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HomeMy WebLinkAbout1996-083A \SLIMMER SER NOTE. SUPPLEMENTAL AGREEMENT SUMBITTED BY PARKS DEPARTMENT ATTACHED TO ORIGINAL.Changed pages are noted � 2 ORDINANCE NO -083 AN ORDINANCE OF THE CITY OF DENTON, TEXAS, AUTHORIZING THE ACTING 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 1996 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 Acting 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 necessary to obtain such funding SECTION II That the Acting 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 certifications as are necessary to carry out the 1996 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 1996 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 42kta_ day of 1996 ATTEST JENNIFER WALTERS, CITY SECRETARY BY , APPROVED AS TO LEGAL FORM HERBERT L PROUTY, CITY ATTORNEY m Page 2 Tons Depwlme� I or SUMMER FOOD SERVICE PROGRAM APPLICATION FOR PARTICIPATION NOTE Give as much information as possible Attach additional shoots H needed, piesse Identify each attachment with the name of the contracting organization FOR ❑ Breaking ❑ A M SupP ❑ Lunch PM SECTION "Funlaun InrUMMA r jWN ID No Talspn" No Hotline No CW*aC" OnOWUNWon Name City of Denton lVencor 17560005146015 (817 ) 566-8125 (817) 566-8125 Melling Mende ($east a P O Box, CRY, , ZIP) 321 E McKinney Denton, Texas 76201 SVW Ams.. Ill dOMMO Named AdMWftVaW Teresa Milam Too Leisure Services Manager Contractor Classification (Check all that apply) Academic Year National ❑ National Youth Sports Program ❑ Youth Sports Program ResidentleyNonresldential ❑ School Food Authority ❑ Summsr Camp B Is your program a year-round program? C Type of Contractor 2 Public Entity (explain) Is your agency oor sidered to be state ownedloperated? Do you deposit your program mlmtwrsement directly into the State Treasury? Do you deposit your program rebnbureement Into a local bank? Unit of Government -Contractor certifies that all food © service saes are operated drectly by the contractor Continuous Calendar ❑ School Year ❑ Private Non-profit ©Yss ❑No ❑Yes QNo ®NIA ❑Yss [:]No [_]N/A ®Yes [-]No If yes, is it erect deposit? []Yes ®No ❑ Private Nonprofit OrganWUon-Tax-exempt status established Attach letter of determnetlon (IRS 501.30) of tax-exempt status from IRS Do you deposit your program reimbursemera into a local bank? ®N)A ❑ Vas ❑ No N yes, Is it direct deposit? ❑Yes []No D Does the organization provide an ongoing year-round service to the community that Is to be served by [Dyes ❑ No the Summer Food Service Program (SFSP)? If no, which of the following circumstances ap01ea7 ❑ Residential Camp ❑ Failure to operate would deny program to ■ Poor was ❑ Serves Migrbnt Children ❑ Faiure to operate would deny a significant number of children saris to program E 1 Does the organization receive $100,000 Of more in federal funds yearly? (Dyes [:]No 2 toes the orgenintion rscehne more than 425,000 but less than $100,000 in federal funds yearly? [Dyes ® No with FSP cy will 9 Attach a copy of the audit conducted including to daCovering It will be conductelast year's d (you mam usttion or documentation that an submita so plMed Form 1569, Special Niutrition $Program - Singes Audit ideriMMfin Data) Form 1506 pops 2 SECTION D-BUDGET Estimate all SFSP costs which will be claimed for reimbursement for 0 I EST RAT D OPERATIONAL COSTS PROGRAM YEAR COSTS Program Labor 4,225 Fringe Benefits 422 Food 26,699 Non-food Supplies 1,500 Utilities Rent Equipment Use Fee Rental of Equipment 2,500 Transportation "Awwr 28 445 Oew t UM Ispeft TOTAL 35,791 Ieprogram year 7. IIS IMAM ADMINISTRATIVE COSTS PROGRAM YEAR COSTS Administrative labor Management Monitor, Clencal) 3,115 Fringe Benefits 311 Rental of Office Specs Utilities Office Supplies 200 Office Building Maintenance Equipment Use Fee Audit Fees legal Fees Transportation Rate Per mile 18 300 ($P**) Mobile Phone (SPOW TOTAL2 3,926 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 ) Scum"f' AM0QV M uied for None = BMW of tnoonte Amr6m1 uutl for $ SECTION 19-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 -she food seMce ) TITLE OF POSmON NUMBERIN SPECIFIC FOOD SERVICE PROGRAM DUTIES Director 1 Conducts training session, monitor sites, prepares reports, coordinates food Services Coordinator 1 Assists Director with duties Form 1506 Pap 3 B Are children charged separately for meals? If yes, see Form 1508, Attachment 8 C Do you want to receive advance payments? If yes,1 For Operational Costs? 2 For Administrative Costs? D If meal service Is self -preparation, do you want to receive commodities? If yes, Forth 1608, Application and Agreement for Commodities, must be completed SECTION IV —PROGRAM OPERATION A 1 Beginning and Ending Dates of Meal Service From May 28, 1996 through 2 Number of sites ❑Yea QNo ❑Yes ❑% No []Yes ❑No ❑Yes ❑No LJYss QNo August 9, 1996 Ust dates and topics or DATES srsr mum TOPICS Site supervisor and monitor training on S F S P guidelines 5/23/96 and Civil Rights training C Is the organization planning to contract with a food service management company for the preparation of unitized meals? If ves, and the contract will exceed $10 000 attach a copy of the Invitation to bid Also give ❑Yes QNo UWA�Wn i of Pubilm6 - -'- - - - Is bd sitpecled to be 51 000 or more? 6 yes gin place at bid npeniN Yea No Aiwa attach a coDv of an 11-day-WC16 menu including all specific menus to be used D Is the organization Contracting with a year-round food service management company? If yes, submit a copy of your procurement procedures, bid, contract, and all amendments []Yes ©No E Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department notifying them of intent to operate a Food Service Program at the site(s) Indicated on the attached She Information sheet (Form 1607) SECTION V—ASSURANCES A Free Meal Policy Statement 1 The contracting organization assures the Texas Department of Human Services (DHS) that all children at the sites described on the Site(s) Information Sheets for the Summer Food Service Program, will be offered the same meals with no physical segregation of, or other willbemade against, al excel be accordance race, with color,disability. Bag this x, national origin, reUgion, or political beliefs No separate charge ny 2 The contracting organization assures OHS that, if @ 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 repented as free or reduced-pnce,Iand d income • The children claimed as Agriculture, DHS Forth free Standards for DeterminingetteFree and Reduced Price Eligibility cards set by the Untied States Department of form ISee Pete 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 If the contracting organization is sponsoring a camp or other enrollment program, this release must contain, at a minimum, a list of all approved sites, a list of the current standards for determining free and recuded price eligibility, and the following statement City of Denton 'The (N. f ft =Vactim manization) 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 Ellgibllily, 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 moo, 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-106, Texas Department of Human Services, P O Box 149030, Austin, Texas 78714.9030 or the Secretary of Agriculture, Washington, D C 20250 NOTE Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services." For all other programs the announcement must contain, at a minimum, a list of all approved sites and the following statement: Citp of Denton 'The (N mabfthaepm Wnaar9anizatlom announces the sponsorship of the Summer Food Service Program Meals will be provided at the alte(s) listed People who are eligible to participate in the program must not be discriminated against because of race, color, national origin, sax, 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-106, 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 Denton Record Chronicle 5/1/96 Dallas Morning News 5/1/96 UNT Daily 5/1/96 NAME OF MEDIA OUTLET DATE OF RELEASE TWU Student Paper 5/l/96 KDNT Radio 5/l/96 KNTU Radio 5/l/96 3 Attach a copy of the contracting organization's public release statement as submitted to the news media and any other materials used to publicize the program's availability and nondiscrimination requirements SECTION VI— CERTIFICATION (see Form 1506, Attachment C) 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 pproved meals served to eligible children during the tours they are in attendance at approved sites I know that deliberate srep sentatlon or withholding of Information may result in prosecution under applicable slats and federal statutes Difie agriaa a actlna Orpenlraaon Rick Svehla ❑APPROVED ❑DENIED If denied, reason Acting City Manager Apgowe auuon Yes No j If yes, give date Form 1608 sent to FDD � Date of Cwvacft awrazeea Data CITY of DENTON, TEXAS February 21, 1996 Ms Laurie Callahan, Registered Sanitarian Environmental Health Department 300 Woodrow Denton, Texas 76205 Dear Ms Callahan, MUNICIPAL BUILDING • 215 E McKINNEV • DENTON, TEXAS 76201 (817) 566-8200 • DFW METRO 434-2529 The Denton Parks and Recreation Department is applying to the Texas Department of Human Services for a grant to provide the Summer Food Service Program to the children of Denton This program will provide lunch for children ages 1 - 18 years of age The food preparation will be contracted with the Denton Independent School District We will be serving sack lunches from igloos at the sites listed below This is a request that your department inspect the locations of food service Time of Site/Address Dates Lunch Service Civic Center Park 5/28/96 - 8/9/96 12 OOpm-1 OOpm 321 E McKinney Phoenix Park 5/28/96 - 8/9/96 12 00pm-1 OOpm Wood Street owsley Neighborhood 5/28/96 - 8/9/96 12 OOpm-1 OOpm Stella Street Dema Park 5/28/96 - 8/9/96 12 00pm-1 OOpm 1001 Parvin "Dedicated to Quality Service" TWU Clubhouse 5/28/96 - 8/9/96 12 OOpm-1 OOpm Mary Hufford Court Village East Apts 5/28/96 - 8/9/96 12 OOpm-1 OOpm 1700 Village East Houston Elem School 6/3/96 - 6/28/96 11 45am-12 45pm 3100 Teasley Rayzor Elem School 6/3/96 - 6/28/96 11 30am-12 30pm 1400 Malone MLK Recreation Center 5/28/96 - 8/9/96 12 OOpm-1 OOpm 1300 Wilson If you have any questions I may be reached at 566-8125 Brenda Burton Cluldren's Programs Supervisor Summer Food Service Program Sack Lunches Menus Eleven Day. Cycle Tuesday - May 28 Peanut Butter/Jelly Sandwich Carrot Sticks Banana Lowfat Milk Wednesday - May 29 Bologna/Cheese Sandwich Carrot Coms Mixed Fruit Potato Chips Lowfat lvhlk Thursday -May 30 Tuna Salad Sandwich Pickle Spears Orange Juice Lowfat Milk 2 oz Peanut Butter, 1 T Jelly, 2 slices Bread 1/4 cup 1/2 cup 1/2 pint 1 1/2 oz Bologna, 1/2 oz Cheese 2 slices Bread 1 /4 cup 1/2 cup 1/2 pmt 2 oz Tuna 2 slices Bread 1 /4 cup 6 oz 1/2 pint Friday - May 31 Ham/Cheese Sandwich 1 1/2 oz Ham, 1/2 oz Cheese 2 slices Bread Whole Pickle 1/4 cup Fruit Cup 1/2 cup Cookie Lowfat Milk 1/2 pint Monday - June 3 Deli Sandwich 2 oz Meat 2 slices Bread Pickle/Carrot 1/4 cup Mixed Fruit 1/2 cup Lowfat Milk 1/2 pint Tuesda - June 4 Peanut Butter/Jelly Sandwich 2 oz Peanut Butter, 1 T Jelly 2 slices Bread Carrot Sticks 1/4 cup Apple 1/2 cup Lowfat Milk 1/2 pint Wednesday - June 5 Deli Sandwich 2 oz Meat 2 slices Bread Pickle/Carrot 1/4 cup Apple 1/2 cup Lowfat Milk 1/2 pmt Thursday - June 6 Tuna Salad Sandwich Pickle Spears Orange Juice Lowfat Milk Fndav - June 7 Ham/Cheese Sandwich Whole Pickle Fruit Cup Cookie Lowfat Milk Monday - June 10 Bologna/Cheese Sandwich Carrot Coms Mixed Fruit Potato Chips Lowfat Milk Tuesday - June 11 Deli Sandwich Pickle/Carrot Banana Lowfat Milk 2 oz Tuna 2 slices Bread 1 /4 cup 6 oz 1/2 pmt 1 1/2 oz Ham, 1/2 oz cheese 2 slices Bread 1/4 cup 1/2 cup 1/2 pint 1 1/2 oz Bologna, 1/2 oz Cheese 2 slices Bread 1 /4 cup 1/2 cup 1/2 pint 2 oz Meat 2 slices Bread 1 /4 cup 1/2 cup 1/2 pint Certification That All Required Pre -operational Site Visits Have Been Conducted At All Proposed Sites Name Of Person Name Of Site Visited Date Of Visit Who Visited Site Civic Center Park February 8, 1996 Brenda Burton Phoenix Park February 8, 1996 Brenda Burton Owsley Neighborhood February 8, 1996 Brenda Burton Dema Park February 8, 1996 Brenda Burton MLK Recreation Center February 8, 1996 Brenda Burton TWU Clubhouse February 8, 1996 Brenda Burton Village East Apts February 8, 1996 Brenda Burton Houston Elementary February 8, 1996 Brenda Burton School Rayzor Elementary February 8, 1996 Brenda Burton School E" &J-cp Signature of Authorized Representative z- & Z l 6 Date IJTV of nEMTBN- TEYd3 MUNICIPAL BUILDING 0 215 E McKINNEY • DENTON, TEXAS 76201 (817) 566 8200 @ DFW METRO 434 2529 MEMORANDUM To Solid Waste Department From Brenda Burton, Children's Programs Supervisor Parks and Recreation Department Date February 9, 1996 Subject Summer Food Service Program The Summer Food Service Program, which provides sack lunches for children throughout the summer, is being sponsored by the Denton Parks and Recreation Department I would like to make you aware that additional trash will be placed in dumpsters on Monday -Friday, May 28 through August 9 at the following locations Civic Center Park Phoenix Park Owsley Neighborhood Denta Park MLK Recreation Center TWU Clubhouse Program Village East Apartments Houston Elementary School Rayzor Elementary School If you have any questions please contact me at extension 8125 AdN ON _dBreTI "Dedicated to Quality Service" Tom Depenment of Human sennees Fmm 1506, Attachment C Febnary 1991 SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CRIMINAL PROVISIONS AND PENALTIES Whoever, in connection with any application, procurement, record keeping entry, claim for reimbursement, or other document or statement made in connection with the program, knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or whoever in connection with the program knowingly makes an opportunity for any person to defraud the United States or does or omits to do any act with intent to enable any person to defraud the United States, shall be fined not more than $10,000 or Imprisoned not more than five years 2 Whoever being a partner, officer, director, or managing agent connected in any capacity with any partner- ship, association, cooperation, business, or organization, either public or private, embezzles, misapplies, steals, or obtains by fraud, false statement or forgery, any benefits provided by the program, or any money, funds, assets, or property derived from benefits provided by this program, shall be fines not more than $10,000 or imprisoned for not more than five years or both If the benefits, money, funds, assets, or property Involved isinot over $200, then the penalty shall be a fine of not more than $1,000 or Imprisonment for not more than one year, or both 3 If two or more persons conspire or collude to accomplish any act made unlawful under this subsection, and one or more such person commit any act to effect the object of conspiracy or collusion, each shall be fined not more than S10,000 or Imprisoned for not more than five years, or both TERMINATION PROCEDURES The following list of deficiencies are grounds for termination Grounds for termination, however, are not limited to this list 1 Non-compliance with applicable bid procedures and contract requirements of Federal Child Nutrition regu- lations 2. The submission of false Information to the Texas Department of Human Services (DHS) 3 Program violations at a significant proportion of the sponsors' sites Such violations Include but are not limited to the following A Non-compliance with the meal service time restrictions B Failure to maintain accurate records. C Failures to adjust meal orders to conform to the variations in the number of participating childrem D The simultaneous service of more then one meal to any child E Service of a significant number of meals which do not Include required quantities of all meal components F. The claiming of program payments for meals not served to participating children. G Excessive Instances of off -site meal consumption H Continued use of food service management companies that are In violation of health codes 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 Din and the City of Denton Denton Independent School District agrees to supply unitized meals inclusive of milk and juice to the C!ty 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, Sam Houston Elementary Summer School, and Razor Elementary Summer School, with and for the rates herein listed Breakfasts $ 0 00 each Lunches $ 1 55 each Snacks $ 0 00 each Supper $ 0,00 each It is further agreed that the Demon 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 tmmmum 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 1 Menu Records, including amount of food prepared 2 Meals, including daily number of meals delivered by type These records must be reported to the institution promptly at the end of each month 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 City of Denton and The Texas Department of Human Services The Denton Independent School Distnct agrees to comply with the requirements of the Immigration Reform Control Act of 1986 regarding emplovment verification and retention of verification fors for any individuals hired 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 of the contractor's books, documents, papers, and records that are pertinent to the contract The Denton Indeoendent School Distract 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, provisions that allow for administrative, contractual, or legal remedies if contractors violate or breach contract terms, and any appropriate sanctions and penalties The Denton Indgpendent 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 times 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 Independent School District agrees to comply with all other applicable laws, including without limitation, any additional applicable Federal Laws or regulations contained in the Summer Food Service Pram ent between the City of Denton and the Texas Department of Human Services If the Denton Independent School Distnct fails to provide services in accordance with the provisions of this contract, the City of Denton may, upon written notice of default to the contractor, immediately terminate the whole or any part of this contract The agreement shall be effective as of Mav 24, 1996 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 ternunation IN WITNESS WHEREOF, the parties hereto have executed tlus agreement as of the dates indicated below Agreed to this date Title Acting City Manager The location of the food preparation site will be Houston Elementary School, 3100 Teasley Denton, Texas, 76205 Agreed to this date School Sponsor - Title DISD School Board President Tuss DOPWh^0^t FOR DNS USE ONLY of Human sWass SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION TX R u s10RZF No ( I Name of Food 9MVIN Sift Owsley Park (817) 566-8125 Aderose of See (Stree4CRY. Stella Street Denton, Texas 76201 (msJttsyyr-mo deyM) NumMrofOp• May Jura July Aug From 5/28/96 th h. 8/9/96 eati Dori• 4 20 D 22 7 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily asto Children Other Site 1 Indicate Type of Site ❑ A.(uMng one to four meals) ❑ C (sowing Sone erving primarily four mseb) ©E (serving one to four meals) Nonresidential Camp She Serving Primarily Homeless Children ❑ S (serving one to four meals) ❑ D (serving one to four meals) Denton 2. Ust ALL counties served by this Shia 3 A. Is your site open EYES [:)NO [:]Yes E No B is your site enrolled? 