod of Food Preparation by Contracting" ani ation"(SFSP Handbook, Section 2)
Yel"Sing School Using Food Service Management Company Using Private Non-profit,
On Site Central IGtchen Food Authority ❑ [] ❑ My (excludes lPyt a contracts with on -site prep) ❑ Organization that 'is SeN Prcp '
Form 1507
Page 2
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2)
Cafeteria -style Children are Seated Children Line Up
❑Meal Service ❑and are Given Meals rand Pick Up Meals ❑ Other:
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve? .. ❑Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2):
I TM.S OF POSITION I NO. IN POSITION I SPECIFIC FOOD SERVICE PROGRAM DUTIES I
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
Indoor Meal Meal Service
r'B'Servics ❑till Be Cancelled ❑Other.
12. Is this site implementing the option to allow off -site consumption of food? ..................................................... Dyes I7do
13. Are meals delivered to the site?.....................................:
..............................................._ Yes No
IF YES, COMPLETE ITEMS 14, 15, a 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14. indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6)
Site Personnel Will Contact Administrative Site Personnel Will Communicate
Staff, Who Will Contact Vendor ❑DirectlyWIMVendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ................................ [Dyes J9 No
if no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service.
16. if there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) -
Stored in Refrigerator Thrown Away Returned to Vendor
f2;;d Served the Next Day Oat the Site Qfor 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 meat service planned for the number of children anticipated. I know that
deliberate misrepres�e/ntation or withholding of information may result in prosecution under applicable state and federal statutes.
//��v Name ofComaac ft OrganaaHon
-�/� yzy.oz o
sipnatu erKlai or cordraebnq Organization _......._.. D,te
Nary. d Off.W (please type or P-9) Ties t —
FOR ❑Approved [:]Denied, reason:
DHS
USE Title
ONLY
Signatum -DNS Representative ,Dale
Texas Deparunent Form 1507/Mar-1 2001
cf Human Services SUMMER FOOD SERVICE PROGRAM
FOR OHS USE ONLY
SITE INFORMATION TX ❑R ❑U
Nam Food Bounce Srte Telephone No. (inc. AIC)
�- i . `
Period of Operation of Food Service (moJtlay/yr.-moJday/yr.) Num r of Op- h May . �June JOY Aug. A Sep
—
From: Z through: orating Days: Y
ATTACH A AP WITH THE SITE SERVICE AREA IDENTIFIED
Residential Camp Site Serving Primarily Migrant Children
1. Indicate Type of Site: ❑ (serving one to three meals) ❑(serving one to three meals)
Nonresidential Camp Other Site
❑ (serving one to three meals) (serving one or two meals)
2. List ALL counties served by this site: -LL^Nbbc r.k
3. A. Is your site an open or restricted open site? ........................................................ arYes ❑ No
B. Is your site enrclled7.......................................................................... ❑Yes ONO
C. Site Eligibility: Enter the percentage of children eligible for free and/or
reduced price meals for the site (SFSP Handbook, Section 2)..........................................
D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For open/restricted
open sites using school data, list the schools used to document site eligibTty; attach formula used by school disL to establish percentage of free
& reduced price children,
E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced -price meats for the site? ..................................... %
4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ (LNJYes ❑ No
A. N ,P t . .
If yes, give name of contracting organization:
5. Monitoring Plan (SFSP Handbook, Section 4) - Enter date of monitoring review to be conducted within:
A. F;rst week of operation
a. Fust Four Weeks dr Operation
C. Additional Reviews
2 Z-
5
S - % 0
6. Meat Service Period Information (SFSP Handbook, Section 2):
TYPES OF MEALS
NUMBER OF
ELIGIBLE CHILDREN
TO BE SERVED
MEAL SERVICE TIME
BEGINNING
ENDING
Breakfast.:._..
A.M. Supplement
Lunch "a
L M
P.M. Supplement
Supper
- i nis muormaucri is conmoerea vy was w-- —.--,y -- •vY--- ,s — �— —,. k— - y
7. Do you plan to feed children under one (1) year old? ................................................................. Dyes ENO
8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) _:..._-
"F-PreparAon Ve'"Vsfng school ,�1{lsing Food Setrlee Management Company Using Private Non -Profit
On Site ❑ Centrai nchen ❑ Food Authority �[J (excludes all -year contracts with on -site prep) 0 Organl atla that is Self -Pap
Forth 1507
Page 2
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2)
Cafeteria -style Children are Seated Children Line Up
❑Meal Service ❑ and are Given Meals Xand Pick Up Meals ❑ Other:
S. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve?..[] Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2):
TITLE OF POSITION
NO. IN POSITION
SPECIFIC FOOD SERVICE PROGRAM DUTIES
�� ,i
t: r
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
ndoor Meal Meal Service
Service ❑Will Be Cancelled ❑Other:
12. Is this site implementing the option to allow off -site consumption of food? ..................................................... []Yes N[No
13. Are meals delivered to the site? ... - _ .. ;
............................................... Yes M No
IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6)
Site Personnel Will Contact Administrative Site Personnel Will Communicate
staff, Who Will Contact Vendor ❑Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)................................9Yes ❑ No
If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service.
16. If ere is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) -
Stored in Refrigerator Thrown Away Returned to Vendor
❑and Served the Next Day 0 at the Site ❑tor Disposal ❑Other.
I C ERTIFY that the information on this form is true and correct to the best of my knovAedge. 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 orwithholding of information may result in prosecution under applicable state and federal statutes.
