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Home My WebLink About1997-100A \SUMMER SER ORDINANCE NO % % AN ORDINANCE OF THE CITY OF DENTON, TEXAS, AUTHORIZING THE CITY MANAGER TO EXECUTE A CONTRACT WITH THE DENTON INDEPENDENT SCHOOL DISTRICT AND ALL ADDITIONAL DOCUMENTS AND AGREEMENTS, AS REQUIRED, TO OBTAIN FUNDING FOR THE 1997 SUMMER FOOD SERVICE PROGRAM, AUTHORIZING THE EXPENDITURE OF FUNDS TO ADMINISTER THE PROGRAM, AND PROVIDING AN EFFECTIVE DATE WHEREAS, the City of Denton, Texas will submit an application for funding under the National School Lunch Act, to the Texas De- partment of Human Services for the purpose of making meals avail- able to eligible children at the City's Summer Action Site pro- grams; and WHEREAS, pursuant to the grant, if received, the City will con- tract with the Denton Independent School District to provide the meals at the various sites, NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS SECTION I. That the City Manager is hereby authorized to execute, on behalf of the City, an application for funding under the National School Lunch Act, and if funded, the Summer Food Ser- vice Program Agreement with the Texas Department of Human Services, a copy of which is attached hereto and incorporated by reference herein, along with any other documents and certificates necessary to obtain such funding SECTION II That the City Manager is hereby authorized to execute a contract with the Denton Independent School District, substantially in the form of the contract which is attached to and made a part of this ordinance for all purposes, to provide meals for eligible individuals at the various sites, and such other documents and certifications as are necessary to carry out the 1997 Food Service Program, and to handle all fiscal and administrative matters relating to the application and the program SECTION III That the expenditure of funds necessary to administer the 1997 Summer Food Service Program is hereby authorized SECTION IV That this ordinance shall become effective immed- iately upon its passage and approval PASSED AND APPROVED this the L day of (,t��, 1997 gw�. � JAC ILLER, MAYOR ATTEST JENNIFER WALTERS, CITY SECRETARY BY Q APP OVED AS TO LEGAL FORM HERBERT L PROUTY, CITY ATTORNEY BY �� O Page 2 AGREEMENT TO FURNISH FOOD SERVICE CITY OF DENTON and DENTON INDEPENDENT SCHOOL DISTRICT FOOD SERVICES THIS AGREEMENT is made and entered into by and between the Denton Independent School Distri and the City of Denton. Denton Independent School District agrees to supply unitized meals inclusive of hulk and juice to the Cily of Denton Parks and Recreation Department; at the MLK Recreation Center, Phoenix Park, Dema Park, Civic Center Park, Owsley Neighborhood, TWU Playhouse Program, Village East Apartments, Borman Elementary Summer School, and Cnmmngs Elementary Summer School, with and for the rates herein listed Breakfasts $QM each Lunches $JM each Snacks $9M each Supper $QM each It is further agreed that the Denton Independent School District, pursuant to the provisions of the Summer Food Service Program Regulations, a copy of which is attached as Exhibit "A" and is part of this agreement, will assure that said meals meet the minimum requirements as to nutritive value and content as outlined in the U S D A's Sponsor Meal Preparation Handbook, and will maintain full and accurate recordings of such, including the following I Menu Records, including amount of food prepared 2 Meals, including daily number of meals delivered by type These records must be reported to the institution promptly at the end of each month Denton Independent School Distnct agrees also to retain records required under the preceding clause for a period of three years and 90 days after the end of the contract period If audits, claims or litigation have not been resolved, all records must be retained beyond the required time period until all issues are resolved in accordance with the Summer Food Service Program Agreement between The Ctty oMenton and the Tice as Department of Human Services The Denton Independent School District agrees to comply with the requirements of the Immigration Reform Control Act of 1986 regarding employment verification and retention of verification forms for any individuals hued after November 6, 1986 who will perform labor or services under this contract The Denton Independent School District agrees to allow for purposes of audit, examination, excerpt, and transcription, the USDA, the Comptroller of the United States, D S and any of their authorized representatives to have access to any other contractor's books, documents, papers, and records that are pertinent to the contract The Denton Independent School District agrees to comply with the required mandatory standards and policies concerning energy efficiency contained in the Texas Energy Conservation Plan issued in compliance with the Energy Policy and Conservation Act (P L 94-163) The Denton Independent School Distnct agrees that except for small purchase contracts, it will comply with and enforcd provisions that allow for ad►mmstratrve, contractual, or legal remedies if contractors violate or breach contract terms, and any appropriate sanctions and penalties The Denton Indapendent School District agrees to be in compliance with Section 103 of the contract Work Hours and Safety Standards Act (40 USC 327-330) as supplemented by the Department of Labor regulations (29 CFR, Part 5) Under this Act, contractors must compute the wages of mechanics and laborers on the basis of a standard work day of eight hours and a standard work week of 40 hours Work that exceeds the standards must be compensated at least 1'/2 tunes the basic pay rate for overtime hours worked These requirements do not apply to the purchase of supplies or materials ordinarily available on the open market or contracts for transportation The Denton Independent School District agrees to comply with Executive Order 11246 entitled "Equal Employment Opportunity" as amended by Executive Order 11375 and as supplemented in Department of Labor regulations (41 CFR, Part 60) The Denton Iriftendent School District agrees to comply with all other applicable laws, including without Imitation, any additional applicable Federal Laws or regulations contained in the Summer Food Program Agmement between the Cily of Denton and the Texas Department of If the Denton Ind=ndent School District fads to provide services in accordance with the provisions of this contract, the City of Denton may, upon written nonce of default to the contractor, immediately terminate the whole or any part of this contract The City of Denton agrees to pay Denton Independent School District for all meals ordered on a daily basis at the rate agreed upon in this contract The agreement shall be effective as of May 23, 1997 It may be terminated by notice in writing given by any party hereto to the other parties at least 30 days prior to the date of termination IN WITNESS WHEREOF, the parties hereto have executed this agreement as of the dates indicated below Agreed to this date 'f y /� 7 Agreed to this date 3 a 5 jq Sponsor Official �— School Sponsor % � a*L Title City Manager Title DISD SchoolBoard The location of the food preparation site will be Borman Elementary 1201 Parvin Denton, TX 76205 APPROVED AS TO LEGAL FORM HERBERT L PROUTY, CITY ATTORNEY 13V SUNIMER FOOD SERVICE PROGRAM AGREEMENT STATE OF TEXAS If COUNTY OF TRAVIS ; The Texas Department of Human Services, hereinafter reterred to as TDHS, AND City of Denton, Texas, A Texas Municipal Corporation at 215 E McKinney Denton, Texas 76201 hereinafter referred to as the contractor, do hereby make and enter into this contract, as required by the National School Lunch Act (Section 13) and the Summer Food Service Program, hereafter referred to as the SFSP, Federal Regulations (/ Code of Federal Regulations (CFRJ, Part 225) -7; I r J rM Q:) 6J MUTUAL AGREEMENTS a, The Parties mutually agree d »" A If the contractor fails to provide services in accordance with the provisions of this contract, the Department may, upon written notice of default to the contractor, immediately terminate the whole or any part of this contract and refuse to pay claims for reimbursement Such termination and/or refusal to pay claims for reimbursement shall not be exclusive remedy but shall be in addition to any other rights and remedies provided by law or under this contract B If federal and state laws or other requirements are amended or judicially interpreted so that the continued fulfillment of this contract, ort the part of either party, is substantially unreasonable or impossible, or if the parties are unable to agree upon any amendment which would therefore be needed to enable the substantial continuation of the services contemplated by this) contract, then the parties shall be discharged from any further obligations created under the terms of this contract, except for the equitable settlement of the respective accrued interest or obligations, including audit findings, incurred up to the date of termination C This contract may be canceled by mutual consent However, if such mutual consent cannot be attained, then and in that event, either party to this contract may consider it to be canceled without cause by giving thirty (30) days notice in writing to the other party and this contract shall thereupon be canceled upon the expiration of such thirty (30) day period Nothing in this paragraph shall be construed to prohibit immediate cancellation pursuant to above paragraphs A and/or B 1I. CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT A The contractor will comply with the SFSP Federal Regulations (/ CFR, Part 225, as amended), Uniform Federal Assistance Regulation Q CFR, Part 3015, as amended), and state policies and procedures as issued and amended by TDHS The contractor further agrees to perform as described in its application (including supporting documents and approved amendments to the application) for participation In the SFSP B The contractor accepts final administrative and financial responsibility for food service operations at each site sponsored by the contractor This responsibility includes the performance of.the coaditionmofrsetilement.of--.any sudibexiMdena or payment deficiency in the program and the collection and repayment of any amount pad in excess of the