19 eh C Site Eligibility' Entertite percentage of children eligible for he and/or reduced prioe meals for the site (SFSP Handbook, Chapter 11) For n sites using D sites,if open to pr this fotafecensus date, esschool list the schools used document ste eliibllitaftach formula used by school to establshpercentage of free reduced docildren Census data from TACAA E For enrolled sites, Form 1631 will be used to document eligibility 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 meats for the site? 4 Did the site partidpate in previous years' SFSP? (SFSP Handbook, Chapter II) City of Denton N Yes, give name of contracting organization Fi Monitoring Plan (SFSP Handbook. Chapter III) Enter date of monitoring review to De conauciea wlmu, 1. Fmt Week or 07, Four WeNu W owation Revbws 5/31/96 6/12/96 7/17/96 100 % ©Yes ❑No 6 Meal Service Period Information (SFSP Handbook, Chapter II)• MEAL SERVICE TIME _ LS ELIGIBLECHILDREN BEGINNING TOSE SERVED' ENDING e 40 12 00 p m 1 00 p.m S,MMf Nllen eppreved Ievel. ( HYWeeek. Cnepw lq 7 Do you plan to feed children under one (1) year old? ❑Yes QNo Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) entlee Us" School Using Food Service Management U64 Private 'a N rofft D On Site ❑Central gMhas ® Food Authority,❑ Company Pncludes All Year Contraete) ❑ Or !9-0 rl Fam 18071Peee 2 Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) d Children Line U ❑ Most Soviete ❑ anhd ildren are Given Meare e s 0 and Pick Up Meals ❑ Other 10 list she personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter Ip T I.9 OF POSmON NO IN POSITION SPECIFIC FOOD SERVICE PROGRAM DU11ES Site Supervisor 1 Supervise and assist distribution of mels, monitor and maintain meal temperature, site clean—up, other duties as assiened Site Helper/Server 1 Assist 11 Indicate whet provisions will be made for meal service during periods of Inclement weather (SFSP Handbook, Chapter II) Indoorges! Meal Service - Service ❑WID Be Cancelled ❑Other 12 0 the she feeds primarily homeless children, what methods are used to ensure that money, food stamps, or unkind services are not required for meals? n/a 13. Are meals delivered to the site? ®Yes ONO 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, Chap II) She Personnel VAR Contact Administrative She Personnel Will Communicate ®Staff, Who WAR Contact Vendor ❑ Directly With Vendor 15 VAR delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ❑- Yes [:]No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 16 If there ban excess of meals delivered, meals will be (SFSP Handbook, Chapter 111) Stored Served the Ns Day ❑attheSits Away ❑b fforDepoe�liVsmbr ❑Otherr I CERTIFY that the informodon on this form Is true and correct to the beat of my knowledge I pertly that this site has been vished and than it has the 15d facilities for the meal service planned for the number of children anticipated I know that deliberate misrepresentationor withhold*0 ma)r suit In prosecution under applicable state and federal statutes 41z.pI City of Denton (plws typos pW Two Rick Svehla I Acting FOR [-]Approved ❑Denied roaeon. txte 118E ONLY TtlM RspnesrpeWe ACL U OF VIRGIIVIA >�c sue) FAX FROM.' Bill Cwpv DATE.^ 4401119, 105 M..• , Dana% TX E ORA 6u tbo Damia Pads a9to (w attached map), aQ ekta are bossW agmr* in 9ua1if 46 block 8taT& hate m to wnbm 1 Civic C4Mw- (The block group is oniy 48% but camas tract 020601 u ova W% r z= � '6%titlL: rp i�i Slt.... ,� aAlfibb !%— -Vm18, 4<t83 = 0206013 115 85 - 0 480 2 Deena Park 71M rite is k�ed in block gaup 0208 3, but only a fbw foot gray ftoai qumld�jqi; block 02094 0206 3 467 82� ^ 0208 4 243 10'7 24 840 3 bGX Rae Ceotw ozl�`J 1028 637 77 —8714 S_phoewx Pelt 0206023 .� Y270 ^ Y .. 138 " 24 Aawrem CMI1Jb~ Udw q%MOW RxMOO ft* a, RlaWW" VA "219 hL• (W 6M-M Fec P" 619-033 r LIM u'r x o� s uj >� O �c cv a�- u 7. TWU Oubb OoMl1 a. V Wwp CAM APL, 504 71 _m� i�l 0 5rf�w: N # Ln co x r in= N WS <p Vo N �1++ w i �w � �LL Texas Dsyvbnea FOR DHe UBE ONLY a Hunan SSWOM SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION TX nR Name ServbSib Dania Park 1(817) 566-8125 1001 Parvin Denton, Texas 76201 From 5/28/96 T _- ._-. _. _. 1hroWh 8/9/96 melingDays V 4 Y 20 2 1 IF ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Slle Serving Pdmadiy Migrant Children Other Site Residential Camp Q E (serving one to four mesh) 1 Indicate Type of Site ❑ A.(serving one to four meals) ❑ C. (serving one to four meals) Nonresidential Camp Site Serving Pdmerly Homeless Children B (serving one to four meals) ❑ D (serving one to four meals) 2 List ALL counties served by this site Den ton []Yes ❑No 3 A Is your site open [:]Yes QNo B Iayour site enrolled? C Site Eligibility' Enter the pencenllege of children eligible for free an Nor reduced price meals for the site (SFSP Handbook, Chapter If) 64 % n sites using D If Ilet the sites, submit schools used documentation site epigiblllM 948d0 formulthis a usedure by school dluch as �st. to ensus t ablish percentaate, school ge of For free& reduced rice children Census data from TACAA E For enrolled sites. Form 1631 will be used to document eligibility If the enrolled site used school data, list the school used to document the F What is the percentage of free or reduced-pdce meals for the site? 4 Did the site participate in previous Years' SFSP? (SFSP Handbook. Chapter II) City of Denton If Yes, give name of contracting organization 5 Monitodng Plan (SFSP Handbook, Chapter III) Enter date of monitoring�� R nuuauu w,un„ views A. Fleet week B Fleet Frew weeks a 5/31/96 6/12/96 7/17/96 B Meal Service Period Information (SFSP Handbook, Chapter 11) 100 % ©Yes ONO NUMBER OF MEAL SERVICE TIME MEALs WWBLE CHILDREN BEOINNIND EDING *TMYPEBIF ent 30 12 p mement Supper op sank» q 7 Do you plan to feed children under one (1) year old? S Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter .x a Vaneed liaise wheel Uelmt Food Service Me QYes QNo Form 1e07lPeee a Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter 11) Cafeteds-style Children are Seated Children Line Up ❑ Meal Semin ❑ and are Given Meals © and Pick Up Meals ❑ Other 10 List site personnel who will be involved to arty extent in the meal service (SFSP Handbook, Chapter II) TITLE OF POSITION 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 11 Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Mom Meal vice Servlm ❑ Will Be C ❑Oancelled ❑Other 12 If 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 the site? 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, Chap 11) Site Personnel WIII Contact Administrative She Personnel WIII Communicate W StaR, Who WIII Contact Vendor ❑ Directly Wlth Vendor 15 Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ®Yes [:]No B no, describe arrangements within standards prescribed by locate health authorities for delivery and holding of meals until time of service 16 If there ban excess of meals delivered, meals will be (SFSP Handbook, Chapter 111) Stored In Refrigerator Thrown Away Returned to Vendor Wand Served the Next Day ❑at the She ❑for Dbposel ❑Other, I CERTIFY Otat the Information on this form is true and correct to the hest of my knowledge. I certify that this site has been Waited and that it has the De d fadlitles for the meal service planned for the number of children anticipated I know that deliberate misrepresentation or withtoWl of info9nadon rruy result in prosecution under applicable state and federal statutes oms City of Denton a nlmctlnpO�pWmtloeI -Saw- Name type or pr" Two Rick Svehla I Acting City Manager FOR DHS USE ONLY ❑AWoved ❑Denbd,reason tale si mbue-om Revesemative Dab ACL U OF VIRGINIA FAX TO: ,'a*. nvub FROM.- B111 Caper WE. 4wi It, 105 M.- , D&%nq, = Except 6or die Dmiia hdc Tito (eee t�ohed map). alt saes aR loeaoed e4�'dY is 9uah0'm8 bbeik frsmpa, Haep en the+aaobas. 1 Cam Gaoler CM block reap is only 41% but am= fta 020601 v am SM V fu !ta. � a'b►'�fe' 0106013 115 55' 0 494 El�'..'�.4 I, 71e sae is *10d is block Emp 0208 3. but oely a fbw fbet way from 4 block 102084, y. p 407 ea 0208 4 243 10`i 2a 50 t 3 W K Rae (;eater 0212 2 1028 657.� 77 _ 714 �1 0200 751� 15 � 761ka " ~270 0206023 138 24 50r� w m m N W= O tv c� 3 AnWOMCMILON"Ulm* g%TbVwO C~ q N� atAWO SM St, jbd w rA VA. 23219 _ FeL f:6 &440M Far (80t,160-21JS 0206021 504 y" 0 == -=w: s M # # l!7 - m= � OS N - w = p V� fV N U4- VC U1� ► w N Texas DepaerTM^t I ofHumea s«won SUMMER FOOD SERVICE PROGRAM FOR CHILDREN I1-- SITE INFORMATION TX Rayzor Elementary School I(817) 566-8125 Number of OP. ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED ResldentW Camp she Serving PrimarilyMlgrent Children Other Site 1 Indicate Type of She ❑ A. (serving one to four meals) ❑ C (serving one Po four mesh) ID E (serving one to Pour meek) Nonnuslidentlai ❑ B (serving onelw to tour meek) ❑ M(servingg oSite ne to four Primarily Homeless Children Denton 2. List ALL counties starved by this site 3 A Is your site open: ❑Yes ®No ®Yes ❑No S Is your site enrolled? C Site Eligibility Enter the percentage of children eligible for free andfor reduced price meals for the site (SFSP Handbook, Chapter II) 0 For n sites using D list them ls pd rondo umens site eplglblg� attach this formulaeu figure ed by(such school dust to establish percentansus date, school ge of freee& reduced price school E For enrolled sites, Form 1631 will be used to document eligibility If the enrolled site used school data, list the school used to document the site 100 % F What is the percentage of free or reduced price meals for the site? [Dyes QNo 4 Did the she participate In previous years' SFSP? (SFSP Handbook, Chapter 11) If Yes, gW name of contracting organization 5 Monitoring Plan (SFSP Handbook. Chapter III) Enter date of monitoring review toPAVconducted within A. Week at B tFour Weem Opemm June 4 June 11 6 Meal Servtoe Period Information (SFSP Handbook, Chapter 11) NUMBBR OF MEAL SBRVICB TIME T 111 0. MUALB HUOIBLB CNU.DRHN BEGINNING ENDING-_ Breakfast AM Supplement Lunch 150 11 P M Supplement Supper -I=eewnrvw, w w.---1—•—...._.. ---- — .. QYes % No 7 Do you plan to feed children under one (1) year OW? 8 Method of Food Preparation by Contracting Organization (SFSP Handbook. Chapter II) vaMeausing School UsingFPoy (Includes All Year Contracts) ❑ Orgaahalion gat b Seh Prof n On Sits ❑ Central Imah m ® Food Autirodh ❑ Form 1507IPap 2 9 Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter 11) Cateteds-style Children are Seated Children Line Up [:]Meal Service ❑ and are Given Meals ® and Pick Up Meals ❑ Other 10 List she personnel who will be involved to any extent in the meal service (SFSP Handbook, Chapter II) TEE OF ►OSRION NO tit ►osmom SPECIFIC FOOD SERVICE PROGRAM Dtrr1ES Supervisor 1 Supervise and assist distribution of meals. monitor and maintain meal temperature, site clean—up, and other duties as assigned Site Helper/Server 2 Assist site supervisor 11 Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) QIndoor meal SOry❑ IC111 will Be rvice Cancelled El Other 12, If 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? 13 Are meals delivered to the site? ®Yes ONO IF YES, COMPLETE ITEMS 14,16, & 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 ti) Se Personnel will Contact Administrative She Personnel Will Communicate ®Staff, Who will Contact Vendor ❑ Directly Wlth Vendor 15 Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) QYes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service. 16 If two Is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 111) Mond In Served theme Next Day ❑at the S eerator Thrown � ❑for DlsposNReturned to Vendor ❑ate 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 Capgldg end I diitles for the meal service planned for the number of children anticipated I know that deliberate misrepresentation or tvithholdl of In o alion may ssuit In prosecution under applicable state and federal statutes City of Denton o antrectlrp enlralbn FOR [:]Approved El Denied, reason OHS uSE Tek ONLY a.Fnnantaay. �u Texas S@rvk h a NumW en Servleea SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION TX I Name of Food SON" slu I (817) 566-8125 TWU Clubhouse Program AeareN W olw toeee4 u4. oYxv, r. , Mar Hufford Court Denton, Texas 76201 L cod (mo M - w4dayM> Number of l)p �j M°y ° day Aug From 5/28/96 through. 8 9/96 smtirlpDart 1 4 20 D 22 7 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving PrimarilyMigront Ctllkiron other Sits �i 1 Indicate Type of Sr. ❑ A.(serving one to four meals) ❑ C (serving one to four meals) X E (serving one to four mals) Nonresidential Camp SRO Serving Primarily Homeless Children ❑ B,(serving one to four meals) ❑ D (serving one to four meals) 2 List ALL counties served bytilde site Denton ©Yes ❑No 3 A. Is your site open ❑ Ysa ©No B Is your site enrolled? C Site Eligibility: EnW to percentage of children elIgible for free andlor reduced pnce meals for the site (SFSP Handbook, Chapter Iq 19 eti ool For n site$ using D IIf open slues, submit le" the schools used ro docume t she mentation eligibility a thispercentage fformulaeusgure ed by school diuch as isstreus date, to establish�percentage of freee& reduced pdoce children Census data from TACAA E For enrolled sites. Form 1531 vdll be used to document eligibility If the enrolled site used school data, list the school used to document the F What is the percentage of free or reduced -price meals for the site? 4 Did the site participate In previous years' SFSP? (SFSP Handbook, Chapter II) If Yes, give name of contracting organization City of Denton 5 Monitoring Plan (SFSP Handbook Chapter Ilq Enter date of monitoring renew to De conuuauu w,un„ A t Week or B Fkrt Four Weeks a Opemrbn C AddivaW Revaws 5/31/96 6/12/96 7/17/96 5 Meal Service Period Infonnatlon (SFSP Handbook Chapter Iq 100 % QYea El No TYPES OF ME" NUMBEROF —' ELITo GIBLE S B ERVED' CHILDREN BEGINNING ENDING Breakfast AM Supplement Lunch 55 12 00 p m 1 00 p m P M Supplement Supper vdl0nsetom eN ap;—~ mW NveL(SFSP NalWaaeK 7 Do you plan to feed children under one (1) year old? S Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) Velwed uaim Sehmi Uslrm Food Service Management [--]Yes LINO Form 1507IPaee 2 Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Cafaterla-We Children are Seated Children Line Up ❑Mal Service ❑ and are Given Meals Eland Pick Up Meals ❑ Other 10 List site personnel who will be Involved to any extent in the meal service (SFSP Handbook. Chapter II). 11 TfL5 OF POSMON NO IN ►OS=N SPECIFIC FOOD SERVICE PROGRAM DUnEe Site Supervisor 1 Supervise and distribute meals, monitor and maintain meal temperature, site clean—up, other duties as assi ne Indicate what provisions will be made for meal service during periods of inclement weather Indoor Meal Meal Service ©Service ❑ Will Be Cancelled ❑Other (SFSP Handbook, Chapter 11) 12 N 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? 13 Are meals delivered to the site? ©Yes []No IF YES, COMPLETE ITEMS 14,15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM 14 Indicate the means of Communication with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap 11) ®Site Personnel WIII Contact Administrative Site Personnel WIII Communicate Stets, Who WIII Contact Vendor ❑Directly With Vendor 15 Nil delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ®Yes []No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until lime of service 16 N there Is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) Stored In Retrlgeretor Thrown Away Returned to Vendor ®end Served tla Next Day ❑et Ns She ❑for Disposal ❑ 0t11er. 1 CERTIFY that the Information on this form Is true and correct to the best of my knowledge. I cartify that this site has been visited and that it has tits! facilities for the meal service planned for the number of children anticipated I know that deliberate misrepresentation or whh of inf tin may resu In prosecution under applicable state and federal statutes mns City of Denton Name al OMOM (phase bee or Print) Tim Rick Svehla I Acting City Manager FOR I ❑Approved ❑DeNsd mason ate USE ONLY ri ACLU OF VIRGINIA 3P"owwwswvw) FAX Ta:. tt*b Bil, Cow LW M- Ap Il It,1"s Aw tbo Dmia rack aao (IN attaobed near), au sacs an kmW sow* in guar Mork Vag& IWO M the fambas 1 Caic Curter, (?be block stoop is only 48% but cares tnlet 020601 u ow SM 7-to .: `''�..@% +tq: _ 11 rift lyi ,_.. uallepxkbpw �.._-ffaA a83'li�: oZo6oss 115 65 0 400 2 Doe Park i 08 sae is block poop oup 0208 3. but only a tbw foot way ftam qual�lyttggi block 6 02 4. 07 aoe2 0208 4 243 10'7 24 840 3 WX iRec Ceara ' •`?�. � _w. � o ia�s.� -: g tb]I ' �� �. ,o�po-la �elmaRa 02s2 2 1028 657M 77 7141 oao� '1 3ei 0206023 z7o Awerfam CMI1Jbefta LWM gfVkVM a Armoo also a.Ridw"MA B219 Ym 00 &4. 0J1 Far 09 66-21" 4 6 a m: s N Y S y W= >s -O U$ CV a-U.. UN q N .■ , •-umpCAM APL !; ko 9© � ■■� o ■ , ■ ■ t §f � t _ §/ �U- Tow Depere—1 of H~ Senron SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION 700 rasa„ rvke (molwy/yr mo dsYM) I Number of Op• "" prom 5/28/96 through 8/9/96 among Days 4 n 22 7 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Site Serving Primarily Migrant Children Other Site Residential Camp E Iserving one to four mals) 1 Indicate Type of Site ❑ A. (serving one to four meals) ❑ C (serving one to four meals) Nonre ldentlel Camp She Serving Primarily Homeba Children ❑ S (arring one to four mall) ❑ D (serving one our mala) Denton 2 List ALL counties served by this she [Dyes [:]No 3 A. Is your site open ❑Yes [Z]No B Is your site enrolled? 100 % C Site Eiigiblllty- Enter tiro percentage of children eligible for free andlor reduced price meals for the site (SFSP Handbook Chapter 11) nsus school n sites using School D If list tithe schoolsubmit used to document site elig,bilitr atttach formulaeused burey school diuch as isst. to establish percentage ofrfreea& reduced P children Cehsus data from TACAA E For enrolled sites, Form 1531 will be used to document eligibility If the enrolled she used school data, list the school used to document the she 100 % F What is the percentage of free or reduced -price meals for the site? ®yes ❑No 4 Did the sloe participate In previous years' SFSP? (SFSP Handbook, Chapter 11) h Yes, ghre name of contracting organization City of Denton 5 Monitoring Plan (SFSP Handbook, Chapter 111))q EEwntt��er date of monitoring review to be conducted within tit�lwaek 5 31/96 e I Fout 6e;;; 9 �'7%s17/96 L O Meal Service Period Information (SFSP Handbook Chapter II) -.,.2. n. MEAL SERVICE TIME TYPES OF, MEALS Breakfast AM Supplement Lunch 50 P M Supplement Supper 7 Do you plan to feed children under one (1) year old? BEGINNING 1200pm a Method of Food Preparation by Contracting Organization (SFSP Handbook Chapter 11) eMW u.I.,,. enAeel Uahw Food Servke Management 100pm ❑Yea QNo Form 15071Pape s Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter 11) Cefalmd"tyle Children are Seated Children Line Up ❑Meal Service ❑ and are Given Meals 0 and Pick Up Meals ❑ Other 10 List she personnel who will be involved to any extent in the meal service (SFSP Handbook, Chapter II) Tm.9 OF POSmON No IN POSmON SPECIFIC FOOD SERVICE PROGRAM DUnaS 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 site 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 ❑Will Be Cancelled ❑Other 12 If the site leads primarily homeless children, what methods are used to ensure that money, food stamps, or in -kind services are not required for meals? 13 Are meals delivered to the site? ®Yes ❑No IF YES, COMPLETE ITEMS 14,15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM 14 Indicate the means of communication with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap 11) She Personnel Will Contact Administrative She Personnel WIII Communicate ©Staff, Who WIII Contact Vendor ❑ Directly Wlth Vendor 15. Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) E]Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals unlit time of service 15 If there Is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 111) Stored In Refrigerator Thrown Away Returned to Vendor ®and Served the Next Day ❑at the She ❑for Dleposal ❑Other: I CERTIFY that the Information on this form is true and correct to the best of my knowledge 1 certify that this aft has been visited and that it has lire a bilMIN td fadlhies for the meal service planned for Me number of children anticipated I know that deliberate misrepresentation or whht; don m ressuuh In prosecution under applicable state and federal statutes Nrro ot 0100101 4ftW It" «PMpToo Rick Svehla I Acting City Manager FW ❑Approved ❑Denied roseon USE 7pN W&V Sipnaaoe-DNS Reproe WM Da4 ' ACL U OF VIRGINIA FAX 3 ow« (,rotudtoa oovar) To.. ' Jaald� MhJleld FROM. Bill c"w DATE Apr111.0, 105 M. , Darns; TX BMW for tbo Do& Par1k eito (see aft" map), aH Ww an looaad aquwa4, in gaa*r4 bloc* Wcupe. Ibm are t6a+a DWM 1 Cmo Caster, aU block 5ooap is only 48% but mm, ew 020601 is ow SM 0206013 lib 55 0 480 2 Dama Pads f !Ue trte ie is block 5taap 0208 3, but Daly a 02094, tbw foot way fanqw&YhU block 407 82 0200 4 243 167 24 8« 3 MLK Roo Geoter oil.' _ Iola Ig). wa �= �e - 1028 857 77 71t 4 Owdey Ndabbodmod 023 " 51 0206023 270 130 24 A+wtam Qvtt LOws" r V-MVW ArMv*00a.AM w mAVA.23210 Tok ON 6"4W2 Far {1"6&2f33 w ZN d W ~w rn _r- m-T �_ O NN � G Cn 0�06600.11w A OZ^ vw�a504 .v10a 2� ,, �9,AvliBAl�y is 1�1� # # r Ln t w o Ai 2 m< u+ H LZ` fV - w W = c p VC fV aW w a � N lu G iS Taxes DepeMneffl FOR VHS USE ONLY d Hunen SWAM SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION-� Houston Elementary School _ I (817) 566-8125 00 Teasley Denton perloo of ppeneon of Food (mo-mslssW) Number of Op- A--y D��' From b/3/96 through 6/28/96 ending Days i 20 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Site Serving Primarily MIgnrt Children Other Site Residential camp 1 Indicate Type of She ❑ A•("Mng one to four msate) ❑ C (Serving ons to four meals) X E (serving one to Pour meals) Nonresidential Camp Site Serving primarily Homeless Children ❑ B (serving one to four meals) ❑ D (serving one to four meals) Denton 2 List ALL counties served by this site ❑Yss ®No 3 A Is your site open ®Yes [:]No B Is your she enrolled? C Site Eligibility Enterthe percentage of children eligible for free and/or reduced pnoe meals for the site (SFSP Handbook, Chapter II) 0 °h nsus date. school open sites using D if open sites, list the schoolsubrrdt used to document she mentation supporting eligibility; its attach this formula used by ure school diuch as vest. to establish percentage ofrfree & reduced P school E For enrolled sites, Form 1631 will be used to document eligibility If fire enrolled she used school data, list the school used to document the site 100 F What Is the percentage of free or reduced price meals for the site? 4 Did the site participate in previous yeah' SFSP? (SFSP Handbook, Chapter II) []Yes No N Yes, give name of contracting organization 5 Monitoring Plan (SFSt49 book, Chapter 111) Enter date �monitforunliggrevie �to wnduatau ^'u "• A l Week ofB t Four sews d 1 6 Meal Service Period Information (SFSP Handbook, Chapter II) NUMBER OF MEAL SERVICE TIME TYPES OF MEALS RUOISLE CHILDREN BEGINNING ENDING TO BE SERVED' Breakfast AM Supplement Lunch 30 P M Supplement 7 Do you plan to feed children under one (1) year old? 6 11.45am I 12:45am Oyes ®No Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) Using private �� endee Wing mfk School USing Food Service Management SNe Central lOiellen Food A Com n eludes All Year ConUaeta mintlon that is SeS•P Femf 1507113ege 2 Indicate the system to be used for the serving of meals and the supervision of children during meal servka period (SFSP Handbook Chapter II) Celeterl"Ityle Children are Seated Children Line Up ❑Mal Service ❑ and are Given Meals Eland Pick Up Meals ❑ Other 10 List site personnel who will be involved to any extent in the meal service (SFSP Handbook, Chapter II) TM.E OF POSmON NO IN POSITION SPECIFIC FOOD SERVICE PROGRAM DUnES Site Supervisor 1 Supervise and distribute meals, monitor and maintain meal temperature, site clean—up, and other duties as assigned 11 Indicate what provisions will be made for meal service during periods of inclement weather Indoor Meal Meal Service ®SOVIN ❑WIII Be Cancelled ❑Other (SFSP Handbook, Chapter In 12. N 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? 13 Are meals delivered to the site? QYes [--]No IF YES, COMPLETE ITEMS 14,15, d,1E 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 II) Site Personnel WIII Contact Administrative She Personnel Will Communicate QStaM, Who Will Contact Vendor ❑ Directly With Vendor 15 WIII delivery be within one hour of the food service period? (SFSP Handbook Chapter II) WYes [:]No N no, describe arrangements within standards prescribed by local health authorities for delivery and holding of mealy unlit time of service 16 N there Is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) Blared In Refrigerator Thrown Away Returned to Vendor ®arid Served the Next Day ❑ at the She ❑for Disposal ❑other I CERTIFY that the Information on this form Is tore and Correct to the beat of my knowledge I certify that this site has been visited and that it has the capgpglll and facilities for the meal service planned for the number of children anticipated I know that deliberate misrepresentation or whhholdi21nfMmaysuitin prosecution under applicable state and federal statutes NGM of tra :J/' /� Wne Cityof Denton _ fPbsee tyae ar prinq 7eN Rick Svehla FOR ❑Approved ❑Denled,roason ONE USE The ONLY RePnnealF&A lob Teter DepeNroM FOR DHa USE ONLY a Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION flit Name of rood giVIC003110.I Phoenix Park (817) 566-8125 i � Wood Street Denton, Texas 76201 From r5/28/96 through 8 / 9 / 9 6 eMingDays: Y 4 Y 20 Y LL y r ATTACH A MAP WITHITHE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Site 1 Indicate Type of Site ❑ A• (serving one to four meals) ❑ C (serving one to lour male) 0 E (serving one to four meals) Nonresidential Camp Site Serving Primarity Homeless Children ❑ S (serving one to four mmda) ❑ D. (serving one to four meals) 2 List ALL counties served by this site Denton ®Yes ONO 3 A. Is your site open. ❑Yea QNo S Is your site enrolled? 31 sti C Site Eligibllitr Enter the percentage of children eligible for he andlor reduced price meals for the site (SFSP Handbook Chapter II) this ure uch as nsus date, school data) open skes using school dam D If open the sdwolsuu ed to document she eligibility. attach formpercentage ufsed by school diisst, to establish ppercantage ofrfree & reduced price children Census data from TACAA E For enrolled sites. Form 1531 will be used to document eligibility 8 the enrolled site used school data, list the school used to document the F What is the percentage of free or reduced -price meals for the site? 4 Did the she participate In previous years' SFSP? (SFSP Handbook Chapter II) H Yes, ghre name of contracting organization City of Denton 5 Monitoring Plan (SFSP Handbook Chapter III) Enter date of monitoring review to De conuumou w,u,,,, A. Finn Week t Four Waalu Operation C Addieer,N Rewm 5/31/96 6/12/96 7/17/96 8 Meal Service Period Information (SFSP Handbook Chapter Il), 100 ©Yes ONO NUMBER OF MEAL SERVICE TIME TYPES OF MEALS ELITOGIBLECHILDREN BEGINNING ENDING BE ERVEW Breakfast A M Supplement 90 1200pm L OOpm Lunch P M Supplement Supper titmn sonim m apprand a" tanks l@"L (EMP HendtweKChOPW Q 7 Do you plan to feed children under one (1) year old? ❑Yes QNo 8 Method of Food Preparation by Contracting vrganu:auon poror r,r...-- —•• IISIN Sohool _Using Food Service!"ement nUsi°9 PrNMs Non -Profit Form 1507P'aaa 2 9 Indicew the system to be used for the serving of meals and the supervision of children during meat service period (SFSP Handbook, Chapter 11) Cefelarl"106 Children are Seated Children Line Up ❑ Meal Service ❑ and are Given Meals ED and Pick Up Meals ❑ Other 10 Ust she personnel who will be Involved to any extent in the meal service. (SFSP Handbook, Chapter II) 11 TM.E OF POSmON NO IN ►OSn10N SPECIFIC FOOD SERVICE PROGRAM DVnES 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 I 1 I Assist site supervisor Indicate what provisions will be made for meal service during periods of inclement weather ®SarviceMeal ❑WIIIl Service BeCancelled ❑Other (SFSP Handbook, Chapter II) 11 9 the she feeds primarily homeless children, what methods are used to ensure that money, food stamps, or in kind services are not required for meats? n/a 13 Are meals delivered to the site? ®Yea [:]No IF YES, COMPLETE ITEMS 14,15, S 15 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 II) She Personnel WIII Contact Administrative Site Personnel Will Communicate X❑Stall, Who WIII Contact Vendor ❑ Directly Wlth Vendor 15 NO delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) E]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 ban excess of meals delhrered, meals will be (SFSP Handbook, Chapter III) Returned to ®Stated In Refrerator Thrownand Served the Next Day ❑at the She Away ❑ror DlsposslVendo► ❑Other I CERTIFY that the Information on this form Is true and correct to the beat of my knowledge. I oertly that this site has been visited and that ft has the cap WII d facilities for the meal service planned for the number of children anticipated 1 know that deliberate misrepresentation or withhold cap Info a9 n may repit in prosecution under applicable state and federal atatutes City of Denton OW FOR ❑Approved ❑Denied,reaaon on USE TWO ONLY RepeteMative DW ACL U OF VIRGINIA FAX � v� ftgdudlva Dover) �,taakl. ii�i�l.1d FF Wt.- Bill Cogotr DATE- Apd110, IM5 RE De>aem TX EXW for ft Dmua M Quo (me aWwbed map), aQ An ars loWW sq=My in qmbfrat block 8=ag& HM are ffie nmabm, I Cme Curter. Ma block group is oniy 48% but om m tract o20601 is over SOX, -Eta* o1o60t3 115 55 0 _ 48' i F 71a aito is k�Ood is block atwp 0208 3. but only 02084 a flow feway f m quabla block . , et Ps 0 20111- ao7 S2 0208 4 243 10'7 24 840 3 NHX Rec Center _:a"„5►18�faJme� Oxl2 2 1028 657. 77 71i 4_Owday N41&arbood _ U1 251 1S 76; S. rbneobt Put 0206023 AmWem CMI Db~ Unim gl "7 W ArNma SIM St. Rid4w "VA. U219 ru ON 6ts n Fier P" 619-21" d K O N s vo N Lu-- LJ z� ► � NW s t, oZo^�6• '' O4��,;,.Dcu�ai:..-3h_Ytt: * # N s m= O, tV Wn p >S c>3= WC cV CV WF � 0-W u1 i ► N Taw DepeNoaM of Haman Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Civic Center Park gas (S"K P) 321 E McKinney Denton, Texas 76201 Period M UPOFUM d pm-1-6lme ayM-r^oloerM)I Numbis'"Is- -" From 5/28/96 through: 8/9/96 eratingDays 4 20 ATTACH A MAP WITH THE SITE SERVICE eside titiE AREA IDEWTIFlED site Serving Pdmadly Nigrant Children p serving one to lour male) 1 Indicate Type of Site ❑ If (servingNonresidential one al four mark) ❑ C Sb Serving primarily Homeless Children Nerving net Comp B (serving one to four male) ❑ D (serving one to four male) Denton 2. List ALL counties served by this site 3 A. Is your site open. (817) 566-8125 0% �1 other Site N! E (serving one to four male) B Is your she enrolled? C She Eligibility Enter the Percentage of chgdren eligible for he andlor reduced price meals for the sfte (SFSP Handbook, Chapter 11) QYes ❑No ❑Yes ©No 22 % ool For n sites using l data. D If list thie schoolsusedto document site on Supporting this attach formulaausgursed byuch as schooldust to establisnsus date, h�percentage of free& reduced prides children CensusCensus data from TACAA E For enrolled sites, Form 1531 will be used to document eligibility If the enrolled site used school data, list the School used to document the F What is" percentage of free or reduced -price meals for the she? 4 Did the site participate in previous yeare' SFSP? (SFSP Handbook, Chapter II) H Yes, give name of contracting organization City of Denton 1•1 Monitoring Plan ($FSP Handbook Chapter III) Enter date of monitoring review to oe conuuww w,u... I RWAWS a Fast wean Part our Weeaa a aperetbn c AOWibrW 17 / 96 5/31/96 6/12/96 6 Meal Service Period Information (SFSP Handbook. Chapter 11) NUMBER OP MEAL SERVICE TIME TYPESOPiiMEALS ELIOIBLe CHILDREN BEGINNING ENDING TO BE SERNEW Breakfast AM Suppleme11 nt Lunch 40 12 00 P m 1 00 m. P M. Supplement Supper rvet q apgwea 7 Do you plan tD feed children under one (1) year aid? S Method of Food Preparation by Contracting Organization (SFSP Handbook. Chapter 11) USA PonarmnUehw School _ Using food Service AlsnyfemeM W 17 I UMslll�pw rillade0 100 % ]Yes ❑No ❑Yes ©No Farm 1e0rIP"o 2 Indicate the system to be used for the serving of meals and the supervision of children during meal service period Cafebda4tyte Children are Seated Children Line Up ❑Meal service ❑ and are Given Meals Eland Pick Up Meals ❑ Other 10 List she personnel who will be Involved to arty extent in the meal service. (SFSP Handbook, Chapter II) 11 (SFSP Handbook, Chapter 11) Tm.E OF POSMON NO IN POSn10N 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 Indicate what provisions will be made for meal service during periods of Inclement weather (SFSP Handbook, Chapter 11) ®Servicee ❑YAll Be Cancelled ❑Other 12 V the she feeds primarily homeless children, what methods are used to ensure that money, food stamps, or In•klnd services are not required for meets? I& Are meals delivered to the site? IF YES, COMPLETE ITEMS 14,15, & 15 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 II) Se Personnel WIII Contact Administrative site Personnel WIN Communicate ©OW, Who WIN Contact Vendor ❑ Directly With Vendor 15 WIN delivery be within one hour of the food service perod? (SFSP Handbook, Chapter II) 0 Yes ❑ No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 15 If there Is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) Stared Served the Next Day ❑at ft SS e�y ❑foDbpoealReturned to Vsndor ❑ I CERTIFY that the Information on this forth Is true and correct to the best of my knowledge 1 certify that this site has been visited and that it has the capability and facilities for the meal service planned for the number of children anticipated I know that deliberate misrepresentation or whhholdp a fors cation m result M prosecution under applicable state and federal statutes came N6A City of Denton Nero type or p" We Rick Svehla I Acting City Manager FOR ❑Approved ❑Denied, moon. om USE TeN ONLY Raparsmatlw Data ACL U OF VIRGINIA 3 PW (m4fts cover) FAX FROM.' B111 Coc w DATE^ Apd1It. %M5 ��siwv►y iA $=w Aw dic Deokia Pack As (!OC O K&W map), all aita an lomw aguanly in quW*% block Vagit. Hato Oro fhc nambm 1 Civic Canter. aU block imp is only 48% but oeom tract o20601 u owr SM 0206C13 115 55 0 488 2 Dun Park f 7M so is Ieded in block g=p 0208 3, but poly a taw last way Sam quaktAM Moak 2G �0208 4. 0206 3 407 82�' 0200 4 243 1057 24 841r 3 IV1 X Roo Ceota �.� ..:ova'it,::rQrb1_„yie�%»:',olai3�(awde�a-��=��,►�g�..» 0212 2 1028 657 77 71q ~ +_ 270 138 24 a 60CW _W H N t+f _ Cox LM = W= CV up > V� Aaewraaa Qvtl lJbw*u Valm V?bVw w or Markh Sbab SR. AkAwo14 VA. 2321.9 rok ON tt4"M For P" 619 J" e. a Wmp cap[ APL aUW%nv?�L Az 0206011 504 2W" # # # 0 N In �tJ cr) ��t7 4 Y= tp c�R vo N N �� ls1 2 CC ► N 1iJ ,� c Tun poperomaal FOR DHS USE ONLY of Human Soft" SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION .X R U eisovne No lag ) Name of Food SWvM Sao (817) 566-8125 MLK Recreation Center 1300 Wilson Denton, Texas 76205 (moldwAn-m ~r) Number of Op- Mer DJaa 5/28/96 through: 8/9/96 WatingDays 4 20 I ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp She Serving Primarily Migrant Children 1 Indicate Type of Site ❑ A.(cerving one to four male) ❑ C (serving one to four male) Nonresidential Camp She Serving Primarily Homeless Children ❑ B (serving one to four malt) Ell) (serving one to four meals) Denton 2. List ALL counties served by this site 3 A. Is your alte open.... B is your site enrolled? 22 Other She © E (serving one to fourmab) X❑Yes ❑No ❑Yes ©No C Site Eligibility' Eller the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) 31 % school n sites using school D If open allies, list the schoolsubmit used documentation ocume t she eligibility. atttach formula ausedrbysuch as census school dist. to establish percentage ofrfree& reduced prim children Census data from TACAA E For enrolled sites. Form 1531 will be used to document eligibility If the enrolled she used school data, list the school used to document the 100 % F What is the percentage of free or reduced -price meals for the she? 4 Did the she participate In previous years' SFSP? (SFSP Handbook, Chapter II) QYea [-]No If Yes, gi ve City of Denton 5 S Monitoring Plan (SFSP Handbook, Chapter III) Enter date of monitoring review to be conouaea warm B FLeI Four Weals of C AddieorW Revawe A. Rid ses 5/31/96 1 6/12/96 7/17/96 Meal Service Period Intormsmon toror nemuw N ..,, NUMBER OF ELIDIBLE CNILDRBN TO BE SERVED P— -v MEAL SERVICE TIME BEBINNINO ENDING it 9( 12 p m100 p m. r ertmnl aeoaq gee alWrovea row eernaa.vei.,ar�� ,+,.,...., _._,._..., 7 Do you plan to feed children under one (1) year old? 1.1 ❑Yes ©No Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) vended Using sohoot Using Food Service Msnagemat Ualg Privs* lbmProih On She 0 Central now ® Food AuUady ❑ Company Oneludes AD Year Contra*) ❑ Otgsn*aUoR fiat Is Self -Prep Fwm 1e07I1'e0e 2 9 Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter Iq Caleterkatyle Children are Seated Children Line Up ❑Mal Service ❑ and are Given Meals Eland Pick Up Meals ❑ Other 10 List site personnel who will be Involved to any extent in the meal service (SFSP Handbook, Chapter 11) TILE OF POSITION NO IN POSn10N 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 II) Indoor Mal Mal Service ®service ❑VAII Be Cancelled ❑Other 12 If the site feeds primarily homeless children, what methods are used to ensure that money, food stamps, or Inddnd arWoes are not required for meals? 13 Are meals delivered to the site? ®Yea [:]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, Chap 11) Site Personnel WIII Contact Administrative Site Personnel Will Communicate ®SteU, Who Will Contact Vendor ❑Directly With Vendor 15 WIII delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11) Yes [:]No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 16 If there Is an excess of meals delivered, meals will be Stored In Refrigerator Thrown Away ®snd Served the Nest Day ❑at the She (SFSP Handbook, Chapter III) ReWmed to Vendor ❑forDlepoal ❑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 If has the capII nd facilities for the meal service planned for the number of children anticipated I know that deliberate misrepresentation or whhhokl M IM tion ma esuh in prosecution under applicable able and federal statutes City of Denton D aGe Rick Svehla FOR [:]Approved ❑Daled,remn DNS USE ONLY ley ReDArweasrs >.Tis ACLU OF WRGIIVIA Pon ciaseara, FAX TO., jMWO Now FROM alucovr DAM Apr!! 19, IM5 M.- - Derr M TX Evept Aw tla Dmmk Pant site (see art aw tmp), au on am Wamd SgQL. y in guar bleak Vw; a. Hate sa the mmbm 1 CrAc Carver. (The block 8raap is only 4l% bat eemue fact o2o601 is over SM �....�.......�4 02060-13 115 as w 0 484; 2 Dem s Park The Ike 11 lqc m in block snap 0208 3, but only a tbw fiat way from gwb>;yiaa bleak 02094 0206 =tT&2 0208 4 243 167 - 24 840 3 WX Roo Ceara 0212 Z 1028 657 77 71} S. Phoenix Past 0206023 270 138 24 6o�, y W => p AaWON COW Marla L WM q%YMBYaM M` �1- aryw* SM St, MaWw4 VA.2321.9 flrt ffl" &" 22 Fat: pe 6f9-2133 VUIVP C4M APL.«v_m,�a,�a7y� .srli urte� .