Name al ConaactwV oryanaaean
—22-OZ k
Sy +eoi or Cons achrig organization Data
Mama.(Off.al fniwe tvas or trim I Title _
FOR
❑Approved El Denied, reason:
OHS
USE
Title
_
ONLY
Signaturr-0HS Representative
Data
�........, ...i.�.r... . . M ...J-+ _ _ ..,...'u Mw x� ...
�alry.✓w.i.A. f c-...�...--.........
...w-., s3...r......_ .v. ...�.�... .... _.. . _ w
it
Texas Department
cfHuman Sernces
Name of Food Serwce Site
Form 1S07
SUMMER FOOD SERVICE PROGRAM - FaR DNS USE ONLY
SITE INFORMATION C
J
Mare 2CO3
esnoo or V wzrjcn 01 r,3 zerv[w trrra✓w-yryr.-�rnv✓aayryr.r Number Of Op- June July rug. Sept
From: 1 n, D 0through: S,,_. 7$:2ooz orating Days: 7 Z(�
ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED
Residential Camp Site Serving Primarily Migrant Children
1. Indicate Type of Site: ❑ (serving one to three meals) ❑(serving one to three meals)
Nonresidential Camp Other Site
❑ (serving one jto three meals) Ejserving one or two meals)
2. List ALL counties served by this site:
3. A. Is your site an open or restricted open site? ........................................................ EyYes ❑ No
B. Is your site enrolled?.......................................................................... ❑Yes eLN17-TJNo
C. Site Eligibility: Enter the percentage of children eligible for free and/or i1 '
reduced price meals for the site (SFSP Handbook, Section 2).......................................... `-'� eta
D. If openlrestricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For open restricted
open sites using school data, list the schools used to document site eligibility, attach formula used by school dist. to establish percentage of free
& reduced price
1�c�"hildren.
` &4,r)n
E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced -price meals for the site? ..................................... eke
4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) .............................
Yes ❑ No
if yes, give name of contracting organization:
L.
5. Monitoring Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within:
A. Fat Week of Operation
e. First Four weeks of operltion
C. Additional Revrewa
3LA
6. Meat Service Period Information (SFSP Handbook, Section 2):
TYPES OF MEALS
NUMBER OF
ELIGIBLE CHILDREN
To BE SERVED
MEAL SERVICE TIME
BEGINNING
ENDING
Breakfast
A.M. Supplement
Lunch
, , 3 D
! D
P.M. Supplement _
_ .... .
Supper
inns nicmiaaon 6 cons+oerva oy 6m wras r --v u ..,,y .,..aa ,s,w, a�r�w a wow `ar ar n.r uvww avuwxi sr
7. Do you plan to feed children tinder one (1) year old? .....................
............_ ..---. -_--. ........ ❑Ye s No
8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Section 2) _
s—tWMparawn Ven"%Ing School Using Food Service Management Company Using Private Non -Profit
❑ On site ❑ Central IGtchen ❑ Food Authority 131w :ludes all-yeer contracts with on -site prep) ❑ Organization that is Self -Prep
Forth 15o7
Page 2
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2)
Cafeteria -style Children are Seated �.�, Children Line Up
❑Meal Service Eland are Given Meals d Pick Up heals ❑ Other.
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve?.. []Yes [:]No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2):
TITLE OF POSITION
No. IN POSITION
SPECIFIC FOOD SERVICE PROGRAM DUTIES
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
Indoor Meal Meal Service
� ervice ❑Will Be Cancelled ❑Other.
12. is this site implementing the option to allow off -site consumption of food? ................................................... .. ❑Yes C ' o
13. Are meals delivered to the site? .................................. .................................................RlYes ❑ No
IF YES, COMPLETE ITEMS 14, 15, b 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6)
Site Personnel Will Contact Administrative Site Personnel Will Communicate
ff, Who Will Contact Vendor ❑Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)................................ ❑Yes [�1+10
If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2)
�kd in Refrigerator Thrown Away Returned to Vendor
andrServedtheNextDay ❑at the Site for Disposal ❑Other:
1 CERTIFY that the Information on this form is true and correct to the best of my knowledge. I certify that this site has been visited
and that it has the capability and facilities for the meal service planned for the number of children anticipated. 1 know that
deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes.
Name or ConoacWV Organu aton
dol urconvacimg Organization Dab
N
//a`F+� or Orfidal (pl�as,Aeyf-y�p� or print) Titlo
yb�ni11_ 1 ,� 1,,1 �r-%ke V►� ln`' Onr fYi rl..11fr to F% _
FOR ❑Approved ❑ Denied, reason:
OHS _
USE TAN ONLY
Signature -OHS Reprosenrativa DaN
iv
.. Ye - �..-.+ ✓.i.ww.F. i�,4 ♦-'-.rL�..KY� { y...�r J ....r..,a� -l..J. �...iw• - .P.. .