proper claim amount which are found after monitoring or auditing by TDHS or the United States Department of Agriculture (USDA) This responsibility applies to this contract, and all subcontracts hereunder C The contractor will apply to TDHS for approval of changes to Its original application and for prior authorization for field trips if meals served on the field trips will be claimed for reimbursement Requests for changes and field trip authorization must be received by TDHS at least five (5) calendar days before the requested effective date for the change or the ,field trip Contractors will notify TDHS within five (5) days of the termination of "an appr6Vbd food service site �n L -r o r, fit. UJ SFSP RECORD KEEPING c� A The contractor will keep financial and supporting documents, statistical records, and any other records pertaining to the services for which a claim Is submitted The records and documents will be kept for at least three (3) years and ninety (90) days after the termination of the contract period if any litigation, claim, or audit involving these records begins before the stipulated time period expires, the contractor wdl keep the records and documents for not less than three (3) years and ninety (90) days after the termination of the contract period and until all litigation, claims or audit findings are resolved The case is considered resolved when a final order is Issued m litigation or a written agreement Is signed by TDHS and the contractor Extensions are considered as separate contract periods B The contractor and its subcontractors will allow TDHS and USDA Officials and other appropriate officials determined by TDHS to inspect facilities and records and to audit, examine, and copy records at any reasonable time This includes seem to all records of costs paid, even in part, by TDHS Non School Sponeon . page 2 IV. CIVIL RIGHTS POLICY COMPLIANCE A The contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (Public Law 88-352), and all requirements imposed by the regulations of the Department of Agriculture (7 CFR, Parts 15, 15a and 15b) Department of Justice (28 CFR, Puts 42 and 50) and USDA and TDHS directives or regulations issued pursuant to that Act or the regulations, Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112), The Americans with Disabilities Act of 1990 (Public Law 101-336), and all amendments to each, and all requirements imposed by the regulations issued pursuant to these acts In addition, the contractor agrees to comply with Title 40, Chapter 73, of the Texas Admuustrauve. Code These provide in part that no persons in the Untied States shall, on the grounds of race, color, national origin, sex, age, disability, political beliefs or religion be excluded from participation in, or denied, any aid, care, service or other benefits provided by federal and/or state funding, or otherwise be subjected to discrimination under any program or activity for which the contractor receives federal' financial assistance from TDHS and USDA and hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement B The contractor agrees to comply with Texas Revised Civil Statutes Article 4419b-4, Sections 5 03 and 5 04 (relating to workplace and confidentiality guidelines regarding AIDS and HIV) C This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants and loans of federal fund, reimbursable expenditures, grant or donation of federal property or interest in such property, the detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease or furnishing of services to the recipient, or any improvements made with federal financial assistance extended to the contractor by TDHS This includes any federal agreement, arrangement, or other contract which has as one of its purposes the provision of assistance such as food, cash assistance for the purchase of food, rental of food service equipment or any other financial assistance extended in reliance on the 'representation and agreements made in this assurance D This assurance is binding on the contractor, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from TDHS or USDA Thg person whose signature appears on this contract is authorized to make this assurance on behdff of the contractor o �z v, �- o V. TDHS CLAIMS PAYMENT o a: a cx TDHS will, subject to the federal appropriation and availability to TDHS of sufficient funds for the SFSP, make program payments to the contractor in accordance with the terms of this contract No reimbursement shall be made for performance under this contract occurring prior to (a) the beginning effective date of this contract or (b) a later date established by TDHS based on the date of receipt of a fully executed copy of this contract Non School Sponsors Page 3 VI. CERTIFICATIONS A Immigration Reform and Control Act of 1986 - The contractor agrees to comply with the requirements of the Immigration Reform and Control Act of 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 B Regarding Debarment, Suspension, Ineligibility, or Voluntarily Exclusion For Covered Contracts - The contractor certifies, by execution of this agreement, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in this contract by any federal department or agency or by the State of Texas By making this certification the contractor agrees to the following terms I The above certification is a material representation of fact upon which reliance was placed when this contract was entered into If it is later determined that the contractor knowingly rendered an erroneous certification, in addition to other remedies available to the federal government, the Department of Health and Human Services, United Stator Department al Agriculture or other federal department or agency, or the Texas Department Department Human of 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 es defined in the attachment. 4 The contractor agrees by submitting this certification that, Should the proposed covered contract be entered into, it shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, and/or the Texas Department of Human Services, as applicable 5 The contractor further agrees by submitting this certification that it will include TDHS Form 2046 titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts" without modification, in all covered subcontracts and in solicitations for all covered subcontracts 6 A contractor may rely upon a certification of a subcontractor that Is not debarred, suspended, ineligible, or voluntarily excluded from the covered coatraet, unless it knows gist the certification is erroneous A contractor must, at a minimum, obtain certifieatiplgs"fromhat covered subcontractors upon each subcontract's initiation and upon each renewal Rac Non School Sponon page 4 VI CERTIFICATIONS (continued) 7 Nothing contained in all the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this certification document The knowledge and information of a contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings 8 Except for contracts authorized under paragraph 4 of these terms, if a contractor in a covered contract knowingly enters into a covered subcontract with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the federal government, Department of Health and Human Services, United States Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Human Services may pursue available remedies, including suspension and/or debarment C Regarding Federal Lobbying - This certification applies only to this contract and is a material representation of fact upon which reliance was placed when this transaction was made or entered into Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U S Code Any person who fails to file t6 required certification shall be subject to a civil penalty of not less than $10,000 and not moT than S400,000 for each such failure z The contractor certifies, to the best of his or her knowledge and belief, that I No federally appropriated funds have been paid or will be paid, by or on behalf of the n undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement 2 if any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer 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 ftdlerally funded contract, subcontract, subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, 'Disclosure Form to Report Lobbying,' in accordance with its instructions 3 The contractor shall require that the language of this certification be included in thdaward 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 The contractor certifies that all information submitted pursuant to this agreement Is true and corr"t The contractor understands that the deliberate misrepresentation or withholding of information is a violation of this contract and may result in prosecution under applicable state and federal statutes Non Sdi nl Sponsors Pn6e 5 V1I EFFECTIVE DATE AND SIGNATURES For the faithful performance of the terms of this contract, the parties hereto in their capacities stated, affix their signatures and bind themselves City of Denton Name of the Contracting Organization (Please Print or Type) Z0 Original signature of the authorized representative of the contracting organization Ted Benavides Name of the authorized representative of the contracting organization (Please Print or Type) City Manager Title Please print or type, to the spaces provided above, the name and tide of the authorized representative signing this agreement on behalf of the contracting organization TEXAS DEPARTMENT 00 HUMAN SERVICES>5 Effective Dates o? '7L �//9 % ,t through � By l Date. Revised February 1994 Non school sponaon Page 6 Tom 0"MMht M M W.. iMm 4� i....