�l7gi�,li�Ta. 02060i1 _ 304 2��� 0 y If Ln W 1L d� m2 Ul [ N r W = Y s p c;$ V c N tV U4•- L1i i; U. L � SUMMER FOOD SERVICE PROGRAM AGREEMENT STATE OF TEXAS 5 COUNTY OF TRAVIS f The Texas Department of Human Services, hereinafter referred to as TDHS, AND City of Denton 321 E McKinney Denton 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 (7 Code of Federal Regulations [CFR], Part 225) I MUTUAL AGREEMENTS The Parties mutually agree A If the contractor fails to provide services in accordance with the provisions of this contract, the Department may, upon written notice of default to the contractor, immediately terminate the whole or any part of this contract and refuse to pay claims for reimbursement Such termination and/or refusal to pay claims for reimbursement shall not be exclusive remedy but shall be in addition to any other rights and remedies provided by law or under this contract B If federal and state laws or other requirements are amended or judicially interpreted so that the continued fulfillment of this contract; on the part of either party, is substantially unreasonable or impossible, or if the parties are unable to agree upon any amendment which would therefore be needed to enable the substantial continuation of the services contemplated by this contract, then the parties shall be discharged from any further obligations created under the terms of this contract, except for the equitable settlement of the respective accrued interest or obligations, including audit findings, incurred up to the date of termination C This contract may be 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 11 CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT A The contractor will comply with the SFSP Federal Regulations (7 CFR, Part 225, as amended), Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), and state policies and procedures as issued and amended by 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 conditionsiof Wdenienkof.any, audit, exceptions or payment deficiency in the program and the collection and repayment of any amount -paid in excess of the proper claim amount which are found after monitoring or auditing by 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 approved food service site III SFSP RECORD KEEPING A The contractor will keep financial and supporting documents, statistical records, and any other records pertaining to the services for which a claim is submitted The records and documents will be kept for at least three (3) years and ninety (90) days after the termination of the contract period if any litigation, claim, or audit involving these records begins before the stipulated time period expires, the contractor will keep the records and documents for not less than three (3) years and ninety (90) days after the termination of the contract period and until all litigation, claims or audit findings are resolved The case is considered resolved when a final order is issued in litigation or a written agreement is signed by 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 access to all records of costs paid, even in part, by TDHS Non School Sporroots - 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, Parts 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 Administrative- 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, tare, 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 The person whose signature appears on this contract is authorized to make this assurance on behalf of the contractor 0 TDHS CLAIMS PAYMENT 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 1 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 States Department of Agriculture or other federal department or 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 as 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 contract, unless it knows that the certification is erroneous A contractor must, at a minimum, obtain certifications from its covered subcontractors upon each subcontract's initiation and upon each renewal Non School Sponrors - page 4 M 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 unposed by section 1352, title 31, U S Code Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure The contractor certifies, to the best of his or her knowledge and belief, that 1 No federally appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement 2 If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer 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 3 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 subrecipiems shall certify and disclose accordingly The contractor certifies that all information submitted pursuant to this agreement Is we 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 Non School Sponsors Page 5 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 Prmt or Type) Original signature of the authorized representative of the contracting organization Rick Svehla Name of the authorized representative of the contracting organization (Please Print or Type) Acting City Manager Title Please print or type, in the spaces provided above, the name and title of the authorized representative signing this agreement on behalf of the contracting organisation Effective Dates By TEXAS DE ,fARTMENTjDF N MAN,SERVICE$Y�Stra '- 4a 3=. through Date Revised February 1994 Non School Spongm - page 6 SUMMER FOOD SERVICE PROGRAM AGREEMENT STATE OF TEXAS COUNTY OF TRAVIS I The Texas Department of Human Services, hereinafter referred to as TDHS, AND City of Denton 321 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 (7 Code of Federal Regulations [CFR], Part 225) MUTUAL AGREEMENTS The Parties mutually agree A If the contractor fails to provide services in accordance with the provisions of this contract, the Department may, upon written notice of default to the contractor, immediately terminate the whole or any part of this contract and refuse to pay claims for reimbursement Such termination and/or refusal to pay claims for reimbursement shall not be exclusive remedy but shall be in addition to any other rights and remedies provided by law or under this contract B If federal and state laws or other requirements are amended or judicially interpreted so that the continued fulfillment of this contract, on the part of either party, is substantially unreasonable or impossible, or if the parties are unable to agree upon any amendment which would therefore be needed to enable the substantial continuation of the services contemplated by this contract, then the parties shall be discharged from any further obligations created under the terms of this contract, except for the equitable settlement of the respective accrued interest or obligations, including audit findings, incurred up to the date of termination C This contract may be 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 (7 CFR, Part 225, as amended), Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), and state policies and procedures as issued and amended by 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 condutkomof eettlement.of.aoy audit-eWsPhons or payment deficiency in the program and the collection and repayment of any amount paid in excess of the proper claim amount which are found after monitoring or auditing by 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 approved food service site III SFSP RECORD KEEPING A The contractor will keep financial and supporting documents, statistical records, and any other records pertaining to the services for which a claim is submitted The records and documents will be kept for at least three (3) years and ninety (90) days after the termination of the contract period If any litigation, claim, or audit involving these records begins before the stipulated time period expires, the contractor will keep the records and documents for not less than three (3) years and ninety (90) days after the termination of the contract period and until all litigation, claims or audit findings are resolved The case is considered resolved when a final order is issued in litigation or a written agreement is signed by TDHS and the contractor Extensions are considered as separate contract periods B The contractor and its subcontractors wdl 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 to all records of costs paid, even in part, by TDHS Nan Seliaol Spaneme - 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, Paris 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 Administrative -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 trom 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 The person whose signature appears on this contract is authorized to make this assurance on behalf of the contractor V. TDHS CLAIMS PAYMENT 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 1 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 States Department of Agriculture or other federal department or 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 as 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 contract, unless it knows that the certification is erroneous A contractor must, at a minimum, obtain certifications from its covered subcontractors upon each subcontract's initiation and upon each renewal Non School Sponsor - 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 the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure The contractor certifies, to the best of his or her knowledge and belief, that 1 No federally appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influeniing 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 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 3 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 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 Non School Sponsors - Page 5 ►A 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) Onginal signature of the authorized representative of the contracting organization Rick Svehla Name of the authorized representative of the contracting organization (Please Print or Type) Acting City Manager Title Please print or type, to the spaces provided above, the name and title of the authorized representative signing this agreement on behalf of the contracting organization Effective Dates By TEXAS DEPARTMENT OF kJUMAN SERY,ICES s< through Date Revised February 1994 Non School Sponsms . Page 6 1996 CONTRACT YEAR Texas IHpaMunt of Human Somioea SPECIAL NUTRITION PROGRAMS SINGLE AUDIT IDENTIFICATION DATA Form 1569 Novemoer t996 Contra= Nama Contact Portion City of Denton Kathy Mosby Address (Street or P O Box, CRY. State LP) 321 E McKinney Denton, Texas 76201 Telephone No Pay" 10 No Convect No (817 ) 566-8125 17560005146013 Contractor twat Year End (ne 04") 1pe of ntrut 09/30/96 ForProOt Non Prom Govemmental 1 t boxes) to Indicate the types) of programs) In which you currently participate or for which you are applying Check the appropi a e COMMODITY ASSISTANCE PROGRAMS CAS; REIMBURSEMENT PROGRAMS A — National School Lunch AD — Adult Day Care B — Charitable Institutions BL— National School Lunch/Breakfast C — Area Agency on Aging CC — CACFP Center G — Summer Camps DH — CACFP Day Home H — Summer Food Service R SF— Summer Food J — Jails SM — Special Milk K —Soup Kitchen TE—TEFAP I — TEFAPCommodities Give the source and amount of any federal financial assistance that your agency receives other than from those programs listed above SOURCE AMOUNT See attached ❑ SINGLE AUDIT EXEMPTION-4 certify that I am not required to submit an audit under the Single Audit Act for the following reason(s) ❑ 1 am a for -profit organization ❑ I 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 ® An Annual ❑ A Biennial audit as a condition of eligibility to participate in the Special Nutrition Programs, and that failure to do so as required could result in adverse action, including the withholding of my claim for reimbursement payments and termination of my contract I also understand that if I am a private non profit organization subject to the requirements of the Single Audit ACLaPA have a financial audit performed annually, I must also obtain a single audit on an annual basis Name (Meat W" or P^m)TOM Rick Svehla Acting City Manager Form 450 ... of Ha servim - CERTIFICATE OF AUTHORITY This Is to certify that Is designated me the authorized representative of Name of Comneong Organoabw City of Denton AdMIS (enact �Cey, SWAG ZIP) 321 E McKinney Denton, Texas 76201 The representative designated above is authorized on behalf of the contracting organisation 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 clal r reimbursement, when appropriate, to the department wy clue SIgMWn—ON4W of CwWaWng Apr Name of Oerael gaGaae type or peal TM Rick Svehla Acting City Manager FOR DEPARTMENT OF HUMAN 511FIVIUrb use c+nf.v. AW M M No Rambo By OaW TX- Form es of H~ ssnton -- CERTIFICATE OF AUTHORITY This Is to certify that NUM of Authorzed MIMI (please type or print) Title Teresa Mil i ilO.ir -- Sleneture—Authorized O 01111 Is designated as the authorized representative of Nerve of ConUeoin6 Orpentr *n City of Denton Add a (BOOM CRY Sme ZIP) 321 E McKinney Denton, Texas 76201 The representative designated above Is authorized on behalf of the contracting organisation 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 algnew IIMNI Of /CVI�tang AWndy Date NUM of OR,CIeI (pNete typo or pnnt) TwoRick Svehla Acting City Manager w� uuu�u aleV a 1141G nut v r'Vrt YGrlMrrwGn, ivr ww„�,� r � ��� AV"N" No meoelted By D" TX• Tea" Department of Human Services Frxra eeee JuIW lees CERTIFICATE OF AUTHORITY This Is to certify that Name of Authorized Official (please type or print) Kyle Hogue Title Summer Food Coordinator Signature —Aut rized Official Is designated as the authorized representative of Name of Contracting Orgammlan City of Denton Adore" (Street City Slate 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 Signature —Official of Contracting Agency Date Name of Official (pl"" type or pang Rick Svehla Title Acting City Manager FOR DEPARTMENT OF HUMAN SERVICES USE ONLY Agreement No ReeNved By Date TX- Tex" DepaPlMnl 1"ee00 - rwy ,seu CERTIFICATE OF AUTHORITY This is to certify that Is designated as the authorized representative of Name of Contracting Orgamulbn City of Denton Addreee (Street City Slate 21P) 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 Name of OtWal (please type w pnnp Title Rick Svehla Acting City Manager FOR DEPARTMENT OF HUMAN SERVICES USE ONLY Tax" DapsAment of Nmnan Service from etas thaw reao CERTIFICATE OF AUTHORITY This Is to certify that NarM of AUNonsed Official (plea" type or print) Title Nicole Henderson Chil//dren's Programs Supervisor ] l.( t l'.1.0_L �.1 0/1',I-lb X �n l Signature— tfionsed Official Is designated as the authorized representative of Name of Contracting Organisation City of Denton Adore" (Street COY State 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 i Signartu —Official of Contracting Agency [leis Name of Official (pile" type or print) Tins Rick Svehla Acting City Manager FOR DEPARTMENT OF HUMAN SERVICES USE ONLY - �-_ --_ar ^e t o m A?IPLICAT,CN AND 1AGREE',IEV FCR -ECE F— CF USDA CCA9hIC,:.ITt23 flare )r ,.ppincant -genc 'sled^cre u i Address (Street City State ZIP) I County Mallmg Address (if different) AIR Contact Person (for commodity information) Telephone No Penoo of operation of Food service (moJday/yr—moJdaytyr ) From through_ APPOINTMENT OF THE AUTHORIZED REPRESENTATIVE —The official who signs this form must appoint an authorized represents live The official may name himself as the authorized representative, If he chooses to serve In that capacity The authorized represen tative Is given full responsibility for all matters pertinent to the receipt, handling, storage, protection, accountability, and use o USDA -donated commodities, and the maintenance of all required records and reports pertaining to the commodities _. .. i ... nee i Teleattone No I certify that I have read the agreement on the back of this form and that my signature below acknowledges this agency's responsibil ity to comply with all of the terms and conditions of that agreement This agreement shall be In effect for no longer than one year It may be extended at both parties' option for two additional one -yeas periods If extended, the applicant must update all pertinent information and must demonstrate that all donated food received durinc the prior contract period has been accounted for The agreement may be terminated for cause by either party upon 30 days writter notice The official who signs this Application and Agreement assumes full responsibility for compliance with the terms and conditions list ad in the agreement TO BE COMPLETED BY DHS MEAL I No Days SERVICE Mealeii INFORMATION will ea Served Breakfast AM Supplement Lunch PM Supplement Supper Signature —Agency official Date Average Total Meals No Days Average Total Meals No Days Average Total Meal. Dail To Be Served Meals Daily To Be Served Meals Daily To Be Served Attendance This Month WIII Be Attandance This Month will ee Attendance This Month Served Served of Agreement To I _ Checked By Stdnalure—DHS Ofnclal Date AGREEMENT THE APPLICANT FOR USDA -DONATED COMMODITIES AGREES 1 To abide by the instructions and regulations issued by DHS and USDA for storing, handling, and using commodities 2 To use commodities only to benefit people served in the applicant's estat�ohej&food services operation 3 To request and accept commodities only in amounts that will be properly stored and fully utilized 4 To not sell trade, or dispose of commodities, including commercial processing of commodities into different end products, without DHS' approval 5 To provide adequate facilities and personnel to handle, store, protect, and use commodities 6 To allow DHS and USDA to inspect, at any reasonable time, the commodities in storage and the facilities used for han- dling and storing commodities 7 To pay the assessments levied by DHS to meet the administrative expenses of the program as provided by state law 8 To accurately maintain all necessary records, including the application and agreement forms, receipts and freight bills, notices of availability, arrival and issuance of donated foods, Forms 506, inventory control sheets, financial and support- ing documents, statistical records, and any other records pertinent to the services for which a claim was submitted, for 3 years and 90 days after the contract period ended, or for 3 years after the end of the federal fiscal year in which services were provided if this contract has no specific termination date If any litigation, claim or audit involving these records be- gins before the 3 year period expires, the contractor must keep the records 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 when DHS and the contractor enter into a written agreement The contractor will keep records of non - expandable property acquired under the contract for 3 years after the final disposition of the property Contract period means the beginning date through the ending date specified in the anginal agreement/contract, extensions are consi- dered to be separate contract penods 9 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 10 To comply with the instructions and regulations issued by DHS for conducting financial and compliance audits 11 To reimburse DHS, according to DHS' procedures, for any improper distribution or use of donated food, or for any loss of, or damage to, donated foods caused by the applicant's fault or negligence 12 That any misuse of donated foods may cause them to be disqualified from program participation, and that reinstatement is at OHS' option 13 That any embezzlement, misuse, theft, or obtainment by fraud of donated foods or donated food -related funds, assets, or property, shall cause the applicant to be subject to Federal criminal prosecution 14 Civil Rights (a) To comply with Title VI of the Civil Rights Act of 1964 (Public Law 88-352), 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 )o 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 persons in the United 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 funding, or otherwise be subjected to discrimination federal and/or state (b) To comply with Texas Revised Civil Statutes Article 4419b-4, Sections 5 03 and 5 04 (relating to workplace and con- fidentiality guidelines regarding AIDS and HIV) (c) To compile date, maintain records, and submit reports as required, to permit effective enforcement of the above Acts and permit authorized DHS and USDA 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, DHS and USDA have the nght 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 DHS The person whose signature appears on this contract is authorized to sign this assurance on the behalf of the Contractor The above assurances are given in consideration of and for the purpose of obtaining any and all federal financial as- sistance, grants and bans 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 purposes 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 extend- ed to the program applicant by DHS This includes any federal agreement, arrangement, or other contract which has as one of its purposes the provision of cash assistance extended in reliance of the representation and agreements made in this assurance Two Deparwwm of K~ser-Ims NONGOVERNMENTAL CONTRACTOR CERTIFICATION Porn 4►42 September 1*4 *he Texas Department of Human Services (DNS) has adopted rules Pertaining to contracting with organizations In which a former board member or employee (whose last day of duty was within the Past two years) has any ownership or control, or who Is an employee or consultant of such organization Also, Human Resources Code 622 0033 prohibits for one year after employment former DNS employees In pay grades equivalent to or above pay grade 17, Step 1, from helping (for pay) another entity obtain a contract with DHS In an area for which the former employee was directly concerned or had administrative responsibility Additionally, DHS has adopted standards for contracting with contractors associated with current or former employees and board members, and their relatives This form Is necessary to help the Department determine compliance with those rules All potential non -governmental contractors for any type of contract must complete this certification The contract, If awarded, may be terminated for cause If (1) the contractor knowingly provides incorrect Information in he certification, or (2) the contractor uses a subterfuge, such as a subcontract arrangement, to avoid the application of state laws or DHS rules Does the potential contractor have as an officer, director, employee, consultant, or owner (in whole or In part) 1 A person who is currently a DHS employee or DHS board member. ❑ Yes ❑ No 2 A person who was a fanner DHS employee or board member whose last day of duty with DHS was within Yes [-]No the past two years? 