M
Texas Department Form 1507/March 200t
dMuman Services SUMMER FOOD SERVICE PROGRAhI
FOR OHS USE ONLY
SITE INFORMATION TX ❑R ❑U
Name pod Serves Site Telephone No. (ins AiC)
A Mss a( Sde (Street, City. State, ZIP)
Penod of O ton of Pocd SetV'Ce tmo�aayryr.-moraayfyr.� May. June July Aug. Sept
22 Number of Op. �
From: Cr.J, 2pp2through:!s Ztjs w orating Days: 90
ATTACH A MAP WITH THE SiTE SERVICE AREA IDENTIFIED
Residential Camp Site Serving Primarily Migrant Children
1. Indicate Type of Site: ❑ (serving one to three meals) ❑ serving ane to three meals)
Nonresidential Camp Other Site
❑ (serving one to three meals) (serving one or two meals)
2. List ALL counties served by this site: L L,000 i_
3. A. Is your site an open or restricted open site? ........................................................ MYes ❑ No
B. is your site enrolled?.......................................................................... ❑Yes allo
C. Site Eligibility: Enter the percentage of children eligible for free and/or
reduced price meals for the site (SFSP Handbook, Section 2).......................................... %
D. If openirestricted open sites, submit documentation supporting this percentage figure (such as census data; school data). For openfrestricted
open sites using school data, list the schools used to document site eligibTty, attach formula used by school disc. to establish percentage of free
& reduced price children.
"�)LC /1
E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced -price meats for the site? .................................... %
4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ MYes ❑ No
if yes, give name of contracting organization:
5. Monitoring Plan (SFSP Handbook, Section 4) - Enter date of monitoring review to be conducted within:
Week of operation
S. Fist Four Weeks o1 Operation
C. Additional Reviews
r,F;r3t
1� l r�
f0'?r (6 261
1 - 6 IZAI Z-0 2
6. Meal Service Period Information (SFSP Handbook, Section 2):
TYPES OF MEALS
NUMBER OF
ELIGIBLE CHILDREN
TO BE SERVED
MEAL SERVICE TUNE
BEGINNING
ENDING
Breakfast
A.M. Supplement
Lunch
(7
1 r. 1D
ka,, 0 .
P.M. Supplement
.Supper
.1 Mil etforrmuum a comawem.a o1 w-- ..,,.., ...w.e ...� �rr••••�•• �...w .�. �r �w ..r ..�....w...., w........ �� ,....
7. Do you plan to feed children under one (1) year old?................................................................_❑Yes No
8.
dethod of Food Preparation by_Contracting OrganiraUon'(SFSP..Haridbook,"Section 2) ..,"
"t-Preparation
vnd'4lsing School 'using Food Service Yanagemeet Company -Using private Non -Profit
❑ on site ❑ Centrai l(Itchen ❑ Food Authority . Vgudes lt-year contralcts wb on -site prep) 0 Organization that is Self -Prep
Farts 1507
Page 2
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2)
Cafeteria -style Children are Seated Idren Line Up
❑ Meal Service Eland are Given Meals and Pick Up Deals ❑ Other:
B. If using cafeteria-styie meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve? .. ❑Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2):
TITILE OF POSITION
NO. IN POSITION
SPECIFIC FOOD SERVICE PROGRAM DUTIES
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
Indoor Meal Meal Service
Service ❑Will Be Cancelled ❑Other;
12. is this site implementing the option to allow off -site consumption offoodl ................::...................................Yes MNo
13. Are meals delivered to the site? .....................................: ._ WYes ❑ No
IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM 1S COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14. indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6)
Site Personnel W71 Contact Administrative Site Personnel W71 Communicate
Staff, Who Will Contact Vendor ❑Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)................................ ❑Yes o
tf no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of servic?4'
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2) -
Stored in Refrigerator Thrown Away Returned to Vendor
FZA
Lp
and Served the Next Day ❑at the Site ❑for Disposal []Other
I CERTIFY that the information on this form is true and correct to the best of my knowiedge. 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.
r
orConta" Organaaeon
FOR
DNS
USE
ONLY
❑Approved ❑Denied, reason:
Signawro-OHS Reprseantative Data
µ
Texas Department
cf Human Services
SUMMER FOOD SERVICE PROGRAM
SITE INFORMATION
Form 15071Marcn 2001
FOR OHS USE ONLY
TX 1711 n U
Nam a< Food SeMCe Jne Telephone No. (inc AC)
r
aedress (5"sL Crty, State, ZIP
n r•�k L ,- lc i; L
Pend of Operation of Food Service (moJdayfyr.-maldayfyr.) Number of Op- May_ June A July_ A Aug. A Sept
From: V�; 2oOZ through: 1Cj'Z0p 11 crating Days: 'r) b
ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED
Residential Camp Site Serving Primarily Migrant Children
1. Indicate Type of Site: ❑ (serving one to three meals) ❑(serving one to three meals)
Nonresidential Camp Other Sibs
❑ (serving one to three meals) (serving one or two meals)
2. List ALL counties served by this site: - - L'w," Y
3. A. Is your site an open or restricted open site? ....................................................... eyes ❑ No
S. Is your site enrolled?.......................................................................... ❑Yes a�No
C. Site Eligibility: Enter the percentage of children eligible for free and/or
reduced price meals for the site (SFSP Handbook, Section 2).......................................... %
D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For operdrestricted
open sites using school data, list the schools used to document site eligibTty, attach formula used by School disc to establish percentage of free
& reduced price children.
IDA4 C14'r -
E. Fer enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program -refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced -price meals for the site? .....................................
4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ [--]Yes ,(y No
If yes, give name of contracting organization:
5. Monitoring Plan (SFSP Handbook, Section 4)- Enter date of monitoring review to be conducted within:
A.F rst Week of Operatrdn B. First Four Weeks a(Operation C. Adddwnar Reviews t
—
6. Meal Service Period Information (SFSP Handbook, Section 2):
TYPES OF MEALS
NUMBER OF
EMISLE CHILDREN
TO BE SERVED
MEAL SERVICE TIME
BEGINNING
ENDING
Breakfast
A.M. Supplement
Lunch
`� '• 0
P.M. Supplement
Supper,_
- Inxf IfadnnaUOn is
7. Do you plan to feed children under one (1) year old? ........ :........................................................ Dyes �!o
a.