�u CERTIFICATE OF AUTHORITY This Is to certify that Nam. of Auftnzw Off" (Ptaaaa type w Pnrd) TnN Ted Benavides City Manager SOWW Author"d Off" Is designated as the authorized representative of Now of Contraamp Orpanw On City of Denton Ad&M (Stan COY SW@ ZIP) 321 E McKinney Denton, TX 76201 The representative designated above Is authorized on behalf of the contracting organization to make written agree- ments with the Taxes Department of Human Services to opente A food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to the department SWWW*- FOR DEPARTMENT OF HUMAN SERVICES USE ONLY TeO DOprwlwm of HWMn sww"s Fans JOde JUN Im CERTIFICATE OF AUTHORITY This Is to certify that NUM of AWwrWp OR" W"M"a pMQ TIM Nicole Fletcher I Children's Programs Supervisor Is designated ae the authorized representative of NWM of Conlrfl "OWnualon City of Denton Aditn (BROW C 1V Sup ZIP) 321 E McKinney Denton, TX 76201 The representative designated above Is authorized on behalf of the contracting organization to make written agrees meets 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 SWWWM--0ekW of Can AC" Aser4y DWO NWM W Off" Bynu typo W prmp Tile Ted Benavides City Manager h FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: AepWMrd No MoWMd ay OWO TX- Tom" Doonff M M W... tom• brit 4m CERTIFICATE OF AUTHORITY This Is to Certify that Nar" of AYmOniaa QR4W W"n typo a pant) Tme Paul Tucker „ Summer Food Coordinator Is designated as the authorized representative of ram of Conirap,ng Organustmn City of Denton 10oraaa (BVM Coy stag ZIP) 321 E McKinney Denton, TX 76201 The representative designated above Is authorized on behalf of the contracting organization to make written agree• ments with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agreement, and to present Claims for reimbursement, when appropriate, to the department h Q SWWA n— MW of Cawaogng Agency IDW— w" of On" (prat" type tx print) TWO Ted Benavidea City Manager FOR DEPARTMENT OF HUMAN SERVICES USE ONLY' Aw""Mem No fiaaaited By ntb TX- h Texas Depenmeni of Numen senoras SUMMER FOOD SERVICE PROGRAM APPLICATION FOR PARTICIPATION NOTE Give as much Information as possible Attach additional sheets It needed, please Identity each attachment with the name of the contracting organization. SECTION I -SPONSOR INFORMATION FOR DNS STAFF ONLY O No „j EI / 061-looe S a� ❑ Breakfast ❑ AAL Supp M Lunch Contracbrp Ori;;W"Bon Name VerMor to No Tebptnrie No Noeine No of Dento Magi Mai6rp Adtlrass (SVeet or P O Box, CityState Zlp) 17560005146015 (817 ) 566-8125 817 566-8125 321 E McKinney Denton, TX 76201 SVeel Adtlress 01 dMerent) Name of Admiustraw Title Nicole Fletcher Children's Pro rams Su ervisor A Contractor Classification (Check all that apply) Residential/Nonresidential ❑ National Youth Sports Program ❑ Summer Camp Continuous Calendar ❑ School Food Authority ❑ School Year B Is your program a year-round program? C Type of Contractor Q Public Entity (explain) Is your agency considered to be state owned/operated? Do you deposit your program reimbursement directly into the St to Treasury? QUnit of Govemment-Contractor cues that all food service sites are operated directly by the contractor ❑ Private Non-profit — r9Yes �]No y� > -_w Ln 4 c ., O 7 w -� LLJ n �Ye�No ©NIA-MYes LJNo Do you deposit your program reimbursement into a local bank? ❑NJA ©Yes ❑No If yes, is it direct deposit? ❑Yes ©No ❑ Private Nonprofit Organization -Tax-exempt status established. Attach letter of determination (IRS 501 30) of tax-exempt status from IRS Do you deposit your program reimbursement Into a local bank? If yes, is it direct deposit? ©N/A ❑Yes ❑No ❑Yes []No D Does the organization provide an ongoing year round service to the community that Is to be served by the Summer Food Service Program (SFSP)? Yes ❑No If no, which of the following circumstances applies? Residential Camp poor area f11 m P ❑ Failure to operate would deny program b a ❑ Serves Migrant Children ❑ Failure to operate would deny a significant number of children accis" to progtom r E 1 Does the organization receive $100,000 or more in federal funds yearly? Q Y6li ❑ No 2 Does the organization receive more than $25,000 but less than $100,000 in federal funds yearly? []Yes ®No 3 Attach a copy of the audit covering last year's program operation or documentation that an audit conforming with SFSP policy will be conducted, Including the date it will be conducted SECTION II -BUDGET Fain tso6 Pep. 2 A Estimate all SFSP costs which Will he daimwA In, .uimh. for the program veer ESTIMATED OPERATIONAL COSTS PROG RAM YEAR COSTS Program Labor 6,273 Fringe Benefits 627 Food 30.256 Non-food Supplies 500 Utilities Rent Equipment Use Fee Rental of Equipment 2, 000 Transportation Rate per mM 28 200 Oilier leoeah) Caw (epedh) COW (epedh) TOTAL 39,856 t ESTIMATED ADMINISTRATIVE COSTS PROGRAM YEAR COSTS Adrninistrativa Labor _ (Management, Monitor, Clerioaq 3,066 Frklge Benefits 307 Rental of Office Space Utilities Office Supplies 200 Office BufldkV Maintenance Equipment Use Fee Audit Fees Legal Fees Rate per ir" Transportation OIMr (NtedrY) Mobile Phone 300 Cow opeady) TOTALS 3,873 8 Indicate projected Income to the food service from all sources other than SFSP teimbursemenL Identify exagly tfle costs this income will (Do not Include state or federal funds ) Ul_ v SECTION III —MANAGEMENT PLAN wtp A Ust administrative level personnel who will be 'responsible for management and monitoring of the SFSP (Do no`1 include su ~ rs, cooks, janitors or other personnel involved in on -site food service ) °° «Q TITLE OF POSITION NUMBER IN POSITIONN SPECIFIC FOOD SERVICE PROGRAM DUTIES POSITION Director 1 Conducts training session, Monitors sites, prepares reports, coordinates food ser`hes Coordinator `r= 1 Assists Director with duties n^ i I.J Forth is06 Pape 3 8 Are children charged separately for meals? ❑Yes Q No If yes, see Form 1508, Attachment B C Do you want to receive advance payments? ❑Yss QNo If yes 1 For Operational Costs? ❑Yes []No 2 For Administrative Costs? Dyes ❑ No D If meal service is seff-preparation, do you want to receive commodities? ❑ Yes ©No If yes, Form 1608, Application and Agreement for Commodities, must be completed SECTION IV —PROGRAM OPERATION A.1 Beginning and Ending Dates of Meal Service From May 27, 1997 through August 8, 1997 2 Number of sdes B List dates and IDpICs of SFSP training 10 DATES TOPICS 5/23/97 Site supervisor and monitor training on S F S P guidelines and Civil Rights training a` m n r>- F� s� Ln 0 C Is the organization planning to contract with a food service management company for the preparation of unitized meals? inA CIO {L � �I.- YeCaJNo If yes, and the contract will exceed $10,000, attach a copy of the Invitation to bid Also WeDate t F U L' Date a ed soon a ed Openv cane ed Openaq is bid expected to be $lop 000 «mae? I n Yes One place a opsryn7 ❑ Yes ❑ No Also, attach a copy of an 1 i-day-cycle menu mduding all specific menus to be used r-- c7'7—� D Is the organization contracting with a year-round food service management company? �QYss LEND it yes, submit a copy of your procurement procedures, bid, contras, and all amendments "' "— a M E Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department no m P ttfytng them of octant to op ate a Food Service Program at the site(s) indicated on the attached Site Information sheet (Form 1507) It o r, SECTION V—ASSURANCES u3<7I— r A Free Meal Policy Statement Site(s) Information Sheets for the Summer Food Service Program, will be offered the same meals with no physical segregation of 1 The contracting organization assures the Texas Department of Human Services (DHS) that all children at the sites described on , her the or ot discrimination against, any child because of race, color, disability, age, sex, national origin, religion, or political beliefs No separate will be made for any meal except in accordance with attachment B of this applicabon charge 2 The contracting organization assures DHS that, M 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-pnoe,and • The children claimed as free or reduced price meet the current family size and income standards set by the United States Department of Agriculture, DHS Form 4504, Standards for Determining Free and Reduced -Price Eligibility Form 1506 Face a 3 If the contracting organization is sponsoring a camp or other enrollment program that charges separately for meals the contracting organization has read Attachment B to this application, 'Additional Assurances for Camps and Other Enrollment Programs that Charge Separately for Meals' and assures DHS that all requirements have been or will be met 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 N the contracting organization is sponsoring a camp or other enrollment program, this release must contain, at a minimum, a list of all approved sites, a list of the current standards for determining free and recuded price eligibility, and the following statement Cit of Denton "The n+,me�theaonnaaM(X9ardzaaon) announces the sponsorship of the Summer Food Service Program Income eligibility will be based on family size and Income using the Standards for Determining Free and Reduced -Price Eligibility, provided by the United States Department of Agriculture Meals will be provided at the site(s) listed People who are eligible to participate In the program must not be discriminated against because of race, color, national origin, sex, age, disability, religion, or political belief Anyone who believes that they have been discriminated against should write Immediately to Director, Civil Rights Division, MC W-108, Texas Department of Human Services, P O Box 149030, Austin, Texas 78714-8030 or the Secretary of Agriculture, Washington, D C 20250 NOTE Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services " For all other programs the announcement must contain, at a minimum, a 09 of all approved sties and the following statement City of Denton "The 114 m of fhe cminidnii agarYzadon) announces the sponsorship of the Summer Food Service Program Meals will be provided at the site(s) listed People who are eligible to participate In the program must not be discriminated against because of race, color, national origin, sex, age, disability, religion, or political belief Anyone who believes that they have been discriminated against should write immediately to Director, Civil Rights Division, MC W-108, Texas Department of Human Services, P O. Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington, D C 202SO 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 outlets) NAME OF MEDIA OUTLET DATE OF RELEASE Denton Record Chronicle e® 5/1/97 Dallas Morning News 5/l/97 UNT Daily 5/1/,7 - NAME OF MEDIA OUTLET DATE OF RELEASE TWU Student Paper 5/l/97 KNTU Radio 5/l/97 uon K, Mug 3 Attach a copy of the contracting organization's public release statement as submitted to the news media arid any otheL)matenals used to publicize the program's avadabift and nondiscnmtpabon requirements r : co ea UJ i Jr,[ SECTION VI— CERTIFICATION (see Form 1506, Attachment C) > a ^xo u, o1339 1 certify that the Information on this application Is true and correct to the best of my knowledge I certify t_ that rolm)ayrrsen aW will be claimed only for approved meals served to eligible children during the hours they are In attendance at approved$ites avow, that deliberate misrepresentation or withholding of Information may result in prosecution under applicable state and federal statutes �— Aq 1'7 1 q rl r a Spnawe- A" a Conirmng urguftation on" h Na" ID"aae IYDe a Will TWO Nicole Fletcher Children's Programs Supdrvisor UNLT :L7 APPROVED ❑ DENIED If denied, reason Appmved for Food Dembufon Date Yes No Res, give date Form 1608 sent to FDD' D 0 ' _L , '57/ri 97 P/l�lLet tit ei Al of Omblit"M wle Tex" Deparorro t Form 1507Nan of Human senses SUMMER FOOD SERVICE PROGRAM FOR CHILDREN _ FOR DNS USE ONLY SITE INFORMATION n( 06/_ /00 Z- I MIt Number of Op. 4 Y 21 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Reaww" Camp Site Serving Primarily Migrant Children Other Site 1 Indicate Type of Site ❑ A. ("wing one to throe meat) ❑ C (serving one to three meals) © E (nerving one to three meals) Nonresidential Camp She Serving Primarily Homeless Children ❑ S (serving one to three mesh) ❑ D (serving one to three meals) 2 List ALL counties served by this she Denton 3 A Is your site open ©Yes ❑No B Is your site enrolled? ❑Yes LO No r C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) 19 ! s D If open sites, submit documentation supporting this percentage figure (such as census date, school data) For open sites using school data list the schools used to document site eligibility; attach formula used by school disc. to establish percentage of free 3 reduced price children Census data from TACAA E For enrolled sitesi Form 1531 will be used to document eligibility (National Youth Sports Program -refer to SFSP Handbook, Chapter 2 ) If the enrolled site used school data, list the school used to document the site F What is the percentage of free or reduced -price meals for " site? 100 sic 4 Did the site participate in previous years' SFSP? (SFSPh Handbook, Chapter II) �,{; 0 Yea ❑ No t, r If Yes, give name of contracting of Denton ng organization �, .. vi w 5 Monnonnc Plan (SFSP Handbook. Chanter 111) Enter date of moNtorinD review to be conducted within A. Posy Week of Opefetwn a First Four WealM of Operadw C Add rvu ReWews ku _ 5/30/97 6/20/97 7/25/97 = To l wr e Meal Service Period Information (SFSP Handbook, Chapter 11) ate._ ELL, TYPES OF MEALS NUMBEROF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M Supplement Lunch 70 12 00 DIM, 1.00 P M Supplement Supper 7 Do you plan to feed children under one (1) year old? a []Yes QNo Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) Sep wepvaton VWWed Using School Using Food Servke Management Wing Pdvate Noo-Profh ❑ On Site ❑ Cantral (hohen ® Food Authority ❑ Company pndudea All Yeu Contracts) ❑ Organbation that ls seh'Prep Form ISull-too Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) ❑Caleterl"tyle Children are Seated CNklron Line Up Mal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Otlwr 10 List site personnel who will be Involved to any extent In the meal service (SFSP Handbook, Chapter II) TTTLE OF POSmON NO IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up, and other duties as assigned Site Helper/Server 1 Assist Supervisor 11 Indicate what provisions will be made for meal service during periods of Inclement weather (SFSP Handbook, Chapter 11) Indoor Meal Meal Service ❑service ID Will Be Cancelled Mother 12 9 rile site feeds primarily homeless children, what methods are used to ensure that money, food stamps, or In•ldnd senrkes are not required for meals? N/A 13. Are meals delivered to the site? Q Yes ❑ No IF YES, COMPLETE ITEMS 14,15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM 14 Indicate the means of communication with the vendor which will be used to adjust meal deliveries (SFSP Handbook (,hap II ®Site Personngj WIII Contact Administrative She Personnel WIII Communicate -t" n Stag, Who WIII Contact Vendor ❑Directly Whit Vendor u` 15 Will delivery be within one hour of the food service period? ($41P Handbook, Chapter 19 'o= 1�� ®Yew ❑ No tl no, describe arrangements within standards prescnlocalbed by khealth authorities for delivery and holding of rtlea ' ibl tlmer&servkaz s r +r 0 16 If two is an excess of meals delivered, meals will be (SFSP Handbook, Chapter Ill) StOrld in ❑Refrigerator theT Next Day ❑attheShe El for Roturned to and Served ❑Other. I CERTIFY that the Information on this form is true and correct to the best of my knowledge I certify that this she has been visaed 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 :72= n under applicable state and federal statutes Name City of Denton sp .e.. oamw of Cworawp Orgamutlon wu Nicole Fletcher FOR "Approved ❑Daled,reaaon DNS uSE TpM ONLY 5/y4 97 c,dx�iQe.f �/`lex,[g�, MpYbDi1s pNenYliw OW Teats Department Of H~ &rrvloes e TWU Clubhouse SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Mary Hufford Court Denton, TX 76201 TX A/'/-/ooa- rperioaaowmw/9From 7through ds«vim(�8/8/97 Number of OP' �M" �J" ��2 �Au6 Sept D1 erallng Days. ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Site 1 Indicate Type of Site ❑ A. (serving one to throe malt) ❑ C (serving one to three meals) © E (serving one to throe meals) Nonrotidentlal Camp Site Serving Primarily Homeless Children ❑ B (serving one to three meals) ❑ D (serving one to three mask) 2 List ALL counties served by this site Denton 3 A Is your site open ED Yes ❑ No B Is your site enrolled? ❑Yes ❑X No C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) 19 So D If open sites Submit documentation supporting this percentage figure (such as census date, school data) For open sites using school data list the schools used to document age eligibility, attach formula used by school cisVto establish percentage of free 6 reduced price children Census data from TACAA E For enrolled sites, Form 1531 will be used to document eligibility (National Youth Sports Program -refer to SFSP Handbook, Chapter 2 ) If the enrolled site used school data, list the school used to document the site F What Is the percentage of free or reduced -puce meals for the site? t ; „ — 10 4 Did the site parhapata in previous years' SFSP? (SFSP Handbook, Chapter II) I IYes % No c � If Yes, give name,*( contracting organization City of Denton M 0 lad—_ te' 5 Monitoring Plan (SFSR Handbook, Chapter III) Enter date of monitoring review to be conducted within A Feat week of Cperetwn B Fit I = Weeb of opermion C Ao MWW Rwrws��- 5/30/97 6/20/97 7/25/97 h e Meal Service Penod Information (SFSP Handbook, Chapter II) TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVEIr MEAL SERVICE TIME BEGINNING ENDING Breakfast A M Supplement Lunch 55 12 00 p m 1 00 P m P M Supplement Supper "nu eMmlaeen is eeneleeree ey U M Mum o spix ' maa M e Wrar rw� —'— ,1 7 Do you plan to feed children under one (1) year old? ❑Yes [!]No 8 Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) skit PreparaWn V0"Nd Using School Using Food Service Management Using Private Ncn,Profft non Site ❑ Central Kitchen ® Food Authority ❑ Company (Includes All Year Contracts) ❑ Organ a n that ls Self -Prep Iblm 1f070Psp Indicate the system to be used for the serving of meals and the supervision of children during most service period (SFSP Handbook, Chapter II) Cafelorls-sMeal service ❑dGiven anen Children areaeals Eland Pick Up Mea Children Line U ❑ls ❑ WMr 10 List site personnel who will be involved to any extent in the meal service /SFSP Handbook Chanter In TrrLE OF POSmON NO IN POSm10N SPECIFIC F000 SERVICE PROGRAM IKMES Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up, and other duties as assigned Site Helper/Server jAssist Supervisor 11 Indicate what provisions will be made for meal service during periods of Inclement weather (SFSP Handbook, Chapter II) Indoor Meal Service ®Service eat ❑WIIIBeCancelled ❑Other 12 If the site feeds pnmaniy, tameless children, what methods are used to ensure that money, food stamps, or In -kind sorb es are not required for meals? N/A 13 Are meals delivered to the site? ® Yea ❑ No Y3 fF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14 Indicate the means of oDmmunlcatan with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap II) ©Site Personnel WIII Contact Administrative She Personnel W61 Communicate Stif, Who Will Contact Vendor 001rsetly With Vendor = 15 VJIII delivery be within one hour of the food service period? (SFSP Handbook Chapter In r u Wp X YES' LJ No If no, describe arrangements within standards prescribed by local health audorit" for delivery and holding of meals�at time or Service, �= r_ ca w_ Ko >1 16 If two Is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) StoredReturned to Served the Next Day ❑at the Site Away Qfa Dispoal Vendor ❑Other I CERTIFY that the information on this forth Is we and correct to the best of my knowledge I certify that this she 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 wMholdm of information may result In prosecution under applicable state and federal statutes Nanr %,bu Cit of Denton a1I of CWWOW a owmtoow IDau isor FOR MApproved ❑Denied,reason OHS USE ONLY T (o-fi_v l,l�%Z�ZeF-Y S/ri %7 1, Ilfl xre'l(w . SgnaOre-oms Rp sic tauw Dam Texas Del a ewt Form 1507Jan of Human Sorvlaes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY SITE INFORMATION TX 061-106 y 1 MR Denia Park 1001 Parvin Denton, TX 76205 Perioa a d Food Sennos (moJdeyryr -rnemsyryr) Number of Op- ' �A21 �JWY D 6o D Sept From 5/27/97 through 8/8/97 alatingDays 2 2 ! ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Resldentlal Camp She Serving Primarily Migrant Children ❑ ❑ Q Other Site 1 Indicate Type of Site A. (serving one to three male) C (serving one to three meals) E (serving one to three meals) Nonnek entlai Camp Site Serving Primarily Homeless Children ❑ a to throe ❑ D one to three meals) (serving one mats) (serving 2 List ALL counUes served by this site Denton 3 A Is your site open QYes []No B Is your site enrolled? ❑Yes Q No C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) 64 e„ D It open sites, submit documentation supporting this percentage figure (such as census date, school data) For open sdes using school data list the schools used to document site eligibility, attach formula used by school dist.'to establish percentage of free 6 reduced price children Census data from TACAA lilt E For enrolled sites, Form 1531 will be used to document eligibility (National Youth Sports Program -refer to SFSP Handbook, Chapter 2cri) If the enrolled site used School Beta, list the school used to document the site 's m o U, X F What is the percentage of free or reduced-pnoe meals for the site? 1 4 Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) rsCon 5;' L=7Yek�E3No If Yes give name of Contracting organization City of Denton I— 5 Monitorino Plan (SFSP Handbook, Chapter 111) Enter date of monitoring review to be conducted within d N 5/30/97 1 6/20/97 1 7/25/97 e Meal Service Period Information (SFSP Handbook, Chapter II) TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast AM Supplement Lunch 30 12 00 p m 1 00 p m PM Supplement Supper -rva edonnaoon is cons"ma W i>nc vmen servov ins approves men servo n pror � Ww, ,q 7 Do you plan to feed children under one (1) year old? ❑Yes QNo 8 Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) Sell Prsparaoon vended Using School Using Food Service Management lking Private Non•Pmfh n On Site ❑ Central Kitchen ® Food Authority ❑ Company Precludes All Year Contracts ❑ 0 anDation that Is Seff-Prep Fmm tae7)Pege Indicate the system to be used for the serving of meals and the supervision of Children during meal service period (SFSP Handbook, Chapter 11) Calatt" Children are ❑ Meal SeMaN ❑ and are Given Seated Meals Eland Pick Up Meals ❑ other 10 List arts personnel who will be Involved to any extent in the meal service (SFSP Handbook, Chapter II)- TRLE OF POSmON NO W POSMON SPECIFIC FOOD SERVICE PROGRAM DUTIES Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up, and other duties as assigned, Site Helper/Server 1 Assist Supervisor 11 Indicate what provisions will be made for meal service during periods of inclement weather ($FSP Handbook, Chapter II) Indoor Meal Service ED Service sal ❑Will Be Cancelled ❑Other 12. h the site feeds primarily homeless children, what methods are used to ensure that money, food stamps, or inland services are not required for meals? 13 Are meals delivered to the site? QYea [I 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 delrvedes (SFSP Handbocki C,,hup ID m ©She Personnel Will Contact Administradn SRO Personnel Will Communicate w4 Stiff, Who Will CaMact Vendor ❑ Directly With Vendor r_ , v w 15 N/Iti delivery be within one hour C the food service period? (SFSP Handbook, Chapter II) c ;r c x 1 Yea I h no, describe arrangements within standards prescribed by local health authorities for delivery and holding of me vs l time of aervbq� o a 16 If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter IIQ Stared In Refrigerator Thrown Away ReWmed to Vendor ❑and Served the Next Day ❑ at the Site Q for Disposal ❑other No I CERTIFY that the information on this form is true and correct to the best of my knowledge I certify that this she 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 withhold i of Information may result in prosecution under applicable state and federal statutes ( Q _ �� ] /Q7 City of Denton wed Of CwitreCng organroon+- name a uman awe type W prmq Two Nicole Fletcher I Children's Proarams Supervisor FOR I Approved ❑ Denied, reason OHS USE y ONLY _ I<. t .. TNN Tau" Department Fom of Kaman 8ennO°s SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR tNIS usI SITE INFORMATION TX 061 100 Z Phoenix Park I (81 Wood Street Denton, TX 76201 renoD w w.nawi a rw a..nw tma+uzym' 4� yin I Number of Op - From 5/27/97 throiah: 8/8/97 sraBnaDays 4 21 22 6 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Reside" Camp Site Serving Primarily Migrant Children Other Site 1 Indicate Type of Site ❑ A. (serving one to throe mals) ❑ C (serving one to three mals) © E (serving one to three meals) Nonresidential Camp Site Serving Primarily Hom kse Children ❑ B (arvkq Gas to three Russia) ❑ D (serving one to three meals) 2 List ALL counties served by this site Denton 3 A Is your site open Yes ❑No B Is your site enrolled? []Yes Q No C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter 11) 31 5, D If open sites, submit documentation supporting this percentage figure (such as census date, school data) For open sdes using school data list the schools used to document site eligibility; attach formula used by school distr to establish percentage of free & reduced price children Census date from TACAA E For enrolled sites, Form 1631 will be used to document eligibility (National Youth Sports Program -refer to SFSP Handbook, Chapter 2 ) If the enrolled site used school data, list the school used M document the site w.n w-- F What is the percentage of tree or reduced -price meals for the site? 100 % k C? T Y ••• a Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter 11) w LJYesItC5 o wtr c>` ' City of Denton If Yes, give name of contracting organization. 5 Monitoring Plan (SFSP Handbook, Chapter III) Enter date of mondoring review to be conducted within A. Fuse Week of Operation B. Feat Four weeks of Operation C Additional ReveAvs 5/30/9 1 6/12/97 1 7/25/97 e Meal Service Period Information (SFSP Handbook Chapter 11) TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED* MEAL SERVICE TIME BEGINNING ENDING Breakfast AM Supplement Lunch 90 12 00 p m 1,00 P m L PM Supplement Supper -m Wennatan is CO wwrea Dy I]M Wrien /earq su approveD row wry a larar rwww„n. fin, — ,,, 7 Do you plan to feed children under one (1) year old? []Yes 0 No 8 Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) Sett Preparation v"oed Using School Using Food Service Management Using Pdvi Non Prolh n On Sne ❑ Central Kitchen I ® Food Authority Q Company (Includes All Year Contracts) Q Organaatlan that is SeHPrcp Pam /6071Pepe Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter 11) caleterwa le Children are Mservice Eland am Olwn Seated Meals Eland Pick Up ❑al Meals ❑ 0dw 10 Ust Me personnel who will be involved to anv extent in the meal sarvim rSFSP 11aMh nnk (pants, 11% THE OF POSMON No IN POSITION - _. _ _.. __ — _. .._..----- I _..,._..., SPECIFIC P000 SMWA PROD DUTIES Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean—up, and other duties as assigned Site Helper/Server 1 Assist Supervisor 11 Indicate what prgvisbns will be made for meal service during periods of Inclement weather (SFSP Handbook, Chapter 11) Indoor Meal Meal Service ❑Service ❑X Will Be Cancelled ❑Other 12 tl the site feeds primarily homeless children, what methods are used to ensure that money, food stamps, or In•ldnd services are not required for meals? N/A 13 Are meals delivered to the site? ®Yee ❑ No W 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 HsndlotoksChhap Ind ®Silo Personnel WIII Contact Administrative She Personnel WIII Comnenicale a. � , rn Staff, Who WIII Contact Vendor ❑ Directly With Vendor 10M 15 WIN delivery be within one hour of the food service period? (SFSP Handbook o Chapter In n ❑Yes_❑ No If no, describe arrangements within standards prescribed by local heahh authorities for delivery and holding of meal MIX servislt� co vx w 16 If there Is an excess of meals delivered, meals will be (SFSP Handbook Chapter Iln ❑Stored feat �aX � VendorEndServedtiDay ❑theSN Bal ❑OtlNr I CERTIFY that the information on this form is true and correct to the best of my Imowiedge I certly that this site has been visited and that it has the capability and facilltles for the meal service planned for the number of children anticipated I know that deliberate misrepresentation or wnhhoW Of information may resuh in prosecution under applicable state and federal statutes Nrae G City of Denton W Camac" Omewiabon IDeli Nicole Fletcher. _ I Children's Programs Supervisor FOR [tAppreved ❑Denled,mason OHSp ONLYUSE L/rl 17 Taw SIOraNs-OHS Rapraasnuwe Dew Teaaa Deparonant Of human Sarvioes Civic Center Park 321 E SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Denton, TX 76201 Tx o(Pl- /a o L MR **"*NO M ) (817) 566-8125 �—.,w , w,. ' � %11•v /1r, -^v Ylrl I Humberof Dp• ""r '""r mil seal. From 5/27/97 through, 8/8/97 1 erallnaDays 4 21 P 22 6 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1 Indicate Type of Site ❑ Residential Camp A (servbhg one to three meals) ❑ Site Serving Primarily Migrant Children C (wrving one o three meals) Other Site 0 E (serving one to Was meals) ❑ I Nonresidential Camp B (serving one to three meals) ❑ Ste Serving Primarily Homeless Children D (serving one to three meals) 2 Ust ALL counties served by this site Denton 3 A Is your site open B Is your site enrolled? ❑X Yes ❑ No ❑Yes (ENO C Site Ekgibilityr-Enter the percentage of children eligible for free andifor reduced price meals for the site (SFSP Handbook, Chapter II) 22 50 D If open saes, submit documentation supporting this percentage figure (such as oensus date school data) For open sties using school data list the schools used to document $ae eligibility, attach formula used by school that., to establish percentage of free 8 reduced price children 13 Census data from TACAA , For enrolled sites Form 1531 will be used to document eligibility (National Youth Sports Program -refer to SFSP Handbook, Chapter 2 ) If the enrolled site used school data, fist the school used to document the site F What is the percentage of tree or reduced -price meals for the site? v , _ 100 % Did the site artici ate�In previous years'SFSP? (SFSP Handbook, Chapter II) x ®4 Yss Ey No « u If Yes give name of contracting organization City of Denton C)cri _ 5 Monitonno Plan (SFSP Handbook. Chapter III) Enter date of monitoano review to be conducted within w; r o A. Fint Waek a Operation a Fiat Four weeps C AaatblW Reviews r, _ 5/30/97 6/12/97 7/25/97 nw E Meal Service Period information (SFSP Handbook, Chapter II) TYPES OF MEALS NUMBER OF ELMISLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast AM Supplement Lunch 40 12 00 p m 1 00 p m P M Supplement Supper rile epwrrwuun w anwaenw � vry w,w,, w,uY ue eyy„nw, nwr w,�,va wwu lar�r r.ro.