3 A person who Is related (see Relationship key below) to a current DHS employee or DHS board member? ❑Yes ❑ No 4 A person who is related (see Relationship key below) to a former DHS employee or DHS board member ❑Yes [:]No whose last day of service to DHS was within the past two years? WHO Brother Stepdaughter Spouse's Sister RELATIONSHIP Husband Sister Stepson Spouse's Brother KEY Father Son Mother-in-law Mother Daughter Father4n-low IF YOU ANSWERED "YES" TO ANY OF THE ABOVE QUESTIONS, YOU MUST COMPLETE FORM 4732-A. CERTIFICATION I certify that the information above Is complete, true and correct to the best of my knowledge I understand that lack of full, true and complete disclosure may be grounds for withholding payment for delivered services and may cause contract termination Nara of POW" rlan.aowmmental cwnc or caromdNo SocW SsoXxy No or VIN PrH a Type Nara W4 Rewm*n ft Dale FORM 4732-A Instructions NONGOVERNMENTAL CONTRACTOR CERTIFICATION (Part 11) PURPOSE Form 4732-A; Nongovernmental Contractor Certi- fication, Part 11, provides a means for collecting and distributing additional needed information about nongovernmental potential contractors who mark "yes" to any of the questions on Form 4732, Nongovernmental Contractor Certification Incorrect or incomplete information tray render a contract unpayable or cause termination The in- formation is tiled to determine whether a contract/ contract renewal can by state law and Department of Human Services' rules be consummated PROCEDURE Potential contractors answering "yes" to any of the questions on Form 4732, Nongovernmental Contractor Certification, must complete the additional questions and the certification in Form 4732-A Form 4732-A is prepared along with Form 4732 It is signed by the person signing Form 4732, and is submitted as an attachment to Form 4732 When to Prepare Form 4732-AI must be prepared and submitted as an attachment to Form 4732 It is sent to the area purchasing the contract prior to consummating a new contract or a contract renewal It must be submitted early enough (usually 60 days prior to the contract's' effective date) so that the purchasing area can provide it to the department's Office of the General Counsel 45 days prior to the contract's effective date If the contract is a new procurement, rather than a renewal, the certification is submitted according to instructions to the request for proposal Number of Copies Complete a certification for each copy of the contract offer/contract renewal submitted to the department Transmittal Forward the appropriate number of certifications to the department's procurement officer (for new contracts) or contract manager (for contract renewals) Form 4732-A is attached to Form 4732 and is submitted as part of the offeror's procurement package or as indicated in the instructions to the procurement package In cases of contract renewals, the Form 4732-A is submitted as an attachment to Form 4732 to the contract manager approximately 60 days prior to effective date of any proposed renewal Form Retention Consistent with the records retention rule, §69 205 and related policies found in Item 2100 of the Contract Admtntstration Handbook, the successful contractor's Form 4732-A must be kept for three years and 90 days after the contract period ends or until all litigation, claims, or audit findings are resolved, whichever is longer Unsuccessful offerors' Form.4732-A must be kept a minimum of six months after the effective date of the contract or until the resolution of any appeal or litigation resulting from the procurement, whichever is longer Texas Dept of Protective and Regulatory Services APS 94-6 Texas Dept AMH 94.14 CACFP-ADC 94.7 CACFP-CCC 94-7 CACFP-DCH 94.7 of Human Services CAH 94-6 NSLP/SBP 94-6 PHC 94-9 SFSP 94-6 SMP 94.5 Instructions Form 4732-A Page 2 DETAILED INSTRUCTIONS t Did you answer "yes". 7 — Self-explanatory Name of Person Associated with Potential Contractor — Enter the names of officers, directors, employees, consultants, or owners (m whole or part) of the rotential contractor who (1) are currently DHS employees or DHS board members, or (2) are former DHS employees or board members whose last day of duty was within the past two years Last/Cunent Position Held at DHS — If the person was/is employed with DHS, use the person's DHS fob title Example: "Clerk Typist II" rather than "Secretary " Use a descriptive title only if the job title is unavailable Begin Date at DHS/Ending Date — The person may have held more than one positron with DHS Enter the person's last period of association with DHS If the person is still associated with DHS, enter the beginning date to the "present " Program/Support Area at DHS — Enter the name of the DHS program or support area in which the person worked. If the person dealt directly with the potential contract, so Indicate. Currant Position with Potential Contractor — Enter the person's current job title with the potential contractor Examples- owner, board member, intake worker Beginning Date — The person may have held positions other than the present one with the potential contractor Enter the person's first date of association during which time the person has been continuously associated with the potential contractor to the present time 25% or More Increase In Compensation — lf as result of discontinuing employment with DHS and by commencing association with the potential contracting agency the person receives a 25 % or more increase m overall annual benefits, including salary or wages, enter "yes " If not, enter 'no " 2 Dld you answer "yes" T — Self-explanatory Name of Person Associated with Potential Contractor — Enter the name(s) of officers, directors, employees, consultants, or owners (in whole or part) of the potential contractor who are related in the following manner (1) to current DHS employees or board members, or (2) to persons who are former DHS employees or board members on or after September 19877 A Wife H Daughter B Husband I Stepdaughter C Father i Stepson D Mother K Mother-in-law E Brother L Father-in-law F Sister M Spouse's Sister G Son N Spouse's Brother Current Pos/don with Potential Contractor — Enter the person's current title with the potential contractor Beginning Date — The person may have held positions other than the present one with the potential contractor Enter the person's first date of association during which tune the person has been continuously associated with the potential contractor to the present time Name ofCiamnW mrerDHS&%aoyee/ Board Mevnber— Enter the time of the person's relative who is associated with DHS Relationship to Pennon Associated with Potends/ Contractor — Self-explanatory Texas Dept of Protective and Regulatory Services APS 93.4 Texas Dept AMH 93-B CACFP-ADC 93-5 CACFP-CCC 93.4 CACFP-DCH 93.4 of Human Services CAH 93.9 NSLP/SBP 93.3 PHC 93-7 SFSP 93.4 SMP 93.2 Instructions Form 4732-A Page 3 Last/Current Position Held at DHS — If the person was/is employed by DHS, use the person's DHS job title Example: "Clerk Typist II" rather than "Secretary " Use a descriptive title only if the job title is unavailable Program/Support Area at DHS — Enter the name of the DHS program or support area in which the person worked If the person dealt directly with the potential contract, so indicate Begin Date at DHS/Ending Data — Over a continuous period of time, the person may have held more than one position with DHS Enter the person's last period of association with DHS If the person is still associated with DHS, emer the beginning date to the "present " 3 Prohibitions Against Contracts with Certain Former Employees — A If "no" is checked, skip to number 4 If "yes" is checked, continue B - D Self-explanatory E If the employee earned a salary equivalent to, or more than, a Group 17, Step 1, of the position classification salary schedule (currently $30,588) enter "yes " If not, enter "no " 4 Financial Interest — Name — Self-explanatory Owns 10% or More — If a former DHS employee, former board member, or their relatives (as specified in question 3 or 4 of Form 4732) owns or controls 10% or more of the contracting firm or its stock, enter "yes " If not, enter "no " $2,500 or More Investment — If a former DHS employee, former board member, or their relatives (as specified in question 3 or 4 of Form 4732) have an investment of $2,500 or more in the contracting agency, enter "yes " If not, enter "no " Certification — The certification at the bottom of the page applies to all information provided on the certification form Name of Potential Nongovernmental Contractor — Give the entity's official name If the entity is registered with the Texas Secretary of State, type or legibly print the [tame as registered with the Secretary of State Contract No — If the certification is prepared as pan of a procurement package, leave tlus space blank If the certification is prepared during the renewal of a contract, enter the contract number If available, use the DHS uniform contract number Social Security No or VIN — If the potential contractor has a vendor idenufrcation number (VIN) from the State Comptroller's Office, enter that number, otherwise, the person authorized to sign the certification enters his Social Security Number (SSN) Description of Contracted ServiceAtem — Emer a description of the service or item to be purchased under the contract Examples. cluld day care, medical transportation, family care, computer software, janitorial services Signature of Authorized Representative/ Date — Self-explanatory Pnnt or Type Name — Print or type the name of the signatory Texas Dept of Protective and Regulatory Services APS 94-6 Texas Dept AMH 94-14 CACFP-ADC 94.7 CACFP-CCC 94-7 CACFP-DCH 94.7 of Human Services CAH 94-6 NSLPISBP 94-6 PHC 94-9 SFSP 94-6 SMP 94-5 Form 4722 A Tam D9prtnm9nl September 1994 of Haan SMi= NONGOVERNMENTAL CONTRACTOR CERTIFICATION (PART II) A r a condition for receiving a contract or having a contract renewed, potential contractors who answered "yes" to either or both of the questions on Form 4732 must complete the questions on this form (Form 4732•A) The questions must be fully answered and the certification on Page 2 must be completed and signed The answers are used tto7determine 9 compliance with Texas Depart- ment of Human Services rules found In the Texas Adm. Code, Title 40. Chapter 79, §9 07 1 REGARDING PAST AND CURRENT DHS EMPLOYEES AND BOARD MEMBERS— Dtd you answer "yes" to question 1 or 2 on Forth 47327 ❑Yes ❑ No If "no," skip to question 2 If "yes," complete the following Information for those persons If they are FORMER DNS employees, Indicate whether assoclatlon with the potential contractor resulted In a 28%or more Increase In overall annual benefits (Including _.. _.._....._.... ..r...A r,han the mention was with DNS. Name of Pantos ASNOOMW Mm PatonMW Poeltbn held a D..a Begin Does a DNB 0artdrta owPrear 9::" Don 25% or More 6taeste In compnta6on is MAVon Ara a DNB rr (Dyes [:]No Name a Portion Aaoxiaed with Poem" rr Po~ Nest a 011a Spin DW a DNB 0__g oW ProarmNaupporl Ara at DNS Crest w6h 6Y ConeaeMr Sege nbtp DW 26% a Mae Yteresse in compensation []yes ❑No Name of Phan Aeeocialed With Paatlal contractor Leguo nwM Position Hew at DNB soon DW a DNS 0Enang DW PrograNBupporl Am at DNS current Poem Mtn PONmW Ooneecror Beginning DW 25% a Mae it crease In oe mpratlon ❑Yes ONO 2 REGARDING THOSE ASSOCIATED WITH POTENTIAL CONTRACTORS AND THE ASSOCIATES' RELATIVES— Dd you answer "yes" to question 3 or 4 on Forth 47327 ❑Yes [:]No is., 1. Ut e.......N.. a of ••ve - mnrnlets the following Information for those persons and fheir relatives .. ...., _.. IF .� qw.._.. _ .. ­ -__ _ _ _ Nam Of boon AoeodWd Mtn POMnIW 00109e1a Dunn pset"n Ma Potential contractor 1Mg6tiitrp DW Name of WMWFaWr DNS EmpipyeelBosN Member RaWbmNp b Petition Associated MM POmniW Oom tw WVCuunt Passim held M DNS Just DNS lob tge, B Possible) pnorset8uPPat Nor a DNB sash DW at DNS 0Endmp Date continued on back ^ Femt 4742•A Paps 2 3 Prohibitions Against Contracts with Certain Former Employees A Has the potential contractor and/or any of his employees been employed by OHS within the last 12 months? [—]Yes ❑ No If "No," skip to number 4 B Is a former employee, or an organization controlled (m part or whole) by a former employee, applying for this contract? []Yes ❑ No C Has (or will) the former employea(s) be paid to aid in the development of or the attempt to obtain the proposed contract? ❑ Yes ❑ No D Does the proposed contract relate to a program or service to which the potential contractor/employee(s) (while with OHS) was directly concerned or had administrative responsibility? ❑ Yes ❑ No If "No," skip to number 4) E If the answer is "Yes" to "B" and "D," or "C" and "D," provide the former OHS employee's name and indicate whether he earned an annualized gross salary of SM.568 or more at the time he bit employment with OHS NAME $30,511e w men? ❑Yes Otto Dyes ONO ova ON, 4 Financial Interest —Provide the name and other requested information about any person who is owner (in pan or whole), officer, director, employee, or consultant employed or associated with your organization and who A. was a member of the OHS Board and who left within the past two years, 8 is now a member of the OHS Board, C was an employse of OHS and who left within the past two years, D Is now an employee of OHS, or E is related in a manner specified in Question 3 or 4 of Forth 4732 to the person(s) In kern A, B. C. or D immediately above NAME Ow,e 10% w men? sedeo w men IneeasnaelT ❑Yell ONO Dyes ONE ❑Yee [--]No ❑y" ONO ❑Yet ONE I ❑Yet ONO CERTIFICATION I certify that the above Information Is complete, true and correct to the bast of my knowledge,) understand that lack of fuN, true and complete disclosure may be grounds for withholding payment for delivered services and may cause contract termination. PMt of Type Name 61paO MYae�Y 111011 Repnuneesa men ***NOTICE*** The 1996 Summer Food Service Program is sponsored by the City of Denton, Parks and Recreation Department, and is offered through a federal grant which requires that sponsors apply each year to retain eligibility to offer the program. It is therefore, our declaration that the SFSP will be offered this summer, from May 28th through August 9th, strictly as a PILOT PROGRAM, and that the City of Denton PARR, is in no way directly liable or responsible for the continuance of the program in the future. SUMMER FOOD SERVICE PROGRAM BUDGET 188E Pmannal Staff Rote Haut Awh*trw t 5024-Sipwview 1 $12 01 88 SO20•COwdnatw 1 481S 300 002� y� +aWM S $6 00 76 8026•Van Drivw 1 $5 00 170 8001 FICA AdmNstrtive Opwwknd 00706 8064-WORK COMP AdmkdwWsd" Oparada" 00234 8101.0Moa OuppEat t8toWknw 6112 Rwaadon Srppe« Mltatetnewn 8602-Spewt Swviaaa Food Avg DAy Davit Priu Lundm 325 63 $1 86 Mabee Pharr Trowportsdan VON Ransil Mlew US" 30 TOW tt 20510 41 848 00 Admin $311310 $3 378 00 48W 00 Opwt i4 225 00 Admin 423016 Opwt $323 21 Admin $72 86 Opert $98 87 8000 TOW $8,07126 020000 41 600 00 $100 Taut $1,700 00 $20 688 76 $300 00 42 600 00 Dwp Rate 63 028 W5 20 0600 Tell 429,943 06 Budget TOW $38 715 21 **Difference of $1.85 is due to rounding Teas Department of Human Samoa I CIVIL RIGHTS ACT OF 1964 Form ISMAtlnchmant A SUMMER FOOD SERVICE PROGRAM FOR CHILDREN January 1990 CIVIL RIGHTS QUESTIONNAIRE A 1 Estimate, by racial/ethnic group, the number of children that will participate In the program at each site If the program consists .d a si . eeinne anar,fv the nrninetad numhar of children bV site and date of session 811E AMERICAN ALABKAN ASIAPACIFIC BLACK HISPANIC WHITE (name of site, school, amp, true) INDIAN NATIVE ISLANDER Owsley Park TWU Clubhouse Program 10 10 35 Dania Pak 58 3S 10 Phoenix ark Civic Center Park 1 MLK Recreation Center 60 20 10 Village East Anarrmonrq 20 100 10 100 20 20 ayzor Elementary cool 25 100 25 Houston Elementary School 10 10 10 2 Describe how this projection was made 0 e , based on comparative enrollment in sites, observation of students, student surnames, etc Observation of neighborhoods B Does the organization have specific membership requirements which result In the denial of program benefits to specific groups? ❑ yes © No If yes, describe those requirements C What efforts Will be made by the organization to contact minority and grass roots organizations about the opportunity to perddpate in the program? Posters displayed in neighborhoods, attend community meetings and public service announcements D What other outreach stops will be taken by the organization to ensure that minorities in the area from which It draws its attendance will have an equal opportunity to participate in the program? S F S P. information will be printed in spanish E Has any agency federal a n notified the organization of non-compliance with the Civil Rights act of 1964? ❑ Yes ElNo If yes, give details including dates, names, and results II REHABILITATION ACT OF 1973 (Section 504) A Does the contracting organization have any policies, practices, or architectural barnefs that limit, deny, or discourage participation in the program or employment by the contracting organization because of disability? If yes, explain ❑ Yes ® No Fenn 13" / AIWWAt1MM A PRO 2 B Are there any policies or practices that result In unequal treatment In the delivery of benefits or services to participants, applicants, or employees according to disability? ❑ Yes ® No If Yes, explain C Does the contracting organization employ 15 or more people? 0 Yes ❑ No If yes 1 Enter the name and title of the coordinator who will work with DHS to ensure that Section Surf requirements are met too "°" ^ n Teresa Milam Leisure Services Manager 2 Has the organization established grievance procedures that Incorporate appropriate due procee3 standards? ® Yes ❑ No If yea, do these procedures provide for the prompt and equitable resolution of complaints that allege an action prohibited by Section 504 of the Rehabilitation Act of 1973? Yes ❑ No 3 Has the contracting organization Informed the public of the right to file a complaint and of the filing procedure? g Yes ❑ No If yes, briefly describe how the public was informed There are posters and flyers posted throughout the City of Denton which acknowledges the City's compliance with the guidelines set by the EEOC, ADA, and the Civil Rights Act These posters give instructions for filing a complaint D Has the orgenizaton taken steps to notify employees, participants, and applicants that the organization does not discriminate on the bests of disability? ®yes; ❑ No If yes, do the people notified Include those with Impaired vision or hearing and members of unions or professional organizations holding collective bargaining or professional agreements with the contracting organization? 