Aethod of Food Preparation by Contracting "organization (SFSP Handbook, Section 2)
sell-Preparaoon ]W"dotsing School UsinQ`Food Serriee lllanagement Compar�i Using Private Nor0roflt
❑ On site ❑ Central latchen ❑ Food Authority 'excludes all -year contracts frith on -site prop) ❑ Organization that is Self -Prep
Form 1507
Page 2
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2)
Cafeteria -style Children are Seated Children Line Up
❑Meal Service Eland are Given Meals and Pick Up Meals ❑Other:
S. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve? .. []Yes ❑ No
10. Ust site personnel who will be involved to any extent in the meal service. (SFSP Handbook. Section 2l:
TrrLE OF POSITION
NO. IN POSITION
SPECIFIC FOOD SERVICE PROGRAM DUTIES
N J
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
Zdoor Meal Meal Service
rvice ❑Will Be Cancelled ❑Other.
12. is this site implementing the option to allow off --site consumption of food?................:....................................QYes QTlo
13. Are meals delivered to the site? „_.., __®Yes ❑ No
IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM 1S COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6)
Site Personnel Will Contact Administrative Site Personnel Will Communicate
Staff, Who Will Contact Vendor ❑Direetty With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ................................ Xyes F ] No
If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2)
Stored in Refrigerator Thrown Away Returned to Vendor
❑and Served the Next Day Toat the Site El for Disposal []Other.
1 CERTIFY that the Information on this form is true and correct to the best of my knowledge. I certify that this site has been visited
and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that
deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes.
Nam or C«macirV organization
naiu�or conbactinc organization Daft
FOR []Approved ❑Denied, reason:
DHS
USE rm.
ONLY " r"
SVnaturr-0HS Repmsentative Data
y � w l.:.t �..,..r...F - F -� W ♦ � a,.ry: � - -. "L3.% ' s. �i' r c ..''e - ss .. � .::. i .. -: 4..
Texas oeoartment
of Human Services
Name of Food Service Site
Acdress of Sits (Street. City, Sta
anp LA
Period of Operation of Food Son
From:
SUMMER FOOD SERVICE PROGRAM
SITE INFORMATION
Number of Op -
Form 1507/M3re 2001
FOR OHS USE ONLY
Tx I MR ❑U
eiephane No. (inc. MC)
-7 (-7 - 2-706"
r�
1, June a l July � 1, Aug.� 1� Sept.
ATTACH A PIJAP WITH THE SITE SERVECE AREA IDENTIFIED
Residential Camp Site Serving Primarily Migrant Children
1. Indicate Type of Site: ❑ (serving one to three meals) ❑(serving one to three meals)
Nonresidential Camp ❑ Other Sits (serving one to three meals) � (serving one or two meals)
2. List ALL counties served by this site: LiA)a6c e lc
3. A. Is your site an open or restricted open site?........................................................1Yes ❑ No
B. Is your site enrolled?.......................................................................... ❑Yes 4!�No
C. Site Eligibility Enter the percentage of children eligible for free and/or
reduced price meals for the site (SFSP Handbook, Section 2)..........................................
D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data; school data). For open/restricted
open sites using school data, list the schools used to document site eligibility; attach formula used by school disL to establish percentage of free
8a reduced price children.
E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program --refer to SFSP Handbook, Section 2.)
If the enroiled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced -price meals for the site? ....................................
4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................Yes ❑No
fl
ff yes, give name of contracting organization:
Aonitoring Plan (SFSP Handbook, Section 4) - Enter date of monitoring review to be conducted within:
A. F-rst Week of Operation 8. Frst Pour Works of eratme C. Ad Reviews
6. Meal Service Period Information (SFSP Handbook, Section 2):
TYPES OF MEALS
NUMBER OF
ELIGIBLE CHILDREN
TO BE SERVED
MEAL SERVICE TIME
BEGINNING
ENDING
Breakfast
A.M. Supplement
Lunch
1
15
P.M. Supplement
Supper
"1 nt3 f1TORnillan R consiaerea aY tine wr>pa avwny ,sw avWvvwo melee sarriw wvei. txx rlarroaawc, �earon L) .. .
7. Do you plan to feed children under one (1) year old? ................................................... ❑YesNo
8.
Aethod of Food Preparation by Contracting Organization (SFSP Handbook, Section 2)
SeIFPapara><on Vend"Jsing School sing Food Service Management Company Using Private Non-profit
❑ On Site ❑ Central Kitchen ❑ Food Authofity (excludes all -year contracts with on -site prep) ❑ Organization that is Self -Prep
Form 1507
Page 2
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2)
Cafeteria -style Children are Seated{, Children Line Up
❑Meal Service Eland are Given Meals d Pick Up Meals ❑ Other:
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve? .. ❑Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook. Section 2):
TITLE OF POSMN
NO. IN POSITION
SPECIFIC FOOD SERVICE PROGRAM DUTIES
t c s
' r
3
U\
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
14 indoor Meal Meal Service
Service ❑Will Be Cancelled ❑Other.
12. Is this site implementing the option to allow off -site consumption of food? ................'........_..................__....... ❑Yes- No
13. Are meals delivered to the site? ................................................... ............._............_ Yes ❑ No
IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14.1ndi to the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6)
4 Site Personnel Will Contact Administrative Site Personnel Well Communicate
Staff, Who Will Contact Vendor ❑Directly With Vendor
15. Will delivery be within one hour of the food service pericd7 (SFSP Handbook, Section 2)................................z(Yes ❑ No
if no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service.