+...w, M�va ^l 7 Do you plan to feed children under one (1) year old? []Yes ©No 8 Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) San Preparatwn n Ve1� Using School Using Food Service Management Using Private Non -Profit ❑ On Site ❑ Central Kitchen I ❑ Food Authority ❑ Componv (Includes All Year Contracts) ❑ Organization that is Self -Prep Form I1a rps" Indicate the system to be used for the serving of meals and the supervision of dntdren during meal service period (SFSP Handbook, Chapter II) Callated" Children am Seated Children Line []mew service e Eland am Olwn Meals 0 and Pick Up Mats ❑ ovi sr• 10 List site personnel who will be involved to any extent In the meal service (SFSP Handbook Chaoter III TTTLE OF POSmON No IN PosnION SPECIFIC 1000 SERVICE PROGRAM DIMES Site Supervisor 1 supervise and assist distribution of meals, monitor and maintain meal temperature, site clean—up and other duties as assigned Site Helper/Server 1 lAssist Supervisor 11 Indicate what provisions will be made for meal service during periods of Inclement weather (§FSP Handbook, Chapter II) Indoor Meal Meal Service ©Service ❑Will BeCancelled ❑Other 12 0 the site feeds primarily tameless children, what methods are used to ensure that many, food stamps, or in -kind services ire not required for meek? N/A 13 Are meals delivered to the site? QYsa []No IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM k 14 Indicate the means of communication with the vendor which will be used to adjust Rled deliveries. (SFSP Handbook, Chap IQ QSite Personnel WIII Contact Administrative Site Personnel WIII Camimindcde Sfafl, Who WIII Contact Venda ❑ Directly With Vendor vi r-- m 15 Will delivery be within one lour of the toad service period? (SFSP Handbook, Clnpw Iq 4z , OYq No H no, describe arrangements within standards prescribed by local heath aulhodbea me for delivery and holding of et} W Mite seMoaao ,a a Ca o a c 16 If there Is an excess of meals delivered, mask will be (SFSP Handbook, Chaplet III) Stored in Refrigerator Thrown Away Retumed to Venda El and! Served the Next Day ❑d 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 visaed and that It has the capability and facilities for the meal service planned for the number of children anticipated I know that deliberate nusrepreser atlon or wMholdi of allormadon may result in prosecution under applicable state and federal statutes N.ms yI��-+/�/ �� o�T City of Denton Inel a Corma�q Oryw:aCon items a u uireeae type w win TI M _ Nicole Fletcher I Children's Programs Supervisor FOR oNs I C�Appreved ❑Danled,reason USE I 1 ^/ Toe ONLY !�,(�-ae�ne lore -DNS Rewpfewaa tor- Dab Texan Depanntent of Human &rows SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION MLK Recreation Center 1300 Wilson Denton, TX 76205 TX 00- /00 z (817) 566-8125 0111KIF �.. M r V V., ,,...,e V,„ taeq/P -nwr yrrl I Number of Op- "'� '^�� +�v rain � From 5/27/97 thmwh 8/8/97 emanoDava 4 21 22 6 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Resideri Camp Site Serving Primarily Migrant Children Other Site 1 Indicate Type of Site ❑ A (serving one to three meals) ❑ C (serving one to throe meals) ® E (serving one to throe meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B (serving one to three meals) ❑ D (serving one to three meals) 2 Ust ALL Counties served by this site 3 A Is your site open B Is your site enrolled? Denton ®Yea ❑No ❑Yes QNo C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook Chapter II) 31 a s D If open sites submit documentation supporting this percentage figure (such as census date, school data) For open sites using school data list the schools used to document sde eligibility, attach formula used by school distr to establish percentage of free 3 reduoed price children Census data from TACAA r- E For enrolled sites, Form 1631 will be used to document eligibility (National Youth Sports Program -refer to SFti.MandtiZ, Chapt&2 ) t, r— If the enrolled site used school data, list the school used to document thin site Uj F What is the percentage of free or reduoed•pdoe meals for the site? � % LLII, 4 Did the site participate In previous years' SFSP? (SFSP Handbook, Chapter 11) ,, [MY** No If Yes, give name of contracting organization 5 Monitoring Plan (SFSP Handbook, Chapter III) Enter date of monitoring review to be conducted within A Fret Week of operation 8 Fiat rwur Weeks on operation C AddWarW Revwwa 5/30/97 6/12/97 7/25/97 E Meal Service Period Information (SFSP Handbook, Chapter II) TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED* MEAL SERVICE TIME BEGINNING ENDING Breakfast A M Supplement Lunch 90 12 00 p in 1 00 p in P M Supplement Supper tun xeonnaton is oons ,re oy u wren atanp cue apptoveo mesi arvwe tevet tarnr nartmeoa. u,.vrer „I 7 Do you plan to feed children under one (1) year old? [:]Yes ©No 8 Method of Food Preparation byContracting Organization (SFSP Handbook, Chapter II) San Preparation verdw Using School Using Food Service Management Using Private Non -Profit n On Site n Central Kitchen I n Food Authority n ComDanv (Includes All Year Contracts) n Onumiradon that Is Se&Preo Fine 18071POS Indicate the system to be used for this serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Cafeterl"tyle Children are Seated CNldren Line Up ❑ M❑ eel ice Sery❑ End are Given Meals ® and Pick Up Meals OUwr 10 List site personnel who will be involved to any extent In the meal service (SFSP Handbook. Cheater III TITLE OF POSmON NO IN POSmON SPECIFIC FOOD SERVICE PROGRAM DUTIES Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up, and other duties as assigned Site Helper/Server --t i 1 Assist Supervisor I I 11 Indicate what provisions will be made for meal service during periods of inclement weather ($FSP Handbook, Chapter IQ Indoor Meal Meal Service El service ❑Will Be Cancelled ❑Other 12 If the site feeds primarily homeless children, what methods ere used to ensure that money, food stamps, or in kind servkxu are not required for meals? 13 Are meals delivered to the site? ©Yes ONO IF YES, COMPLETE ITEMS 14, 15, fk 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 delhiedw (SFSP Handbook, Chap II) Ske Personnel Wiil Contact Administrative atle Personnel WIII Communicate ® Staff, Who WIII Contact Vendor ❑ Directly With Vendor 15 Will delivery be within one hour of the food service period? (SFSP Handbook Chapter IQ MY" []No If no, describe ariangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 16 If there is an excess of rivals delivered, meals will be (SFSP Handbook, Chapter III) ❑Stored In RefrigeraW Thrown and Served the Next Day ❑ el the site Vendor Returned to ® far DloposaI❑Otller I CERTIFY that the Information on this forth is true and correct to the best of my knowledge I certify that this site has been visited and that a has the capability and facilities for the meal service planned for the number of children anticipated I know that deliberate misrepresentation or withholdirip of Information may result in prosecution under applicable state and federal statutes L. i�" City of Denton reel of Cm scenrpanz e Oafion a DW Name of Ofri w (Piaaw"m Pr" Tall Nicole Fletcher I Children's Programs Supervisor FOR D/IS I Approved ❑Denied,reason USE / -, ///% neeONLv �i/ff( Signakrs-DHS flwesmtaws Daa Tom Dspiimm t Farm or Nu'un Sarno°' SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FDR ONE USE SITE INFORMATION TX al-/ObZ- 1700 Village East Denton, TX 76201 Period of OPSMon of oo�, moJdey/yr-MASYNTbe Numrof0 May'I1R1e �"'e From 5/27/97 through, 8/8/97 orating Days 4 21 22 6 D ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1 Indicate Type of Site ❑ Residential Camp A. (serving one to three meals) ❑ She Serving Primarily Migrant Children C (serving one to throe meals) Q Other Site E (serving one to three meals) ❑ Nonresidential Camp B (serving one to three meals) ❑ Site Serving Primarily Homeless Children D. (serving one to three meals) 2 List ALL counties served by this site Denton A Is your site open B Is your site enrolled? MY** ❑No ❑Yes QNo C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) 100 area D If open sites submit documentation supporting this percentage figure (such as census date, school data) For open sdes using school data list the schools used to document site eligibility, attach formula used by school dlst.'tD establish percentage of free 8 reduced price children Census data from TACAA t E For enrolled sites, Form 1631 will be used to document eligibility (National Youth Sports Program -refer to SFSP Handbook, Chapter 2 ) If the enrolled site used school data, list the school used to document the site r— m F What is the percentage of free or reduced -price meals for the site? xr 100° h w ,aZ Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) ®Yes No n 00 - If Yes give name of contracting organizadon City of Denton LLJ = uj' Monitonng Plan (SFSP Handbook. Chapter Ilp Enter date of monkonng review to be conducted within ;1 ` — U !- ,l First Week d OperaWn B Fran Faur Weeks of operation C Atl(WiorW Rwewe + i 5130197 6/20/97 7/25/97 Meal Servoe Penod Information (SFSP Handbook Chapter III TYPES O"EALS NUMBER OF ELIGIBLE CWLDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast AM Supplement Lunch 50 12 00 p m 1 00 P m, P M Supplement Supper 'its kaomeaoon is oonsKwed by pHs when seierq to approved meal servios WM (SFSP Hwidbook. [;crepe nV 7 Do you plan to feed children under one (1) year old? ❑Yes El No B Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) Sep Prgoarauon Vw1ded Using School Using Food Service Management Using Private NowPmfh n On Sde n Central Kitchen I ® Food Authority ❑ Company (Ineludes All Year Contracts) ❑ Organization that is Self -Prep Fmm 1t1011Psee Indicate the system to be used for the serving of meals and the supervision of chilki en during meal service period (SFSP Handbook, Chapfer II) "tyle Children are Seated � Children Uno Up ❑ mowServio ❑ and are GI a Meals © and Pick UpMeals ❑ 00W 10 list Site personnel who will be Involved to any extent in the meal service. (SFSP Handbook. Chanter In WILE OF POSmON NO IN POSmON SPECIFIC FOOD SERVICE PROGRAM DUnES Site Super isor 1 Supervise and assist distribution of meals monitor and maintain meal temperature, site clean-up, and other duties as assigned. Site Helper/Server 1 Assist Supervisor 11 Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter IQ O� MMeal Meal Service ❑WIfiSoCancelled []Other 12 it the site feeds primarily homeless children, what methods are used to ensure that money, food stamps, or in kind services are not required for me&? N/A 13 Are meals delivered to the site? ®Yea ❑No IF YES, COMPLETE ITEMS 14,15, 616 IF NO, FORM IS COMPLTE EXCEPT FOR CERTIFICATION AT BOTTOM 14 Indicate the means of communication