0 Yes ❑ No If yes, briefly describe how they are notified The visually or hearing impaired are notified through radio and television advertisement Also flyers, announcements, etc. are mailed E DO 811 organization forms, publications, and recruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the organizattondoes not discriminate on the basis of disability? In Yes ❑ No If no, indicate steps being taken to comply with this requirement F Does the organization have a procedure to ensure that the rememal or corrective action has been or will be taken if non-compliance with non discrimination requirements is found by DHS, USDA, or the contracting organization Itself? 0 Yes ❑ No If yes, explain If not handled within the department in question, the City gererally channels all complaints through the Legal Department Y PUBLIC SERVICE ANNOUNCEMENT FOR NON -ENROLLED SITES the Denton Parks and Recreation Department announces the sponsorship of the 1996 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-106, Texas Department of Human Services, P O Box 149030, Austm, 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 Dates Sites May 28-Aug 9 Civic Center Park May 28-Aug 9 Dema Park May 28-Aug 9 MLK Rec Center May 28-Aug 9 Owsley Neighborhood May 28-Aug 9 Phoenix Park May 28-Aug 9 TWU Playhouse Program May 28-Aug 9 Village East Apartments Address Time 321 E McKinney 12pm-Ipm 1001 Parvm 12pm-lpm 1300 Wilson 12pm-Ipm Stella St 12pm-lpm 308 S Ruddell 12pm-lpm Mary Hufford Court 12pm-lpm 1700 Village East 12pm-Ipm PUBLIC SERVICE ANNOUNCEMENT FOR THE ENROLLED SITE The Denton Parks and Recreation Department announces the sponsorship of the 1996 Summer Food Service Program Income Eligibility will be based on family size and income using the Standards for Determimng Free and Reduced -Price Eligibility, provided by the United States Department of Agriculture Meals will be provided at the site 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-106, 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 Dates Sites Ad ress Time June 3-28 Houston Elementary 3100 Teasley Lane 11 45am-12 45pm June 3-28 Rayzor Elementary 1400 Malone 11 30am-12 30pm Form 1606/Attachment 6 SUMMER FOOD SERVICE PROGRAM FOR CHILDREN January 1990 ADDITIONAL ASSURANCES FOR CAMPS AND OTHER ENROLLMENT PROGRAMS THAT CHARGE SEPARATELY FOR MEALS As required in Section V of this application, the contracting organization assures the Taxes Department of Human Services that 1 The method of collecting meal payments will protect the anonymity of children who receive free meals 2 The organization has or will establish a hearing procedure for families wishing to appeal a denial of an application for free meals, which provides the following A That a�simple, publicly announced method will be used for a family to make an oral or written request for a hearing, B That the family will have the opportunity to be assisted or represented by an attorney or other person, C That the family will have an opportunity to examine the documents and records supporting the decision being appealed both before and during the hearing, D That the hearing will be reasonably prompt and convenient for the family, E That adequate notice will be given to the family of the time and place of the hearing, F That the family will have an opportunity to present oral or documentary evidence and arguments supporting its position 0. That the family will have an opportunity to question or refute any testimony or other evidence and to confront and cross examine any adverse witnesses, H That the hearing will be conducted and the decision made by a hearing official who did not participate In the action being appealed, I That the decision will be based on the documentary evidence presented at the hearing and made part of the record, J That the family and any designated representative will be notified in writing of the decition, k That a written record will be prepared for each hearing which includes the action being appealed any documentary evidence and a summary of oral testimony presented at the hearing, the decision and the reasons for the decision, and a copy of the notice sent to the family, and L That the written record will be maintained for a period of three years end 90 days following the conclusion of the hear- ing, during which it will be available for examination by the family or Its representatives, and officials of the Texas Do pertinent of Human Services (TONS), the United States Department of Agriculture and other relevant officials as deter mined by TDHS at any reasonable time and place 3 If a family requests a hearing, the child(ron) will continue to receive free meals until a decision is rendered Form 150&Anachment It SUMMER FOOD SERVICE PROGRAM FOR CHILDREN Paget COLLECTION OF PAYMENT OPTIONS FOR PROGRAMS THAT CHARGE SEPARATELY FOR MEALS (Camps and Other Enrollment Programs Only) COLLECTION PROCEDURE 1) Each day, children can buy tickets in the food service manager's office, but they do not receive the tickets The food ser vice manager sends the purchased tickets and tickets for free meal recipients to the site each day The site supervisor distributes the tickets just before meal time The tickets are coded for accounting purposes COLLECTION PROCEDURE 2 Each day, children pay for their meals in an office A list with the names of all children who paid or are eligible for free meals is prepared and sent to the meal service area A staff member who knows the children checks the names as children pass through the line or otherwise receive their meal After the service of the meal the list is returned to ttie office for accounting purposes This method works only in a small site where the staff member knows all the children COLLECTION PROCEDURE 3 The site supervisor gives each child an envelope for daily, weekly, session or monthly payments Children return the anal opes with the payments enclosed, or empty if eligible for free meals The envelopes are collected in the office and coded tickets are issued to each child COLLECTION PROCEDURE 4 Parente pay in advance by the month or session Each site supervisor receives a list of those children who have paid The site supervisor marks the list as paid for children who receive free meals Only the bookkeeper knows which children receive a free meal The site supervisor keeps daily records of each child served and sands the records to the office for as counting purposes COLLECTION PROCEDURE 5 Meal payments are collected in the office Payments can be made by children or parents on a daily, weekly, session or monthly basis The secretary records payments and knows which children qualify for free meals At the sites, the secretary distributes Identical tickets labeled only with the children's names Since the parents may make payments, even children who receive free meals may not know whether their meals are free or paid COLLECTION PROCEDURE a Parents am billed monthly or by session for paid meals their children are served Parents mail In ill payments All partieipaa ting children receive a coded ticket each month, which is punched at each meal service At the end of the month, the tic kets are collected and a clerk calculates the amount to be billed COLLECTION PROCEDURE 7 Other Explain In detail (attach a sheet if more space is required) The contractor must ensure that this method prevents the overt Identification of children receiving free meals SUPPLEMENTAL ATTACHEMENT TO ORDINANCE,N0.96-083 Changed pages are noted TEXAS DEPARTMENT OF HUMAN SERVICES Special Nutrition Programs 3023 Bledsoe Street, Suite D Fort Worth, Texas 76107-2950 41-011ANY" FAX (817) 335-9703 PHONE 18171 870-2278 14 May 23, 1996 TX #061 1002 Mr Ted Benavides, City Manager Center of Denton 321 East Mckinney Denton TX 76201 SUBJECT Summer Food Service Program (SFSP) Approval for Participation FY96 Dear Mr Benavides Your organization is approved to participate as a Sponsor in the Summer Food Service Program (SFSP) for Fiscal Year 1996 A fully approved Form 1506 and a SFSP Agreement with original signatures of the authorizing Contract Manager affixed are enclosed Also enclosed are program operation forms The attached information table identifies the program operation forms, the number of forms enclosed and general instructions for completion, submission, or maintenance Specific instructions to the forms are contained in Section 12 of the Summer Food Service Program Handbook with the exception of the Weekly Call -In Report Instructions to the Weekly Call -In Report are attached to the forms enclosed You, as a Sponsor, are required to use the TDHS program operations forms enclosed with the exception of Form 1514, Claims for Reimbursement Worksheet, and SFSP Daily Meal Production Form The use of Form 1514 and the sample SFSP Daily Meal Production Form is optional I recommend the use of Form 1614 for compiling data to complete the claim for reimbursement Food service personnel must document meal production each day The sample meal production form enclosed is offered for your use However, you may use another form of choice that is an informational equivalent to the sample form All the program operation forms enclosed may be duplicated by program sponsors with the exception of NCR (carbonless) Forms 1613 and Form 1513-A Contact this office if additional forms are needed Your organization should maintain, as part of their official contract files, copies of forms completed and forms submitted to TDHS Sponsors must comply with the requirements for farm retention The requirements for forms retention are specified in the instructions for the form in the SFSP Handbook Please contact me at (817) 870 2278 should you have questions SSii nncc`ee erne ll y7�, David J Claire�� Area Program Manager Enclosures SUMMER FOOD SERVICE PROGRAM SERVICE AGREEMENT APPROVAL & PROGRAM OPERATION FORMS The Summer Food Service Program (SFSP) approval documents are the Application for Participation, Form 1506 and the SFSP Agreement A fully approved Form 1506 and a SFSP Agreement with original signatures of the authorizing contract manager affixed are returned to you The attached information table identifies the program operation forms, the number of forms enclosed, and general instructions for completion, submission, or maintenance Specific instructions to the forms except the Weekly Call -In Report are contained in Section 12 of the SFSP Handbook Instructions to the Weekly Call -In Report are attached to the forms enclosed Sponsors are required to use the TDHS program operations forms enclosed Food service personnel must document meal production each day A sample form is offered to sponsors to document your orgamzation's meal production However, sponsors may use another form of choice that is an informational equivalent to the sample form that is enclosed The program operation forms enclosed may be duplicated by program sponsors with the exception of NCR (carbonless) Forms 1513 and Form 1513-A Contact this office if additional forms are needed Sponsors should maintain, as part of their official contract files, copies of forms submitted to TDHS Sponsors must comply with the requirements for form retention The requirements for forms retention are specified in the SFSP Handbook Your next Single Audit Report for Fiscal Year Gt is due Sponsors should contact their Area Program Manager at the follows marling address and telephone number should you have questions David J Claire Texas Department of Human Services Special Nutrition Programs 3023 Bledsoe, Suite D, 128-2 Ft Worth, Texas 76107 L Texas Department M He omen Si`vk°a SUMMER FOOD SERVICE PROGRAM APPLICATION FOR PARTICIPATION I FOR DHS STAFF ONLY I 061-1002 Approved For ,,.�/ _ NOTE Give as much Information as possible Attach additional sheets II needed, ❑ Breaklast ❑ A M Supp g Lunch please identify each attachment with the name of the contracting organization P M Supp Supper All SECTION 1-SPONSOR INFORMATION Contracting Organization Name Vandor ID No Telephone No Holhrte No City of Denton 1 17560005146015 ( 817 ) 566-8125 (817) 566-8125 Mailing Address (Street or P 0 Box CRY Stale ZIP) 321 E. McKinne Denton, TX 76201 Street Address (a dwomt) Name 01 MMMstrator Title Teresa Milam Leisure Services Manager A Contractor Classification (Check all that apply) ❑ National Youth Sports Program ❑ School Food Authority 8 Is your program a year-round program? C Type of Contractor ® Public Entity (explain) Academic Year National ❑ Youth Sports Program Residentlal/Nonresldential ❑ Summer Camp Is your agency considered to be state owned/operated? Do you deposit your program reimbursement directly Into the Stale Treasury" Do you deposit your program reimbursement Into a local bank? If yes, is it direct deposit? Unit of Govemment-Contractor certfies that all food ❑X service sites are operated directly by the contractor Continuous Calendar ❑Private Non-profit ❑ School Year QYes []No Dyes ©No ®N/A ❑Yes ❑No El N/A ®Yea ONO ❑Yes QNo ❑ Private Nonprofit Organization-Tax<xempt 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? 0 yes is it direct deposit? ®NIA [_-]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)? QYes []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 1 Does the organization receive $100,000 or more in federal funds yearly? [Eyes [:]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 (You must submit a completed Form 1569, Special Nutrition Programs - Single Audit Identification Data ) n raps 2 SECTION II —BUDGET A Estimate all SFSP costs which will be claimed for reimbursement for the program year 1 ESTIMATED OPERATIONAL COSTS PROGRAM YEAR COSTS Program Labor 4, 225 Fringe Benefits 422 Food 26,699 Non food Supplies 1,500 Utilibes Rent Equipment Use Fee Rental of Equipment 2,500 Transportation Rafe per"le 28 445 OSMr ppecoy) Clow (Specify) Ogler (epedy) TOTAL 35,791 "I 0� 1 ESTIMATED ADMINISTRATIVE COSTS PROGRAM YEAR COSTS Administrative Labor (Management Monitor Clerical) 3,115 Fringe Benefits 311 Rental of Office Space Utilities Office Supplies 200 Office Building Maintenance Equipment Use Fee Audit Fees Legal Fees Transportation aI e per m e .28 Clew (epeoN) Mobile Phone 300 OIMr IewaN) TOTAL2 3,926 B Indicate protected income to the food service from all sources other than SFSP reimbursement Identify exactly the costs this Income will cover fDo not include state or federal funds ) Source of blooms AM OMt Will be used for i Swipe of Income Anaunt we be 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 NPOOMSIT WIC SPECIFIC FOOD SERVICE PROGRAM DMES Director 1 Conducts training session, monitor sites, prepares reports, coordinates food services Coordinator 1 Assists Director with duties B Are children charged separately for meals? If yes, see Form 1508, Attachment B C Do you want to receive advance payments? If yes,1 For Operational Costs? 2 For Administrative Costs? D If meal service is self -preparation, do you want to receive commodities? If yes, Form 1608 Application and Agreement for Commodities, must be completed SECTION IV —PROGRAM OPERATION A 1 Beginning and Ending Dales of Meal Service From May 28, 1996 2 Number of sites B List dates and topics of SFSP training through Form is" Pape J Dyes ©No Dyes ©No ❑Yes ❑No Dyes ❑No Dyes QNo August 9, 1996 DATES TOPICS 5/22/96 Site supervisor and monitor training on S.F.S.P. guidelines and Civil Rights training C Is the organization planning to contract with a food service management company for the preparation of unitized meals? N yes, and the contract will exceed $10,000, attach a copy of the Invitation to bid Also give ❑Yes QNo Date of BW Publication Plate of Publication Oats of sit Ope" Tone of sW Dp"" Is bid expected W be $100,000 or mare? x yes 0" Waco of bid operwV Yes ONG Also, attach a copy of an 11-day-cyde menu including all specific menus to be used D Is the organization contracting with a year-round food service management company? If yes, submit a copy of your procurement procedures, bid, contract, and all amendments ❑Yes ®No E Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department notifying them of intent to operate a Food Service Program at the site(s) indicated on the attached Site Information sheet (Form 1507) 61i;(*1i1*RPbV*111X1IN A Free Meal Policy Statement t The contracting organization assures the Texas Department of Human Services (DHS) that all children at the sites described on the Site(s) Information Sheets for the Summer Food Service Program, will be offered the same meals with no physical segregation of, or other discrimination against, any child because of race, color, disability, age, sex, national origin, religion, or political beliefs No separate charge will be made for any meal except in accordance with attachment B of this application 2 The contracting organization assures DHS that, if It is sponsoring camps or other enrollment programs • The contracting organization has or will obtain family size and income data about all children whose meals will be reported as free or reduced -price, and • The children claimed as free or reduced price meet the current family size and income sta idards set by the United States Department of Agriculture, OHS Form 4504, Standards for Determining Free and Reduced Price Eligibility W .4 3 If the contracting organization is sponsoring a ramp or other enrollment program that charges separately for meals the contracting organization has read Attachment 8 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 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 all approved sites, a list of the current standards for determining free and recuded price eligibility, and the following statement "The (�iiW1themn(ra%%ty0a nizabon 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-106, Texas Department of Human Services, P O. Box 149030, Austin, Texas 78714.9030 or the Secretary of Agriculture, Washington, D C 20250 NOTE Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services " For all other programs the announcement must contain, at a minimum a list of all approved sites and the following statement. 