16. If there is an excess of meals deliver , meals wlI be (SFSP Handbook, Section 2)
Stored in Refrigerator rown Away Returned to Vendor
❑and Served the Nezt Day at the Site ❑for Disposal ❑ Other:
1 CERTIFY that the Information on this form is true and connect 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
defiberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes.
Nano Contra UV Organ=04on
Sly dial of camraainy Organization Dato
FOR ❑Approved ❑Denied,reason:
DHs
USE. lee
ONLY
Signature-DHS Representative Data
77
•
Texas Departrnent
cf Human Services
SUMMER FOOD SERVICE PROGRAM
SITE INFORMATION
L
Forth 1507/Mar-t 20(
FOR OHS USE ONLY
TX,.. ❑R El
Diephon e1N,o.. (inc AIC)
Penod of Opwatan of Fooa service tmojaayryr.-mc.raayryr.) Number of Op. h may. June A July �Aug. Sept.
From: rough: 31A orating Days: !)I) L
ATTACH A MAP WITH THE SITE SERVICE -AREA IDENTIFIED
Residential Camp Site Serving Primarily Migrant Children
1. Indicate Type of Site: ❑ (serving one to three meals) ❑(serving one to three meals)
Nonresidential Camp er Site
❑ (serving one to three meals) ,carving one or two meals)
2. List ALL counties served by this site:
3. A. Is your site an open or restricted open site? ........................................................ VYes ❑ No
B. Is your site enrolled?.......................................................................... ❑Yes �o
C. Site Eligibility: Enter the percentage of children eligible for free and/or 0
reduced price meals for the site (SFSP Handbook, Section 2).......................................... - l %
0. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data; school data). For openlrestricted
open sites using school data, list the schools used to document site eligibTty; attach formula used by school dist. to establish percentage of free
if reduced price children.
E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program -refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced -price meals for the site? ..................................... %
4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ []Yes ANO
If yes, give name of contracting organization:
5. Monitoring Plan (SFSP Handbook, Section 4)- Enter date of monitoring review to be conducted within:
6.
L ?-VOL ,1..,,, � n - .1. _( t_.1r; ' I I )Inrti. L(1 - ll,1n'1�ti,
Meal Service Period Information (ter*r rmanooGOK, ziecuon 1):
TYPES OF MEALS
-
NUMBER OF
ELIGIBLE CHILDREN
TO BE SERVED
MEAL SERVICE TIME
BEGINNING
ENDING
Breakfast
A.M. Supplement
Lunch
0
' .3
P.M. Supplement
Supper
*This information is considered by DMJ wn*n 30=9 um aPIRM" o meat aervfce wyeL tarar nana000R. .ewon L)
7. Do you plan to feed children under one (1) year old? Oyes No
8.
Aethod of Food Preparation by contracting Organization (5F5P. Handbook, Section z) . y ....- "t-Pfeparawn .
vnde4lsing School Using Food Service Management Company _ Using Private Non -Profit
❑ On S'de ❑ Central l(Itchen I [:)Food Authority ❑ (excludes all -year contracts with on -site prep) ❑ Organization that Is Self—
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period
Cafeteria -style Children are Seated Children Line U
❑Meal Service ❑and are Given Meals ^end Pick Up Meap
ls ❑ Other:
Forth 1507
Page 2
(SFSP Handbook, Section 2)
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve?.. ❑Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2):
TITLE OF PosrTloN
NO. IN POSITION
SPECIFIC FOOD SERVICE PROGRAM DUTIES
tf-S s r
{�
t L t
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
Indoor Meal Meal Service
rvice ❑Will Be Cancelled ❑Other,
12. Is this site implementing the option to allow off -site consumption of food?•,.•.,.,...._.,.',,,,,,,,,,,,,,,,,,•,,,,...,_._,,....DYes '>-No
13. Are meals delivered to the site?....................................................................................._4Yes ❑ No
IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM 1S COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6)
:Site Personnel Will Contact Administrative Site Personnel W81 Communicate
taff, Who Will Contact Vendor ❑ Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) .................................
............................. Yes ❑ No
tf no, describe arrangements within standards prescribed mebed by local health authorities for delivery and holding of meals until •cf service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2)
Stored in Refrigerator rows Away Returned to Vendor
Eland Served the Next Day at the Site ❑for Disposal ❑ Other:
I CERTIFY that the information on this form is true and coneet 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.
Naar of Cor&acfing Orgv=abon
-2 2 •v z _ C
raal d Cantrac ing Organization Dab
N of Official (plow*"or pr"
Title
7�O C Le-�kc,' r
FOR ❑Approved El Denied, reason:
DHS
USE T" ONLY
Signature-DHS Representative Dab
Texas Department
of Human Services
Name of Food Service Sde `
SUMMER FOOD SERVICE PROGRAM
SITE INFORMATION
Form 1507/March 2001
FOR OHS USE ONLY
TX QR n
0>MWVIN
Penrod of Operation of Food ServlCe (moJaayryr.—=Juay/yrj Number of op- May June Ju1� Aug Sept -
From: DLV, rough: erdting Days: �— U
ATTACH A 4AP WITH THE SITE SERVICE AREA IDENTIFIED
Residential Camp Site Serving Primarily Migrant Children
1. Indicate Type of Site: ❑ (serving one to three meals) ❑(serving one to three meals)
Nonresidential Camp Other Site
Elng{servi
one to three meals) • (serving one or two meals)
2. List ALL counties served by this site: O,00r 1L
3. A. Is your site an open or restricted open site? ........................................................Yes ❑No
B. Is your site enrolled?.......................................................................... ❑Yes ErNo
C. Site Eligibility: Enter the percentage of children eligible for free and/or
reduced price meals for the site (SFSP Handbook, Section 2).......................................... %
D. if opedrestricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For openirestricted
open sites using school data, list the schools used to document site eligibility, attach formula used by school dist. to establish percentage of free
& reduced price children.