with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap II) QSite Personnel Will Contact Administrative She Personnel Wltl Communicate Sfaff, who Will Carried vendor ❑Diraeity With vendor 15 Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter IQ " ` 1s I YON No A4 �+ If no, dasaibe arrangements within standards prescribed by local Ilealtfl authorldes for delivery and holding of mleals" Who "rvice »� ttl+t' q W^ s_ 16 If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter IIQ ❑arStored In Refrigerator Thrown Away ❑� IVendor ❑OIheP il Served the Next Day ❑at the site I CERTIFY that the information on this forth Is true and correct to the best of my knowledge I car* that this site has been visited and that d has the capability and facilities for the meal service planned for the number of children anticipated I know that deliberate misrepresentation or wMholdrrg of Information may result In prosecution under applicable state and federal statutes Nicole Fletcher Chi FOR NApproved ❑Denied, mason DHS USE TiW ONLY &angers-ONS MWeantauve Due Tease Deparmwt Of Humeri Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Moore Learning Center 815 Cross Timbers FOR OHS t TX 1061- /od (817) 566-8125 rNgo a upersaw a row Jervos Imo4MM-mo�aaYryr 1 Number 01 Op "� �" -N �' From 6/2/97 through, 8/8/97 sratlngDays 0 21 22 6 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Faaldentlal Camp She Serving Primarily Migrant Children Other Site 1 Indicate Type of Site ❑ A. (servkg artistic throe meals) ❑ C (serving one to three meals) DE (serving one to three meals) Nonrosldendal Camp Site Serving Primarily Homeless Children ❑ B (serving one to three meals) ❑ D (serving one to three meals) 2 Lust ALL counties served by this site 3 A Is your site open B Is your site enrolled? Denton C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) [Dyes ❑No []Yes ®No D If open sites submit documentation supporting this percentage figure (such as census date, school data) For open sites using school data list the schools used to document site eligibility; attach formula used by school dist., to establish percentage of free g reduced price children E For enrolled sites, Forth 1531 will be used to document eligibility (National Youth Sports Program —refer to SFSP Handbook, Chapter 2 ) If the enrolled site used school data, list the school used to document the site F What is the percentage of free Or reduoed•pnce meals for the site? 100 r 4 Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) ❑Yes ©No If Yes give name of contracting organization m 5 Monitoring Plan (SFSP Handbook, Chapter III) Enter date of monitoring review to be conducted within i." z E A- Fuss w«. a Openiron a Fiat Four weeks a Opemilm C AddkWW R*~G .. a `- o 6/6/97 6/27/97 7/25/97 na^ .; Meal Service Period Information (SFSP Handbook, Chapter 11) —�L TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME a. r BEGINNING Bloom .ors Breakfast AM Supplement Lunch 75 12 00 p m 1 00 P m P M Supplement Supper "im udormation a oonsoered by DFLS Wron «Nip me approvw inea mirvioe rvei t4ror � awl vm „i 7 Do you plan to feed children under one (1) year old? ❑Yes ®No 8 Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) son Preparation ve v> d Using School Using Food Service Management Using Private PIOmProfit n On Site El Central Kitchen R❑ Food Authority ❑ Company (Includes All Year Contracts) ❑ 0 anirallon that rs Seit-Prep Form 11I07IPpe Indicate the System to be used for the serving of meals and the supervision of &MM during meal Service period (SFSP Handbook, chapter 11) Cafeteria -style Children are Seated Children Line Up Mal Henke ❑ and are Given Meal ® and Pick Up Meals ❑ Otlwr El 10 List Me personnel who will be Involved to anv extent in the meal service (SFSP Handbook. Chanter III THE OF POSmON NO IN POSmON SPECIFIC Food SERVICE PROGRAM DUTIES Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up, and other duties as assigned Site Helper/Server 1 desist Supervisor 11 Indicate what provisions will be made for meal service during periods of Inclement weather ($FSP Handbook, Chapter II) Indoor Meal Meal Service ElService ❑Will Be Cancelled ❑other 12 1 the site feeds primarily homeless children, what methods amused to ensure that money, food stamps, or in -kind services are not required for msals? N/A 13 Are meals delivered to the site? ® Yee ❑ No # IF YES, COMPLETE ITEMS 14, 15, i 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, Chap IQ ®Site Personnel Will Contact Administrative Site Personnel Will Communicate Staff, Who Will Contact Vendor ❑ Directly With Vendor r ti3 a 15 Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter IQ Yes au ] No B no, descd arrangements within standards prescribed by local health autladdes for delivery and holding of meals" time of 5arvice -.2 rr °' 0 c.> 16 It there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) ❑Stored In Refrigerator Thrown Away Returned to Vendor and Sainted the Next Day ❑at the She ®for Disposal ❑other: I CERTIFY that the information on this form is true and correct to the best of my lotowledge I candy 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 wMholdr of info on ma re uit in prosecution under applicable state and federal statutes / Name xre-0erael of Cormaaug Oraararahan —E '' fi City of Denton Nicole Fletcher I Children's Programs Supervisor I FOR L[ AXroved ❑ Denied, reason DNS // USE ONLY -� &aneoee-DNS RWeeenuuve Diu Tskae Dsiui mom Form of Human stomas SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DNS WE SITE INFORMATION TX 06,/ 1p6Z School 1 (817) 566-8125 1201 Parvin Denton, TX 76205 Pored of OPOration or Fad Servfoe (ma4dayfyr-majday/yr) Number of n Mot' 'hale 'heY Au, SapL From 6/2/97 threuch• 6/27/97 araNmDays Y 0 20 0 y 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1 Indicate Type of Site ❑ Residential Camp A (serving one to throe meals) ❑ She Serving Primarily Migrant Children Other Site C (serving ow to throe msele) 0 E (serving one to three meals) ❑Nonresidential Camp B (serving one to three meals) ❑ She Serving Primarily Homeless Children D (serving one to three meals) 2 List ALL counties served by this site Denton 3 A Is your site open B Is your site enrolled? QYes []No ❑Yes ®No C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) 64 eic D If open sites, submit documentation supporting this percentage figure (such as census date, school data) For open odes using school data list the schools used to document site eligibility; attach formula used by school dlst.,w establish percentage of free 3 reduced price children M Census data. from TACAA , E For enrolled sites, Form 1531 wail be used to document eligibility (National Youth Sports Program -refer to SFSP Handbook, Chapter 2 ) If the enrolled site used school data, gat the school used to document the site F What is the percentage of tree or reduced•prwe meals for the site? i u a 100< % �r 4 Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) Yes No zC:, If Yes give name of contracting organizaton e�Be 5 Monitoring Plan (SFSP Handbook, Chapter III) Enter date of monitoring review to be conducted within e A- FIRt Weak cI Operaan B First Four Weeks or Oparslon C Additional Bevan" 6/6/97 6113197 E Meal Service Period Information (SFSP Handbook, Chapter II) TYPES OF MEALS NUMBER OF ELknBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENOIN(L" Breakfast 1 "� A M Supplement Lunch 150 11 30 a m 14-30 p c�� sec P M Supplement Supper „`- -m sawmanon ,s oonsre§rea W tins wnen scans cur approved R" service war. (bran Han mom uwpw n) 7 Do you plan to feed children under one (1) year old? Dyes ®No 8 Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) Seri Reparation Vanded Using School Using Food Service Management Using Private Non-ProB n On Site n Central Kitchen I [M Food Authority n Comoanv (Includes All Year Contracts) n Oroanbation that is Self-Preo Fam 110T)Page Indicate the system to be used for the serving of meals and the supervision of Children during meal service period Calsteria-le Children are Children Line Meal Servic ❑ and are Given Meals ❑X and Pick Up Mea ls ❑ Otter 10 List site personnel who will be Involved to any extent in the meal service, (SFSP Handbook, Chapter 10 11 (SFSP Handbook, Chapter II) TrTLE OF POSITION NO IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUTIES Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up, and other duties as assigned Site Helper/Server 1 Assist Supervisor k Indicate what provisions will be made for meal service during periods of inclement weather ©Service []Will Service l Re Re Cancelled ❑Other (SFSP Handbook, Chapter In 12 t the site feeds primarily homeless children, what methods are used to ensure that money, food stamps, or mdnnd services are not required for meals? N/A _ 13 Are meals delivered to the site? ❑% Yea ❑ No r} W YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATIQN AT BPTOM 14 Indicate the means of communication with the vendor which will be used to adjust meal deliveries (SFSP Handbool�`Cflep 11)ZE Site Personnel Wiii Contact Administrative Site Personnel WIN Communicate >-? o Q Staff, Who NNI Contact Vendor ❑ Directly With Vendor a i co w� � 15 Wig dakvery be within one lour of the food service period? (SFSP Handbook, Chapter In y, u c 7 Y&UNo tl no, describe arrangements within standards prescribed by local health auth often for delivery and holding of misslontll dme iPeN*I-- a cq .cx 4- 16 If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 110 Stored in Refrigerator Thrown Away Rewmed to Vendor ~ x ❑and Served the Next Day at the Site for Disposal ❑other: 'r l ' - I CERTIFY that the information on this font is true and correct to the best of my knowledge I certify that this skit hits been -sited artd that n has the capability and facilities for the meal service planned for the number of children anticipated I know that deliberate marepres4Iyrbon or withholding of information may result in prosecution under applicable state and federal statutes rn Hama City of Denton tact '�Orgararaaon �W Nicole Fletcher I Children's Programs Supervisor FOR 'MApproved ❑Denled,reason DNS USE TqM ONLY : �), , �X -/Y'/J7 I -rim Signaurs-DHS %Wes Wve Dale L Tax" Depsni, nt of Hamm Somices SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION s Elementary School 820 Sun Valle Denton, TX 76201 Pena d noon d Food