'The (NJ(;4W6Qft1bCQ41Aizaaoni announces the sponsorship of the Summer Food Service Program Meals will be provided at the site($) 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-106, 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 " 9 This nuhur release was or will be Dubhshed in the following news media outlet s NAME OF MEDIA OUTLET DATE OF RELEASE Denton Record Chronicle 5/l/96 Dallas Morning News UNT Dail NAME OF MEDIA OUTLET DATE OF RELEASE T KDNT Radio 5/l/96 KNTU Radio 5/l/96 Attach a copy of the contracting organization's public release statement as submitted to the news media and any other materials used to publicize the program's availability and nondiscnmmation requirements SECTION VI —CERTIFICATION (see Form 1506, Attachment C) 1 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 �e- Kyle Hogue una vac v111-r APPROVED ❑DENIED If denied, reason Approved for Food Dutnoutwn n It ate ❑ Yes ❑ No j If yes give date Form 1608 sent to FDD li TNe 5-1-3-9 t 0ZT C Date CITY o/ DENTON, TEXAS February 21, 1996 Ms Laurie Callahan, Registered Sanitarian Environmental Health Department 300 Woodrow Denton, Texas 76205 Dear Ms Callahan, MUNICIPAL BUILDING • 215 E McKINNEY • DENTON, TEXAS 76201 (817) 566.8200 • DFW METRO 434 2529 The Denton Parks and Recreation Department is applying to the Texas Department of Human Services for a grant to provide the Summer Food Service Program to the children of Denton This program will provide lunch for children ages 1 - 18 years of age The food preparation will be contracted with the Denton Independent School District We will be serving sack lunches from igloos at the sites listed below Thus is a request that your department inspect the locations of food service Site/Address Civic Center Park 321 E McKinney Phoemx Park Wood Street owsley Neighborhood Stella Street IMM 5/28/96 - 8/9/96 5/28/96 - 8/9/96 5/28/96 - 8/9/96 Tune of Lunch Service 12 00pm-1 OOpm 12 00pm-1 OOpm 12 OOpm-1 OOpm Dema Park 5/28/96 - 8/9/96 12 00pm-1 OOpm 1001 Parvin "Dedicated to Quality Service" TWU Clubhouse 5/28/96 - 8/9/96 12 OOpm-1 OOpm Mary Hufford Court Village East Apts 5/28/96 - 8/9/96 12 OOpm-1 OOpm 1700 Village East Houston Elem School 6/3/96 - 6/28/96 11 45am-12 45pm 3100 Teasley Rayzor Elem School 6/3/96 - 6/28/96 11 30am-12 30pm 1400 Malone MLK Recreation Center 5/28/96 - 8/9/96 12 OOpm-1 OOpm 1300 Wilson If you have any questions I may be reached at 566-8125 Brenda Burton Children's Programs Supervisor 4 Summer Food Service Prog am Sack Lunches Menus Eleven Day Cycle Tuesday - May 28 Peanut Butter/Jelly Sandwich Carrot Sticks Banana Lowfat Milk Wednesday - May 29 Bologna/Cheese Sandwich Carrot Coms Mixed Fruit Potato Chips Lowfat Milk Thursday -May 30 Tuna Salad Sandwich Pickle Spears Orange Juice Lowfat Milk 2 oz Peanut Butter, 1 T Jelly, 2 slices Bread 1/4 cup 1/2 cup 1/2 pmt 1 1/2 oz Bologna, 1/2 oz Cheese 2 slices Bread 1 /4 cup 1/2 cup 1/2 pmt 2 oz Tuna 2 slices Bread 1 /4 cup 6 oz 1/2 pint Friday - May 31 Ham/Cheese Sandwich Whole Pickle Fruit Cup Cookie Lowfat Milk Mond a - June 3 Deli Sandwich Pickle/Carrot Mixed Fruit Lowfat Milk Tuesday - June 4 Peanut Butter/Jelly Sandwich Carrot Sticks Apple Lowfat Milk Wednesday - June 5 Deli Sandwich Pickle/Carrot Apple Lowfat Milk 1 1/2 oz Ham, 1/2 oz Cheese 2 slices Bread 1/4 cup 1/2 cup 1/2 pint 2 oz Meat 2 slices Bread 1/4 cup 1/2 cup 1/2 pint 2 oz Peanut Butter, 1 T Jelly 2 slices Bread 1/4 cup 1/2 cup 1/2 pint 2 oz Meat 2 slices Bread 1/4 cup 1/2 cup 1/2 pint Thursday - June 6 Tuna Salad,Sandwich 2 oz Tuna 2 slices Bread Pickle Spears 1/4 cup Orange Juice 6 oz Lowfat Milk 1/2 pint Fnday - June 7 Ham/Cheese Sandwich 1 1/2 oz Ham, 1/2 oz cheese 2 slices Bread Whole Pickle 1/4 cup Fruit Cup 1/2 cup Cookie Lowfat Milk 1/2 pint Monday - June 10 Bologna/Cheese Sandwich 1 1/2 oz Bologna, 1/2 oz Cheese 2 slices Bread Carrot Coms 1/4 cup Mixed Fruit 1/2 cup Potato Chips Lowfat Milk 1/2 pint Tuesday - June 11 Deh Sandwich 2 oz Meat 2 slices Bread Pickle/Carrot 1/4 cup Banana 1/2 cup Lowfat Milk 1/2 pint 9 Certification That All Required Pre -operational Site Visits Have Been Conducted At All Proposed Sites Name Of Person Name Of Site Visited Date Of Visit Who Visited Site Civic Center Park February 8, 1996 Brenda Burton Phoenix Park February 8, 1996 Brenda Burton Owsley Neighborhood February 8, 1996 Brenda Burton Dema Park February 8, 1996 Brenda Burton ULK Recreation Center February 8, 1996 Brenda Burton TWU Clubhouse February 8, 1996 Brenda Burton Village East Apts February 8, 1996 Brenda Burton Houston Elementary February 8, 1996 Brenda Burton School Rayzor Elementary February 8, 1996 Brenda Burton School Signature of Authorized Representative z �2- � Date w CITY o/ DENTON, TEXAS MUNICIPAL BUILDING • 215 E McKINNEY • DENTON, TEXAS 76201 (817) 566-8200 • DFW METRO 434 2529 MEMORANDUM To Solid Waste Department From Brenda Burton, Children's Programs Supervisor Parks and Recreation Department Date February 9, 1996 Subject Summer Food Service Program The Summer Food Service Program, which provides sack lunches for children throughout the summer, is being sponsored by the Denton Parks and Recreation Department I would like to make you aware that additional trash will be placed 1n dumpsters on Monday -Friday, May 28 through August 9 at the following locations Civic Center Park Phoenix Park Owsley Neighborhood Dema Park MLK Recreation Center TWU Clubhouse Program Village East Apartments Houston Elementary School Rayzor Elementary School If you have any questions please contact me at extension 8125 .PEW1.. _ .... "Dedicated to Quality Service" Texas Depanment of Human &antes Form 1506 Aeacmmnt C February 1991 SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CRIMINAL PROVISIONS AND PENALTIES Whoever, in connection with any application, procurement, record keeping entry, claim for reimbursement, or other document or statement made In connection with the program, knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or whoever in connection with the program knowingly makes an opportunity for any person to defraud the United States or does or omits to do any act with intent to enable any person to defraud the United States, shall be fined not more than $10,000 or Imprisoned not more than five years 2 Whoever being a partner, officer, director, or managing agent connected in any capacity with any partner- ship, association, cooperation, business, or organization, either public or private, embezzles, misapplies, steals, or obtains by fraud, false statement or forgery, any benefits provided by the program, or any money, funds, assets, or property derived from benefits provided by this program, shall be fines not more than $10,000 or Imprisoned for not more than five years or both If the benefits, money, funds, assets, or property Involved Is not over $200, then the penalty shall be a fine of not more than $1,000 or Imprisonment for not more than one year, or both 3 If two or more persons conspire or collude to accomplish any act made unlawful under this subsection, and one or more such person commit any act to effect the object of conspiracy or collusion, each shall be fined not more than $10,000 or Imprisoned for not more than five years, or both TERMINATION PROCEDURES The following list of deficiencies are grounds for termination Grounds for termination, however, are not limited to this list 1 Non-compliance with applicable bid procedures and contract requirements of Federal Child Nutrition regu- lations 2 The submission of false Information to the Texas Department of Human Services (DHS) 3 Program violations at a significant proportion of the sponsors' sites Such violations include but are not limited to the following, A Non-compliance with the meal service time restrictions B Failure to maintain accurate records C Failures to adjust meal orders to conform to the variations In the number of participating childrem D The simultaneous service of more than one meal to any child E Service of a significant number of meals which do not Include required quantities of all meal components F The claiming of program payments for meals not served to participating children G Excessive Instances of off -site meal consumption H Continued use of food service management companies that are In violation of health codgs 12 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 jet and the City of Denton Denton Independent School District agrees to supply unitized meals inclusive of milk and juice to the CU 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, Rivera Elementary Summer School, and Wilson Elementary Summer School, with and for the rates herein listed Breakfasts $_D-a each Lunches $_1„55 each Snacks $—DQ2 each Supper $ 0.00 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 winch is attached as Exhibit "A" and is part of this agreement, will assure that said meals meet the muiimum 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 1 Menu Records, including amount of food prepared 2 Meals, including daily number of meals delivered by type These records must be reported to the institution promptly at the end of each month Denton Independent School District 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 I> 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 City of Denton and The Texas_ 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 venfication and retention of verification forms for any individuals hired after November 6, 1986 who will perform labor or services under this contract The Denton Indenendent School Dtstnct 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 of the 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 District agrees that except for small purchase contracts, provisions that allow for administrative, contractual, or legal remedies if contractors violate or breach contract terms, and any appropriate sanctions and penalties The Denton IndcMWent 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 CM 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 hour; Work that exceeds the standards must be compensated at least 1 '/2 times the basic pay rate for overture hours worked These requirements do not apply to the purchase of supplies or materials ordinarily available on the open market or contracts for transportation ly 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 Iri ftendent School District agrees to comply with all other applicable laws, including without limitation, any additional applicable Federal Laws or regulations contained in the_Swn= Food Service Program Agreement between the City of Denton and the Texas Department of Human If the Denton Indc=dent School District fads to provide services in accordance with the provisions of this contract, the City of Denton may, upon written notice of default to the contractor, immediately terminate the whole or any part of this contract The agreement shall be effective as of MaT24 1996 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 dat<. Sponsor Official ' /t--" Title --, Cay Manager The location of the food preparation site will be Houston Elementary School, 3100 Teasley Denton, Texas, 76205 Agreed to this date `S/ ` / /,(a School Sponsor S" Tana° Department of Human Servloes Fonn 1e07 mbar 199 SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OHS USE ONLY SITE INFORMATION Name of Food Servke site �T!ptinN, R U Owsley Park pro. I Address of Site (SfreeL Giy, sole, zfP) '817) 566-8125 Stella'Street Denton, TX 76201 Period or Operetlon of FoI IrvM;I (I I I l,lM-moiiiiii ) 5/28/96 Number a s �1M°r 4 �uu"B 20 �Ju 22 �Auo through 7 Sept From 8/9/96 Numbero O y 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 four meals) ❑ C (serving one to four meals) © E (serving one to four meals) ❑Nonresidential Camp Site Serving Primarily Homeless Children B (Serving one to four meals) ❑ D (serving one to four meals) 2 List ALL counties served by this site Denton 3 A Is your site open ®Yea ❑No 8 Is your site enrolled? ❑Yes ®No C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) 19 It D If open sites, submit documentation supporting this percentage figure (such as census date, school data) For open sites using school date, list the schools used to document site eligibility, attach formula used by school disc to establish percentage of free & reduced price children Census data from FACAA E For enrolled sites, Form 1531 will be used to document eligibility 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 the site? 100 % 4 Did the site participate In previous years' SFSP? (SFSP Handbook, Chapter 11) ❑X Yea [:)No If Yes, give name of contracting organization City of Denton A Monitorng Plan (SFSP Handbook, Chapter III) Enter date of monitoring review to be conducted within A IMt weer of OpereOon a Flret Four VVI of OparalbIt C Additional Reviews 5/31/96 6/12/96 7/17/96 6 Meal Service Period Informal fRFep laar ti Pt —i n. TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN MEAL SERVICE TIME BEGINNING ENDING TO BE SERVED' Breakfast A M Supplement Lunch 40 12 1 00 P.M. PM Supplement Supper morrnatbn is considered by D when aening oe approved meal UMft oval ISFSP HaMhonY .ne,,,., m 7 Do you plan to feed children under one (1) year old? a ❑Yas ©No Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) See Pteperetlon Vended Using School UsingFood Service Management ❑ On Site []Central Kitchen g Using Private Non Profit ® Food Authority ❑Company (Includes All Year Contracts) ❑ Organlratlon that It Seg Prep 14 Form 1e0111'age 2 Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Cafeteda-style Children are Seated Children Llne Up n u..I service ❑ and are Given Meals ® and Pick UP Meals alter f $l 11 Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter n) r-VIIndoor Meal Meal Service ED Other Service ❑win Be Cancelled 12 "the ale feeds primarily homeless children, what methods are used to ensure that money, food stamps, a in kind services are not required for meals? N/A ®Yes []NO 13 Are meals delivered to the site? IF YES, COMPLETE ITEMS 14,15, & 16 IF N0, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM indicate the means of communication with the vendor which will be used to adjust meet deliveries (SFSP 14 Handbook, Chap Iq tWill Communicate El Site PrICeon�dministrative �lrectly with Vendor Who n VendorD ®Yes ONO 15 Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) t no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of servks 16 If there is an excess of meals delivered, meals will be (SFSP Handbook. Chapter III) Slaed In Refrigerator Thrown Away Retufor urned to vendor Other ©and Served the Next Day ❑at the Site e I tify that this site has en visited has the capability the and Inffaciormation for to meal service planed for the umber of cIt mect to the best Of hildren landdpated I know fret deliberateemisrepresentationlor withholding of Information may result in prosecution under applicable state and ecleral statutes Sr-- -1 Kyle Hogue � I I Appmod ❑Danled,reason eE I 51_2_\( ONLY P.0 ------ e —ate•- r-"�_ Dai ACL U OF VTRGINIA Moss (smv) FAX TO. ,aa. noem FROM. Btll Cogw DA9- Ap ill9. 1995 M.• D.rmlm TX "PI *w the D=k Park ow (w ftoW �map), all ahea ales loewd 9n8 block Soaps, Bare ere the nmobw 1 Ckvio Cemer, ('The block Soup is only 48% but a ma4 mad 020601 is am SM :.:bil &W F ' ; 'e 10 S 41IL = 020601� us� aa o ass 2 Damis Park 0 The aloe is k ed in block Skxip 0204 3. but Only a ibw tbet way 5tam 4 bk+aic 020841 0308 aC7 83 te3 r(o w�-_S4,,4AQW-.0 0208 4 243 10�j 20! 24 SO 3 NX ltec Cmw �.. __ •=8talt itQ� " 0212 3 _ 1028 S. Pli0lnbt Pstk '�.wwar aA 0106023 Amrlevk Owl l"Ww Nklos g1WBt W ArAWVk&AV,JPIe% I VA.2321P flki:• (W 6t4= Far JW 6.9-2M s Lim) _FF��yy LA S _ GS _ S W= N W39 vc �` N 2 020601l 504 0 2!i L•' r s W 6— y m=a kn fV 0 W oz- a-L6 N 5� TOM Deparbnent of Human SeMms Form 1501 Demmm SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY SITE INFORMATION Name of Food Service Site TX R Denia Park Telephone No (im NC) Addreia of Sile (Street Gty Stan L� IR1 71 5 6 6 812 5 Ferbd of reaon and ,vim mo d. Denton, Texas 76201 ( J vm moJd.vnr l Number of Op. 6 Mav 1 uune ��uy f�nuu sa t From 5/28/96 through 8/9/96 eretingDays y 4 �1 20 22 y 7 p 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 four meals) ❑ C (serving one to four meals) 0 E (serving one to four meals) ❑Nonresidential Camp Site Serving Primarily Homeless Children B (serving one to four meals) ❑ D (serving one to four meals) 2 Llst ALL counties served by this site Denton 3 A Is your site open QYes ❑No B Is your site enrolled? ❑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) 64 % 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 & reduced price children Census data from TACAA E For enrolled sites, Forth 1531 will be used to document eligibility If the enrolled she used school data, list the school used to document the site F What is the percentage of free or reduced -price meals for the site? 100 % 4 Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) ®Yes ❑ No If Yes, give name of contracting organization City of Denton 5 Monitoring Plan (SFSP Handbook, Chapter III) Enter date of monitoring review to be conducted within A First Week of Operation B First Four Weeks of operawn C Additionid A"em 2 7/17/96 6 Meal Service Period Information (SFSP Handhr,Me r1Ha,.. in TVPES OF MEALS ELIIN UM OMER MEAL SERVICE TIME ENDING TOEGINNING BreakfastA M SupplementLunchP M SupplementSupperIMortnatlon b mnsltlere0 M H Wl en 80ninp P := �. , „, 7 Do you plan to feed Children under one (1) year old? 8 ❑Yes ®No memos or hood Preparation by Contracting Organization (SFSP Handbook, Chapter II) Seri preparet on vo Using School Using Food Service Management ❑ vate Non Profit On Site ❑ Central Kitchen ® Food ❑ Authority ❑Company (Includes All Year Contracts) orgaolradt on that is self Prep I0 Form 1507IPage 2 9 Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook Chapter 11) Cafeteda-style Children are Sealed Children Line Up EJ Other ❑ Meal Service ❑ and are Given Meals ® and Pick Up Meals er 11) 10 List site personnel who will be involved to any extent in the meal service (SFSP SPECIF C FOOD SERVICE PIROGRAM DllnES TITLE OF POSmON NO IN POSmoN Site Supervisor ) Sue Ise sais i other duties as 11 Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter 11) ®SeN Meal �WIIIBeal eCancelled ❑Other 12 0 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 ®Yes ONO 13 Are meals delivered to the site? ORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM IF YES, COMPLETE ITEMS 14,15, & 16 IF NO, F 14 indicate the means of communication with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap 11) Site Paeonnel Will Conlscl Administrative �Site D errractly onnWith l Will Communicate E]StaM, Who Will Contact Vendor ®Yes ❑No 15 Wilt delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) 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, Chapter III) Stored in Refrigerator Thrown Away Returned to Vendor Other ®and Served the Next Day ❑ al the Site ❑for Disposal e I Dertly that s site has en visited and hags the lcapabg� and facilities for the meal service planform is true and ed for the numrrect to the est of my ber of childrenanticipatedI know thlat deliberatemis misrepresentatit ion withholding of information may result In prosecution under applicable state andfederalr l statutes rigroen�voe [tCmescydg erganizo n' I \ um Summer Food Coord FOR �Pproved ❑Denied,reaeon DHS Title USE _ S"2-3 n1 to C—' N i iLA t M ANC, G ONLY (`�,� J �— a _.......e,..o Date ACL U 4F VMGINIA FAX 3 i� Crr►e�udtoDover) M. JWk t ftw.b PAW.. B111 Cacper DAT- AP1119.1995 E�koept 6u the Daodt Patlk Tito (in et Cw map). Ali dto are wmw 9 Oi �dk groape Hake ue the av: Wm is Civic Caour. MW block 8rmp is Only 48% but Oxrus naa 020601 is ow 30'1<. 0266013 11S as " o 48% 2 Deana Pak i 020e dW is is block gmp 0208 3. but only a tbw Raat way San qahtyhublack IF 0208 4 Z<s 10 40iflb s4 84• 3 NOX Rec Ceater of l.� " to.,?J.ia� __._�..+�ia yam•�a!�_ 1028 6D7. _ 77 71t shrAwa sho st. RAGiaao 14 VA. J3210 A& ON &4 M Far MM 649-2'13i zN �a w en L^ _F- m, =x G N S W� VO NN N WF. U r ' G, Y.. a m` = i �1 0212 -� 020EH60I1 # 29• Lin Wtz UP vo N a + 964. N cr �w c i Texas Depa nt of Numen Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DNS USE ONLY MIN SITE INFORMATION Nine of Food Servge Site TX ❑ R Rayzor Elementary School Telephone No (tm AJ ) Address Of Sae fabeef- CIN. Stata. 