E. For enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program -•refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced -price meals for the site? ..................................... e�
4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ KYes ❑ No
If yes, give name of contracting organization:
5. Monitoring Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within:
A. Fast Week of Operation
8. F•vst Four Weeks d Operation
C. Addib.-I Renews
5/Q'P)J�V�.-b110
Sikh z kibdo
572-sl,2- blrIb2
6. Meal Service Period Information (SFSP Handbook, Section 2):
TYPES OF MEALS
NUMBER OF
EL1G19LE CHILDREN
TO SE SERVED
MEAL SERVICE TIME
BEGINNING
ENDING
Breakfast
A.M. Supplement
Lunch
1
P.M. Supplement
Supper
-Thls Wormim IS cons cerw oy L Q wrnan sarong Qla 4pprwe0 meal 34rV= level. (JrZW tlanODOOK, Q06Gnon C)
7. Do you plan to feed children under one (1) year old? ................................................ ................ _ oyes(-RNo
8.
Aethod of Food Preparation by Contracting Organization (SFSP Handbook, Section 2)
Self -Preparation vendetsing School sing Food Service Managemerd Company Using Private Noel-Prcfiit .
❑ on site ❑ Central Kitchen ❑ Food Authority (excludes alt•year contracts with on -site prep) ❑ Organization that is Self -Prep
Form 1507
Page 2
S. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2)
Cafeteria -style Children are Seated r,'A,Z, Children Line Up
❑ Meal Service Eland are Given Meals nd Pick Up Meals ❑ Other:
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve? .. ❑Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook. Section 2):
TITLE OF POSITION
NO. IN POSITION
- SPECIFIC FOOD SERVICE PROGRAM DUTIES
r
�
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
Indoor Meal Meal Service
Service ❑Will Be Cancelled ❑Other:
12. Is this site implementing the option to allow off -site consumption of food? ................ .................................... ❑Yes.,RNo
13. Are meals'delivered to the site7..................................................................................... _ PRYes ❑ No
IF YES, COMPLETE ITEMS 14,15, b 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6)
S'Ite Personnel Will Contact Administrative Site Personnel Will Communicate
Staff, Who Will Contact Vendor ❑Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2)...............................XYes [:]No
If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service.
16. if there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2)
Stored in Refrigerator Thrown Away Returned to Vendor
❑and Served the Next Day �qt the Site ❑tar Disposal ❑Other.
I CERTIFY that the information on this form is true and correct to the best of my knowledge.) 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.
Zz--e 2
Date
t;,
Texas Departrrient Form 1507/March 2001
cf Human Services SUMMER FOOD SERVICE PROGRAM FOR OHS USE ONLY
SITE INFORMATION .X
❑R U
Namevaf•Food Service SAe n Telepncn� No. (ins A!q
t\J •
to
L Ty. !�ALAO
Period of jper2t;cn
From: ,i
of Food Service (=Jdayl)r.—moJdayyr.)
A n o (� through:- s„`,
Numberof 0 May.JuneJutAug.
crating Days
'
SepL
L'
ATTACH A MAP WITH THE SITE SERVICYAREA IDENTIFIED
Residential Camp - Site Serving Primarily Migrant Children
1. Indicate Type of Site: ❑ (serving one to three meals) ❑(serving one to three meals)
Nonresidential Camp er Site
❑ (serving one to three meals) r(urvingoneortwomeaI3)
2. List ALL counties served by this site: I nh� O r k
3. A. Is your site an open or restricted open site? ........................................................ EvYes ❑ No
B. Is your site enrolled?.......................................................................... Dyes 5�NO
C. Site Eligibility: Enter the percentage of children eligible for free and/or - 1 l
reduced price meals for the site (SFSP Handbook, Section 2).......................................... t
D. If opentrestricted open sites, submit documentation supporting this percentage figure (such as census data; school data). For open/restricted
open sites using school data, list the schools used to document site eligibility, attach formula used by school dist. to establish percentage of free
& reduced price children.