Sarvine (M0 M -iioJdeYM) NumMr of Dp• Mat' 'aa1e From 6/2/97 through 6/27/97 trahngDays 0 20 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED t' RealdentW Camp She Serving Primarily Migrant Children 1 Indicate Type of Site ❑ A. (serving one to three n,*) ❑ C (serving one to three meats) ElNonresidential Camp She Serving PrimarilyHomeless Children B (serving one to three meals) ❑ D (serving one to three meals) 2 List ALL counties served by this she Denton 3 A Is your site open B Is your site enrolled? FOR DNS use ONLY Tx o061-/oo z OR (817) 566-8125 0 If 0 Other She Q E (serving one to three meat) ❑Yea ®No QYes ❑No C Site Eligibility Enter the percentage of children eligible for free andW reduced price meals for the site (SFSP Handbook, Chapter IW) 0 ' e D If open sites submit documentation supporting this percentage figure (such as census date, school data) For open ;Res using school data list the schools used to document site eligibility, attach formula used by school dust, to establish percentage of free 3 reduced price children / E For enrolled sites, Form 1531 WWII be used to document eligibility (National Youth Sports Program —refer to SFSP Handbook, Chapter 2 ) If the enrolled site used school data, list the stdlooI used to document the site F What is the percentage of free or reduced-pnos meals for the site? 100 % d Did the site participate In previous years' SFSP? (SFSP Handbook, Chapter II) ❑ Yes ©No r� If Yes, give name of contracting organlzatbn m 5 Monitoring Plan (SFSP Handbook. Chapter III) Enter date of monitonno review to be conducted within _« A. Foie t weak d Opwawn 9 Fiat Fro Weslw ofOpe anon ws Additional Revw 6/6/97 6/13/97 c,Y' m E Meal Service Period Information (SFSP Handbook Chanter In TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED• MEAL SERVICE TIME cx.4- BEGINNING ENDINO'tt Breakfast A M Supplement Lunch 25 11 30 a m 12 30 p in P M Supplement Supper ,w �wwnerwnr ra waw.rorw uI rite wren aasne ue a{prwaa seal epY1Le sip. ti�Jr'rrpr®ppl� Vrpprp „/ 7 Do you plan to feed children under one (1) year old? ❑Yes ©No e Method of Food Preparation byContracting Organization (SFSP Handbook, Chapter II) Sere Preparaion Verkwd Using School Using Food Service Management (king Private Non-Pmfh ❑ On Site ❑ Central Kitchen 1 ® Food Authority ❑ Company (Includes All Year Contracts) ❑ Organfrallon that 13 Seh-Prec Form tso7lPa" Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Csfderls-s❑ Msal service e El and and are Give Meals }C❑ and Pick Up MeChildren are Seated ChIliciren Line als ❑ Other 10 List aft personnel who will be involved to any extent In the meat service (SFSP Handbook, Chapter II) TITLE OP POSmON NO IN POSITION SPECIM FOOD SERVICE PROGRAM Olft1ES Site Supervisor 1 Supervise and assist distribution of meals monitor and maintain meal temperature, site clean—up, and other duties as assigned. Site Helper/Server jAssist Supervisor 11 Indicate what provisions will be made for meal service during periods of Indemant weather RFSP Handbook, Chapter 11) Indoor Meal Meal Service QService ❑ Will Be Cancelled ❑Other 12 1 the site feeds primarily homeless children, what methods are used to ensure that money, food stamps, or in kind services are not required for meals? N/A -- 13 Are meals delivered to Itm site? ®Yea []No r� 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 ad)ust meat deliveries (SFSP Handbook, Chap 11) Site Personnel Will Contact Administrative Site Personnel WIII Comntudeate ❑% SUN, Who WIII Contact Vendor ❑ Directly Wlth Vendor 15 Will delivery be within one hour of the food service period? (SFSP Handbook Chapter tl) ,,,,, i�® Yee ❑ No N no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meald5mill bmdd serAce 00 w � O U"m 16 If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 110 Stored In Refrigerator Thrown Away Retuned to Vendor a ❑and Served the Next Day ❑at the Site ❑X for Dlaposal ❑Other I CERTIFY that the information on this form Is true and correct to the best of my knowledge I cerbfy that this site has been visited and drat if has the capability and faalities for the meal service planned for the number of children anbapated I know that deliberate misrepresentation or wnhfroldrng of information may result in prosecution under applicable sstatte_ and federal statutes rwne City of Denton esel erVacom Ormrwaaon Nicole Fletcher Children's Pr FOR oApproved ❑Denied,reason OHS USE ONLY &gnaews-DOS RepewmWe -- - Oete Taws Dsp&nmera ar Hunan servlwa .L y y L 1. V iN 1 l%xil., l 1 r.tu< SPECIAL NUTRITION PROGRAMS SINGLE AUDIT IDENTIFICATION DATA Pam lsaa Naral,Oa leas Convactw Name Ew"M Porwn City of Denton Nicole Fletcher AEMau (Svaal or p) 321 E McKinney Denton, TX 76201 Teiepixina No (IPay" l No. 817 ) 566-8125 17560005146015 p�1- 100Z 09/30/97r (mNa j 0of contrad For Profit Non Profit X Governmental Check the appropriate box(es) to Indicate the type(s) of program(a) in which you current) articl at 1 hi h COMMODITY ASSISTANCE PROGRAMS s or or w c ou are Spill Ing CASH REIMBURSEMENT PROGRAMS A - National School Lunch AD - Adult Da Care B - Charitable Institutions BL- National School Lunch/Breakfast C - Area Agency on Aging C3 CC - CACFP Center G -Summer Camps DH - CACFP Day Home H - Summer Food Service X SF- Summer Food J - Jails SM - Special Milk K - Soup ktchen TE-TEFAP I - TEFAPCommodities Give the source and amount of any federal financial assistanee that your ■aenev rer.Ivpe nth., ohs„ & .... •ti..._ -_- n-•_. SOURCE AMOYW See attached - � ti r` s W 0 W +eZ ❑ SINGLE AUDIT RXEMPTION-1 certify that 1 am not required to submit an audit under the Single Audit Act for the following reason(s) 111 am a for -profit organization ❑ 1 receive less than $25,000 annually In total federal funding ❑ SINGLE AUDIT ASSURANCE-1 understand that If I meet the requirements of the Single Audit Act, I will agree to submit. ❑X An Annual ❑ A Biennial audit as a condition of eligibility to paniapate in the Special Nutrition Programs, and that failure to do so as required could result in adverse action, including the withholding of my claim for reimbursement payments and termination of my contract 1 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 Y, PMQ Tow Nicole Fletcher __ Children's Programs Supervisor n, MY an Semces Oacemev i99� HISTORICALLY UNDERUTRAM BUSB&SS (HUB) SUBCONTRACT CERTIFICATION The Texas Department of Human Services IDHS) will make a good faith effort to ensure that HUBS receive their respective share of the total value of all contracts it awards each fiscal year which begins September 1 and ends August 31 Based on the 1994 Texas Disparity Study, and in accordance with the Texas General Services Commission (GSC) rules, DHS has established the following minimum HUB goals I, • Commod ties include equipment, furniture, software, supplies, vehicles, food, fuel chemicals, and lubricants 12 6% • Heavy Construction includes highway, street, bridge, tunnel, water, sewer, and power line construction 11 9% • Bullding Construction includes residential, industrial, and other nonresidential budding construction 26 1 % i • Special Trade Construction includes plumbing, heating, air conditioning, painting efec,rical, masonry, P dry wall carpentry, floor laying, roofing siding, concrete, excavation, and demolition work 57 2% • Professional Servjcesinclude architecture, engineering, financial and accounting services, medical services and surve, 20 O,k • Other Services 17lude computer programming, consulting, legal, maintenance and repair and other miscellaneous services 33 0% P� GOOD FAITH EFFO T COMPLIANCE By implementing the following procedures a contractor shall be presumed to have made a good faith a fort when subcontracting 1 To the extent corisistent with prudent industry practice, divide the contract work into the smallest reasonable lots 2 Notify HUBS of the work the Contractor intends to subcontract The notice shall be in writing The notice shall include a description of the subcontracting opportunities and identify the location to review contract specifications The notice shalt ed be provid[o pqI ential subcontractors prior to submission of the contractor bid 3 The Contractor shall send such notice to at least five HUB firms in the GSC master bidders list and HUB directory that perform the type of work required If the GSC master bidders list and HUB directory do not have at least five businesses then the Contractor shall send the required notice to HUBS on lists of minority and women -owned businesses maintained by other govemm nt agencies or organizations If the Contractor uses sources other than the GSC master bidders list and HUB directory th selected HUB subcontractor must become certified by GSC in accordance with GSC procedures 4 If a non -HUB subcontractor is selected through means other than competitive bidding, or a HUB bid is the lowest price responsive biddet to a competitive bid, but not selected, the Contractor will be required to document the selection procedures 5 Maintain recoras Qocumenting HUB compliance for audit purposes Quarterly reports MAY BE required by the `agency, and the contractor will be given sufficient notification if required to report n� When the contractor) is a HUB, it may satisfy the good faith effort requirement by performing at least 25% of the contradt Nork with its employees as defined by the Internal Revenue Service (IRS) The HUB Contractor may also be requiraarito report ouarterly to the agency � J � "� i Form a9C_ Pape Plssss answer the following Questions I Are you a certified HUB) yes X� No If yes, please provide your GSC HUB Certification No 2 Do you plan to utilize a subcontractor, supplier, or material provider for all or any portion of the contract? yes X❑ No If yes, describe the scope of work the subcontractor(s) will do a cT r , r� 3 Approximately what percentage of the total contract award will be subcontracted? V 0 qb a Aoproximately what percentage of the total contract award will be subcontracted to HUBs� ' % AuOnrYad PAP M totM IpNaaa ppa a pre" conV«t No City of Denton Nicole Fletcher 061 1002 1 CERTIFY that the above information is true and correct 1als/J the terrify that I will make a good faith effort to comply with the HUB subcontradt gods established by DHS agnatun—Auprorpad maprapntabva n.e'. FOR DHS USE ONLY wrrawad av _ n Dq T72� GL 8 7 �70 zz k o �0)4OOpct cpd. M+I cod. pn.