IA0 r!!snn
E. Fcr enrolled sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program -refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced -price meals for the site? .................................... %
4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2)............................AYes r No
If yes, give name of contracting organization I� L bA L yA i or_
5. Monitorina Plan (SFSP Handbook, Section 4)— Enter date of monitoring review to be conducted within:
A. Ft Week of Operation
e., First Four Weeks of Operation
C. Additional Reviews
3L&
Ury v) oaL
— 2
t
6. Meal Service Period Information (SFSP Handbook, Section 2):
TYPES OF MFJLLS
NUMBER OF
ELIGIBLE CHILDREN
TO BE SERVED
I MEAL SERVICE TIME
BEGINNING
ENDING
Breakfast
A.M. Supplement
Lunch
_
P.M. Supplement
Supper
_
- � no inromuuon s cnnswenv � �.,� ....... �....,, ..._ _•��--� ...�. �....._ ._._.. �... � .._..,._.....,, ..__.._.. _, ,
7. Do you plan to feed children under one (1) year old? .... ............ ..... ............. ............. ❑Y ... es [UNo
a UathAA of =ew%A oronarutinn by Contracdna OraanizaUcn'fSFSP Handbook Section 21 - . "
"t-Preparation Venftsing School Using Food Service Management Company Using Private Non -Profit
[]on Site ❑ Central Kitchen ❑ Food Authority (excludes ail -year contracts with on -site prep) ❑ Organization that is Self -Prep
Forth 1s07
Page 2
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP Handbook, Section 2)
Cafeteria -style Children are Seated �y Children Line Up
❑Meal Service and are Given Meals �nd Pick Up Meals ❑Other:
B. if using cafeteria -style meal service and if sponsor is a school food authority, will the site be implementing offer vs. serve?.. ❑Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2):
TITLE OF POSITION
NO. IN POSITION
SPECIFIC FOOD SERVICE PROGRAM DUTIES
SKn
A I k br,i
r
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
Indoor Meal Meal Service
Service ❑Will Be Cancelled ❑Other.
12. Is this site implementing the option to allow off -site consumption of food? ................::.... ............................................ ❑Yes ® No
13. Are meals delivered to the site? ........................... YyYes /❑ No
IF YES, COMPLETE ITEMS 14, 15, 316. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6)
Site Personnel WHI Contact Administrative Site Personnel Will Communicate
taff, Who Will Contact Vendor ❑Directly With Vendor
15. Will ddd....elivery be within one hour of the food service period? (SFSP Handbook, Section 2) .......................... Yes ❑ No
If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until ' e of service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2)
Stored in Refrigerator rown Away Returned to Vendor
[land Served the Next Day at the Site ❑for Disposal ❑Other:
I CERTIFY that the Information on this form is true and correct to the best of my knowledge. I certify that this site has been visited
and that It has the capability and facilities for the meal service planned for the number of children anticipated. I know that
deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes.
Nam. or Coup Orpa n¢ationn
_�- 2-02, L .
sip Kiel 0r Contr dMg Organization Date
FOR ❑Approved ❑Denied, reason:
OHS
USE TO
ONLY
Spnatun-OHS Representative Pate -
Texas Department
of Human Services
SPECIAL NUTRITION PROGRAM
CERTIFICATE OF AUTHORITY
This is to certify that the following person(s):
is (are) designated as an Authorized Representative of
Name of Contracting Organization
Addres, Street, City, State, ZIP)
i�.O. �ox '�oc�c� L�,sti ocic , 1 x �ci�1�r7
Form 4508
May 2000
The representative(s) designated above, and myself, acknowledge that each is individually authorized on behalf of
the contracting organization to make written agreements with the Texas Department of Human Services to operate a
food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when
appropriate, to the department
By signing this document, we certify individually and collectively that to the best of our knowledge and belief, all
documents submitted physically or electronically on behalf of the above named Contracting Organization pursuant to
our participation in any and all programs administered by Special Nutrition Programs, TDHS, aretwill be true and
correct in all respects, that they arelwill be completed according to the terms and conditions of existing agreements
including amendments, that records arelwill be available to support any and all claims, and that we will not submit
claims (excluding amendedladjusted claims) for goods or services for which we have already received payment We
recognize that we are fully responsible for any excess amounts which may result from errors made in relation to the
completion and submission of claims. We are also aware that deliberate misrepresentation or withholding of
information may result in prosecution under applicable state and federal statutes.
We or print) /AI Ttie „ Attest To:
Rebecca Garza
ity Secretary
DELETED AUTHORIZED REPRESENTATIVES:/A contracting organization may not have more than three (3)
Authorized Representatives, including the Offidal of the Contracting Agency. If you are replacing or deleting an
Authorized Representative, list the name(s) of the individuals) to be removed as Authorized Representative(s) below
Name of Deleted Representative Name of Deleted Representative Name of Deleted Representative
-FOR DHS USE ONLY
Contract No. :: Received By✓ Date Received
NORTH D157RIC7 LINE 15 i
LjTRA)-.
BLUEFIELD GREET
L DISTRICT ENCOMPASSES �W
)DARE MILES. E
UrsuNne S1. '
XI MATE VALUE OF °�'sy_-' T), I ■ARNETi - I
L PROPERTI ES I °. WESTERNERI4
FIELD - a'ACAOO i` t
ILLION.
I \ d SRH1� ( NORTH 4
�+ �+ I Erskine St. 1' WO EL'c� Ti
ACRES • / I TRACT E suing St. I
01 SCHOOL PLANT PARKWGY
aVAZOS HUNT . E N I 1
TUBBS GUADAIU.E f
ELE ELEM. I
TRaGTi� � � M• INCWHOR t ,.y
ELEM. ACKSO ALD ON >� M P c EO�Etxn_ V I
ELE., HI
I
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aacu
eI HAV
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■HCRD:v�Cx t?USH ELE, .
START
c_EM.
cam-
/
ACMINIS1 ATI'/�
L GCcS
Le,elicitd H� hwov
I9
i th�7`
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19th St. I j ;c h cI
PEF1 FM' �y yl,Qzi:.
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LOM-i X CENTER I
WILSON ELE.
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' ILES ' i .
1
i wIISON
c� JR.HI
OVERTON
ELEM.
BEAN cEM. ELEm. OUNBAR JR. HI
HUTCHINSON �dR.HI ■
�HEA7LEY
cLEME O
0t°�
CORON
DO SR. HI
JR.�HI l
- 1WRTIN arc ( ELEM. 341h St. i
3ath St.
FFA. FARM
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l
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3A
tSTUBBS
+ _HEAD START i
WHEEL CK ELEM '
rIEL
4
MAEDGEN ELEM:
r.
WESTER ELEM.
"TT HEART
MONTEAEY a
■■
SCth SI. ELEM.
d d
SR. Ht 50th St. i
HOD
ES
VANS JR.HI
ATKINS ELEM.
�JR.HI
i
TRANSPORTATION
I
WILLIAMS ELEM.
�HAYNE5
PARSONS
ELEM. 1
I
ELEM
BAYLESS ELEM.
56th St
I
ooth S
-
_
MURFEE
FIELD
m
1pt
WHtTESIDt
*ATERS
MEGLE�
nH
as
ELEM.
ao
FIELD
❑
aELEM
'
iIRONS
JR. HI
C" Co
c TRACT
J
jya
It.
82nd St.
u
0
MAP INFORMATION AS OF(Jf1NE, 1998
SMITH ELEM
HONEY ELEM.
TRACT
;
• c �
L
98th St. 981h St.
ATTACHMENT
SUMMER FOOD SERVICE PROGRAM (SFSP) APPLICATION
OUTREACH PLAN FOR OPEN AND RESTRICTED OPEN SITES
If you operate open sites or restricted open sites, indicate your plans for conducting
outreach to inform persons about the operation of the SFSP at your sites and promote
participation at your sites. Check all that apply.
❑ Make television announcements. ❑ Send letters to potential participants.
❑ Make radio announcements. ❑ Distribute flyers to potential participants.
1►d Display posters at locations visited by potential participants.
cc Offer activities other than meals at sites.
❑ Partner with other organizations to advertise and promote the program.
&U Other. Ex lain:
P
�P rl
a�eserl< a-6%-10o;.reZ.
January,2002
Texas Cepartment
156
ct Human Semmes SPECIAL NUTRITION PROGRAMS Form March 200 200
SINGLE AUDiT IDENTIFICATION DATA
For Program Year 2002_
(SNP Use Only)
Check the appropriate box(es) to indicate the type(s) of program(s) in which you currentiv aarticiaate or for which you are annlvina:
cOMMOOr'y ASSISTANCE PROGRAMS
PROGRAM NOS.
❑ A — National School Lunch
❑ B — Charitable Institutions
❑ C — Area Agency on Aging
❑ G — Summer Camps
❑ H — Summer Food Service
❑ J —Jails
❑ I — TE:XCAP
❑ CS — Commodity Supplemental Food Prog.
CASH REIMBURSEMENT PROGRAMS
PROGRAM NOS.
❑ AD — Adult Day Care
TX-
❑ BL— National School Lunch/Breakfast
TX -
CC — CACFP Center
TX-
❑ DH — CACFP Day Home
TX-
SF— Summer Food
TX-
❑ SM — SpecW Milk
TX-
❑ TE — TEXCAP
TX-
CS — Commodity Supplemental Food Prog. I
TX -
Give the source and amount of any federal funds that your agency expends other than from those programs listed above:
SOURCE
AMOUNT
J
0&0
❑ SINGLE AUDIT EXEMPTION—1 certify that I am not required to submit an audit under the Single Audit Act for the following reason(s):
111 am a for -profit organization. ❑ I expend less than $300,000 annually in total federal funding.
SINGLE AUDIT ASSURANCE-1 understand that if i meet the requirements of the Single Audit Act,1 will agree to submit an audit
as a condition of eligibility to participate in the Special Nutrition Programs, and that failure to do so as required could result in
adverse action, including the withholding of my claim for reimbursement payments and tremination of my contract I also
understand that if I am a private non-profit organization subject to the requirements of the Single Audit Act and have a financial
audit performed annually, I must also obtain a single audit on an annual basis.
el% M
Name Wease type or prtu) I'AnAefl\e�1
Mc
IINiAT. -ui U2MV) IU:�4 Lisa - SUFT. OFG. TEL:806 �66 1210
2001-2002 ECONOMICALLY DISADVANTAGED STUDENTS
ELEMENTARY SCHOOLS
CAMPUS
ENR
#ECON DISADV
%ECON DISADV
ALDE SON
572
979b
ARNETT
242
223
920/6
BAYLESS
774
558
72%
BEAN
532
511
98%
BOWIE
275
103
37%
BOZEMAN
181
171
94%
BROWN
495
430
87%
DUPRE
339
313
92°%
GUADALUPE
211
139
90%
HARDWICK
588
223
38°%
HARWELL
402
384
W%
HAYNES
345
87
25%
HODGES
S97
535
90%
HONEY
477
53
11 °%
ILES
318
293
a%
JACKSON.:z- .
312
296
959A
MAEDGEN
394
231
59%
11lOWHORTER
MURFEE
313
31
10°%
OVERT'ON
341
239
70%
PARKWAY
200
185
94%
PARSONS
557
254
46%
RAMIREZ
488
427
88%
RUSH
593
261
42%
SMITH
769
61
8%
STEWART
415
261
63%
TUBBS
316
260
79%
WATERS
646
182
28%
WESTER
432
287
86%
WHEATLEY
227
215
95%
WHEELOCK
399
291
73%
WHITESIDE
892
67
10%
WILUAMS
439
186
38%
WtLSON 1
458
162
35°%
WOLFFARTH
504
459
91%
WRIGHT
147
115
7a%