71M _ (817) 566-8125 1400 Malone Denton, TX 76201 Petbd of Operatlon of Food Servbe (=Jdaftr -tnoJdaYryr ) From 696 through 6/28/96 Number of Op nMar June �Juy �Auo Sept erating Days j� 20 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 four meals) ❑ C (serving one to four meals) X❑ E (serving one to four meals) ❑Nonresidential Camp $He Serving Primarily Homeless Children B (serving one to four meals) ❑ D (serving one to four meals) 2 List ALL counties served by this site 3 A is your site open 8 Is your site enrolled? []Yes; ®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) 0 e/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 dist to establish percentage of free & reduced price children E For enrolled sites, Form 1531 will be used to document eligibility 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 the site? 100 % 4 Did the site participate in previous years, SFSP? (SFSP Handbook, Chapter II) ❑Yes QNo If Yes, give name of contracting organization 5 Monitoring Plan (SFSP Handbook, Chapter III) Enter date of monitoring review to be conducted within A First Woek W Opereaon B. First Four Weeks of Operation C Addibonal Reviews r Tune 4 ,Tune 11 6 Meal Service Period Infra mntinn rcFca uanat.....i, TYPES OF MEALSDREN MEAL SERVICE TIME BEGINNING ENDING ED• Breakfast AM Supplement ONF Lunch JQ 12 30 P M Supplement Supper 'tide information Is OOneidered ley S W it setWIg the approved meal somm IZZI !SFSP HAMNnx Cl,en,e. In 7 Do you plan to feed children under one (1) year old? a ❑Yes ❑X No Memod of Food Preparation by Contracting Organization (SFSP Handbook Chapter II) Seri Preparation vended Using School Usin Food Service Management ❑ On Site ❑ Central Kitchen ® Food Authors g g Using Private Non Proftt ry ❑Company (Includes All Year Contracts) ❑Organization that Is Seg Prep 7L Fom 1507IPaga 2 9 Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Cafeteria -style Children are Seated Children Line Up ❑❑ Meal Service and are Given Meals 0 and Pick Up Meals Other 10 List site personnel who will be Involved to any extent in the meal service (SFSP SPECIE Candbook. Chapter 11)' DUTIES Supervisor 1 Supervise and assist distribution of mealsr monitor and maintain meal, temperature, site clean—up, and Site Helper/Server other duties as Assist site 11 indicate what provisions will be made for meal service during penods of Inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service ®Service ❑WIIIBeCancelled Other❑ 12. If 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? A QYes ❑No 13 Are meals delivered to the site? ORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM IF YES, COMPLETE ITEMS 14,15, & 16 IF NO, F 14 Indicate the means of communication with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap II) Sit# Personnel ll ®WhoVAIICointactVe dor� Administrative Dlts Personnel rectlyWithVenldorommunlcate Stets, 15 Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ©Yoe ❑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, Chapter III) Thrown Away Returned to Vendor ❑Other Stored In Refrigerator y ❑for Disposal ®and Served the Next Day at the Site 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 lt has the capability and facilities for the meal service planned for the state eand federal statutes anticipated I know that deliberate misrepresentation or withholding of Inforrtna9o/n may result to prosecution under applicable erne o onveau anlzat on - (6 (� City o£ Aenton gpney lariat ofI `_�"'1YY \ nit. Fon Approved ❑Denied, reason OHS Title ONLY S- 23,`'1 1i �� oat. Texas Department of Human Servkoes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION TWU Clubhouse Program Mary Hufford Court Denton, TX 76201 TX ot,l (u j Pb9 From 5/28/96 through 8/9/96 I Numoerofop 9m4 °Ono 20 DJ022 �" pL 9 orating Days Y 7 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 four meals) ❑ C (serving one to four meals) ® E (serving one to four meals) ❑Nonresidential Camp She Serving Primarily Homeless Children B (serving one to four meals) ❑ D (serving one to four meals) 2 List ALL counties served by this site Denton 3 A Is your site open ®Yes ❑No B Is your site enrolled? ❑Yea ®No C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter 11) 19 % 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 she eligibility, attach formula used by school dkst. to establish percentage of free & reduced price children Census data from TACAA E For enrolled sites, Form 1631 will be used to document eligibility 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 the site? 100 % 4 Did the site participate In previous years' SFSP? (SFSP HQndbook, Chapter 11) QYes ❑ No If Yes, give name of contracting organization City of Denton 5 Monitoring Plan (SFSP Handbook, Chapter 111) Enter date of monitoring review to be conducted within A First week or Operaton a Fkat Four weeks of Operation C Addworial Revbws 5/31/96 6/12/96 7/17/96 6 Meal Service Period Information rSFsp NanAHnn r us .e, in TYPES OF MEALS ELINUMBER OF GIBLE CHILDREN MEAL SERVICE TIME BEGINNING ENDING TO BE SERVED' Breakfast A M Supplement Lunch 55 12 00 p.m 1 00 P.M. P M Supplement Supper -rNe Information IS oonslMrod by DHS when ee ant apprOVed meal saNiM level !SFSP HRMM .,.a...., n, 7 Do you plan to feed children under one (1) year old? 8 ❑Yea QNO Method of Food Preparation by Contracting Organization (SFSP Handbook Chapter II) sett P eperedon VBmw Using School UsingFood Service Management ❑ On Site ❑ Central Kitchen ® Food Authority g OrgaUsinnization Private Non Profit ly Company (includes All Year Contracts) ❑Organization that Is Self Prop Fm 1e071Page2 9 Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Cafeterialetyle Children are Seated Children Line Up ❑❑Meal Service and are Given Meals 0 and Pick Up Meals Other er 11) 10 List site personnel who will be Involved to any extent in the meal service (SFSP Handbook, SPECIE C FOOD SERVICE PIROGRAM DUTIES 777TF9=f; - - ise and distribute meals, moniemperature, site clean—up, and as assigned 11 Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service Other ®teService ❑WIIIBeCancelled ❑ 12 6 the site feeds primarily homeless children, what methods are used to ensure that money, food stamps, or in kind services ere not required for meals? N/A QYes []NO 13 Are meals delivered to the site? IF YES, COMPLETE ITEMS 14,15, S 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 II) X❑ SRO personnel nel Will Contactte Administrative or ❑ Directly Wsite ith Personnel Will Communicate ®Yes []No15 VAII delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11) If no, describe arrangements within standards prescribed by local health authomles for delivery and holding of meals until time Of service 16 If them Is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 111) Thrown Away Returned to Vendor ®and Served ❑Other Stored In at the Site ❑for Disposal the he Next Day Cl s site has been visited and e I certify that th I CERTIFY Eas tl Te oepab I, Ithe information on Ity end facilities for theit smeal service planform is true and ed for the number of rrect to the best of children lanticipat d I know thiat deliberate misrepresentation tor withholding of information may result in prosecution under applicable state anrd� a rcaol svtoa sraar on �� -a I-9 City of Denton Summer Food Coordinator PDR Approvad ❑Denied,eoson OHS Tiae USE ONLY ___ .__nue c. nteave Dale ACL U OF VIRGINIA FAX 3 ma (Vwu&8 cam) TO moat m d fur Burcacpa DAT1~- Apd! 19, 1995 M. , Dam TX Ekoept Far tbo DvW& Poch giro (w attached map?. alI sites see WOMW bgaaraly In q block 8<ag& Fav as ft raaabm 1 Cmc Curter, aU black 8roap is only 49V% but crnaua tray o20601 u ovsr l09i 3 115 .43riYs�li._-.-.�- m fr- 0206016So - ":C*% 48% 2 Dmm Park ibe rite �a k�ged is block stoop 02013. but only a lbw tbat way from qua inp8 black 020 407 82 0 0f�==° 0208 4 243 161 24 840 3 14 K Rec Ceuta oZi�� --- 1028 "oinliaiL .rtl. 1t 0206023 270 138 34 60 " O= W= lV y >� N p U3: Awotmr Owl Lbm" URI" VTkVmw arAwa aso S, ma4ww4 VA. 23210 - rm. mm 6EIdOJ2 Far PQ 60-21M 2 0206011_ r 504`...- 0 s mac? s - - — m= un GS N - y= o V.. c N N LU uy �w �r OW.U. N c Texas Deparoronl of Human SaMoes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Village East Apartments 1700 Village East Denton, TX 76201 Period of OPemoon of Food berVIN (MJdayM- rnoJtlayty May June From 5/28/96 through 8/9/96 Number um eDasp 4 20 9 Y ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children 1 Indicate Type of Site ❑ A (serving one to four meals) ❑ C (serving one to four meals) ❑Nonresidential Camp Site Serving Primarily Homeless Children B (serving one to four meals) ❑ D (serving one to four meals) 2 List ALL counties served by this site 3 A Is your site open B Is your site enrolled? FOR DNS USE ONLY TXG`k_jQ, R Telephone No (inc N I (817) 566-,8125 N22 7 AAug DSept V ®Other Site E (serving one to four meals) EIVes ❑No ❑Yes ®No C Site Ellgibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter ll) 100 •�, 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 & reduced Price children Census data from TACAA E For enrolled sites, Form 1531 will be used to document eligibility 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 the site? 100 % 4 Did fhe site participate in previous years' SFSP? (SFSP Handbook, Chapter II) ®Yes [:]No If Yes, give name of contracting organization CJ Lv of Dgut n 5 Monitoring Plan (SFSP Handbook, Chapter III) Enter date of monitoring review to be conducted within A First Week of n 8 no Few Weeks of Operation C Atltlmonal I 5/31/96 6/12/96 7/17/96 6 Meal Service Penod Informatinn rcl:cP unn.rr,....i, TYPES OF MEAM�� EROF ELIGIBLECHILDREN MEAL SERVICE TIME SERVED' BEGINNING ENDING Breakfast A M Supplement Lunch12.00 ,m, 1 00 P M Supplement .m. Supper `TNa I onnatlon b meal service level (SFSP Hantltxnx rn..,., w 7 Do you plan to feed Children under one (1) year old? 8 []Yes ®No Method of Food Preparation by Contracting Organization (SFSP Handbook Chapter II) San Preparation"not- Using School UsingFood Service Mana emenl D On Site ❑ Central Kitchen Food Authority El company (Includes All El Contracts) Ofganlzationethat Is Self Prep Form 1507IPaae 2 9 Indicate the system to be used for the serving of meals and the supervision of Children during meal service period (SFSP Handbook, Chapter II) Cafeledametyle Children are Seated Children Line Up Cl Other El Meal Service ❑ and are Given Meals 0 and Pick Up Meals er 11) 10 List she personnel who will be Involved to any extent in the meal service ( SPECIE C FOOD SERVICE PiROGRAM DUTIES 7fTLE OF POSfTIOisoN NO IN POSmON Site Supervr 1 Superiise sad assist distributi other duties Site 11 Indicate what provisions will be made for meal service during periods of inclement weather (SFSP Handbook, Chapter II) indoor Most Meal Service ®Service ❑WIIIBeCancelled Other 12. tl 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? ®Yes ❑No 13 Are meals delivered to the site? 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, Chap II) Site personnel ll ®gm ,Personnel rsonneWillCantedllnt nAdministrative �D� �Vendorommunlcato dor ®Yes ONO 15 Nil delivery be within one hour of the food service period? (SFSP Handbook, Chapter 11) M no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service 16 If thereIs an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) Storod In Refrigerator Away Returned to Vendor Other ®and Served the Next Day Oat the Site ❑for Disposal 1 CERTIFY that the Information on this form is true and correct to the best Of my knowledge I Denly that this site has been visited and that k has the ding obInformation adlacilifies for the may result in meal service wituuon under applicableJ for the stateandfederal statutes r of children ated I know that deliberate misrepresentation a No fed vac0q en OW FOR Approved [:]Oenled,reason OHS Tire use 1 N L /A C L ONLY r�An Dale ACL U OF VIRGINIA 3p"(WICN&SCOM) FAX TO: A". fto#M FROM.- B111 Cocr LW M- .401110, 1995 M . &M%n TX ExOept for tbo DaWs Ptak rho (tee ttt dW rasp), all An are W=W 9�i'�ng black Wmpa. Hate AM the anbws. �Y bt 1 Cmc Canter. M" block Group is only 49% but amm ovot 020601 it OW SO'14. 02066i3 :— 9iolt1153l55 � 4.ta3Y�t�t�!l �laiY�d�3Ni r= 2 Demu Park A;• IFU 020t 4srte iKft is block soap 0208 3. but only a Pew foot way from quWA ink block J. �7782 0200 4 243 167 24 940 3 N" Rec Now _..-Oi_n1tj�L :r4lol j%.- �a4eliY _�te3t'ieidS'ke. 0212 2 1626 657. Y 77 71t 2 -W ... =2 1 4 N .d. +MMt. • ri. l.e-'u^w•1 YWT;�x& `n �270 LS Y'�a i W 0206023 lit 24 60 �" NC�j c�3 Awrloel G7vNLbwtlei tANe� `%t'by1�MR• c a� At Mw* shm &, AW worA VA. 021P AL ON 6"" rim (d Q 6/0-2m 298 C i r- Form 1507fPage 7 tam to be used for the serving of meals and the up of Lin of children during meal service period (SFSP Handbook, Chapter II) 9 Indicate the sys Caleteda style Children are Seated D and Pick Up Meals Other Meal Service ❑ and are Given Meals ❑ .._ ... ....emnu SPECIFIC FOOD SERVICE PROGRAM DtrmES 10 List site personnel who will be Involved to any extent in the meal service (SFSP Handbook, Chapter I ement weather (SFSP Handbook, Chapter II) 11 Indicate what provisions will be made for meal service during periods of Ind Indoor Meal Meal Service Other QIndoor QWill Cancelled ad to ensure that money food stamps, or In kind services are not required for meals? 12 N the site feeds primarily tameless children, whet methods are us ®Yes ❑No 13 Are meals delivered to the sits? ORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM IF YES, COMPLETE ITEMS 14,15, !r 16 IF N0, F meal 14 Iodinate the means 01 commuMcatioS n with the vendor which will ite bePeraonmrte WIIICommunicate Site(SFSP Handbook, Chap 11) Site Personnel WIII Contact Administrative Directly With Vendor ®Yes ❑ No ®Staff, Who WIII Contact Vendor If ill describe vftin one hour standards prescribed by local health authorities for delivery and holding of meals until time of service 15 WIII delivery be WhhM one hour of the food service period? (SFSP Handbook, Chapter ts 18 If there is an excess of meals delivered, meals will be (SFSP Handbook, oReturned to Vendoer 111) r 0 Other Stored In Refrigerator Thrown Away olor Dlefwsal ©and served the Next Day ❑at the Site It dormati a for the meal service planned for the number of children anticipated I know that deliberate misrepresentation or I CERTIFY that the Information on this form is true and correct to the best of my knowledge I certib that this site has been visited and that has the capability �^ applicable state and federal statutes withholding of information may Nameo neamng resuh In proseation under app f Denton _2 9 City o V.. JC0 _ ._- -- Date pprovd ❑penled,roasan IFORAUSE 1-3 w titi r1At i hi(1n A G£� ONLY Daie m...., HS raaama e _ Texas Doparmwl of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION Houston Elementary School 3100 Teasle Denton, Texas Parbd of Operedon of Faso Santis (moJdavM-moJdarryr ) 16111 From 6 3 9 6 through 6/ 2 8/ 9 6 eruad^9 Ua �o- D MW A June U 2 0 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED 1 Indicate Type of Site ❑ A Residential Camp (serving one to four meals) Site ServingPrimarily Migrant Children ❑ C (serving one to four meals) E] B Nonresidential Camp one to four meals) She Serving Primarily Homeless Children ❑ D (serving one to four meals) 2 list ALL counties served by this site 3 A Is your site open 0 817) 566-8125 ®Other Site E (serving one to four meals) B Is your site enrolled? ❑Yes ®Nof� C SltOEllglbllity Enter the tag g p LDYes ❑No Percentage of children eligible for free and/or reduced rice meals for the she (SFSP Handbook, Chapter II) 0 /e e D If open sites, submit documentation supporting this percentage figure (such as census date, school data) For open sites using school date, 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, Form 1531 will be used to document eligibility 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 the site? 4 Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) If Yes, give name of contracting organization 5 Monitoring Plan (SFSP Handbook, Chapter III I Enter date of monitoring review to be conducted within ti Fbst week of operetlon B First Four Weeks of O reaon 6/ 4/ 9 6 6/ 11 / S 6 Pe c Aodltkuni R.vknvs 6 Meal Service Period information (SFSP Handbook, Chapter III 5SuPplament 1' moan yr ELIGIBLE CHILDREN MEAL SERVICE TIME TO BE SERVED' BEGINNING 30 11: 454 m Supper 7 Do you plan to feed children under one (1) year old? 8 Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) Sea Preparelbn vended Using School Usin ❑ Onite El Central Kitchen ; 2 it , e,,,�_.,.. r-I _ g f00d Service Management 1 ff 0 ys ❑Yes ®No ENDING 12:45pm ❑Yes ®No Using Private Non Profit 'I < Texas Deparrbrrnt 01 Human Setvloss SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY Its SITE INFORMATION TX R U Telephone No (inc At ) (8I7) 566-8125 Number of op. ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED I G4 r r r Realdentlal Camp Site Serving Primarily Migrant Children Other Site 1 Indicate Type of Site El A. (serving one to four meals) ❑ C (serving one to four meals ©E (serving one to lour meals) ElNonresidential Camp She Serving Primarily Homeless Children B (serving one to four meals) ❑ D (serving one to four meals) 2 List ALL counties served by this site 3 A Is your site open ®Yea ❑No B Is your site enrolled? ❑Yas ®No C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) 31 0 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 & reduced price children Census data from TACAA E For enrolled sites, Form 1531 will be used to document eligibility If the enrolled site used school data, tist the school used to document the site F What Is the percentage of free or reduced -price meals for the site? 100 % 4 Did the site Participate In previous years, SFSP? (SFSP H#ndbook, Chapter II) ©Yss ❑No 5 If Yes, give name of contracting organization City of Denton Monitoring Plan (SFSP Handbook, Chapter 111) Enter date of monitoring review to be conducted within A. First Week of Operatkxl B First Four Week' o perstlon C Atltllaonal RaWews 5/31/96 6/12/96 7/17/96 6 Meal Service Period) Infnrnnatinn /SPRP TYPES OF M EALS NUMBER OF ELIGIBLE CHILDREN MEAL SERVICE TIME TO BE SERVED' BEGINNING ENDING Breakfast AM Supplement Lunch ' 90 12.00 p.m, 100 P M Supplement p,m, Supper thismlormatan Is oonakNred by HS omen se the approved meal service level (FSP Handbook. so 7 Do you plan to feed children under one (1) year old? 8 ❑Yes [!]No method of Food Preparagon by Contracting Organization (SFSP Handbook Chapter II) Sirs P epa odor Vantled Using School Using Food Service Management Usin Profit ❑ On Site El Central Kitchen [1� Food Aulhodty El Company (Includes All Year Contracts) ❑ Organimrlti nethon at Is San Prop 1� Fq 1607IPaaa 2 9 indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Cefetedaatyle Children are Seated Children Line Up ❑ Other ❑Meal Service ❑ and are Given Most$ ® and Pick Up Meal$ 10 List site personnel who will be Involved t0 any extent in the meal service (SFSP SPECIE C FOOD SERVICE Chapter 11) Dtlr1ES 177LE OF POSMON NO IN POSmON Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean—up, and Site Helper/Server other duties as assigned Assist site supervisor 11 Indicate what provisions will be made for meal service during periods of Inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service ®Service []Will so Cancelled ❑Other 12 0 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 QYe$ []NO 13 Are meals delivered to the site? IF YES, COMPLETE ITEMS 14,15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM 14 Indicate the means Of communicagon with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chop II) site Personnel ll ®Step, Who al WillContact Administrative ❑D Contact Vendormcdy With Vendo�mmunlcate ®Yes er 11) 15 Will delivery be within uInstandatls presPeriod? rbed la��� odses for delivery and holding of meals until time of service p no, describe arrangements 16 0 there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter 111) Thrown Away Returned to Vendor ®StorodlnRelrigN ❑attheSlte ❑for Disposal ❑ -- -- ❑ No and Served the a Y I CERTIFY that the Information on this form is true and correct to the best of rimy knowledge I oerdfy that this site has been visited and that h has the capability that end Information facilitiefor 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 edserei statutes on �� II ^�oJlf� �--„�j,Cjj� City of Denton FOR approved []Denied, reason —_ ����_ �- iQ n. G Z M Iti C Fri DNs 7roe� USE Dane ACL U OF vMGINIA 3 Pia c�tteic� otwr� FAX TO: Ja*t ft? Oem FROM: I muco"r Ap►il 19. 1995 ' DmM 1Y Except for the Dow& park tiro (tee M%Ghed MP). ail titea an Would *4vanly is qulkern8 block $=PC HINS ae the ambers. 1 Cme Cater. Cl*" bloek IMP is only Me, bat oetmn Ufa 020601 it ovor 304t 2. Deana Park 02081so it is block Smp 0208 3. bat oaiy a lbw fogaay atom quotu 0204 _. _it i' •8.� 8je3'3 iim � �.�05 0208 d 243 10`i 0 20• 2a a4• 3 b" Rec Ceota 0212 ? 1028 657" ' Jp18�yam;.. it 71t 0206023 AmMaar Owl L dw &Aube StarYNO S M SC. Md w rA VA. 22210 Tit Ow t "4w Pau: po 6&2m Ln 11t�1 �N 60 �'� a �W rW m2 K S OS N `J= WW NN V 39 W 00 N o.— J 2 0206011 504 i go - W iC ~N JI rz P1 v+ W� y = Zs O U� Co N �F- wn � W � N G Texas Oeperonent of Humeri Services Form 15o7 tuber 1e3 SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OHS USE ONLY SITE INFORMATION Name of Food Semce Site TX R U Civic Center Park Tebpnone No (inc N ) Address of sne(SIreeL Cay ...... ) (8 R7) 566r8125 321 E, McKinne Denton TX 76201 Period of Operation of Food liervbe (moJdaYM-moltlaYNr ) From 5/28 96 through 8 9 95 Number of so- May 4 DJunDJuy D Auo e D�pL 9 Y 20 22 7 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Site 1 Indicate Type of Site ElA.(serving one to four meals) ❑ C (serving one to four meals) E (serving one to four meals) ❑Nonresidential Camp She Serving Primarily Homeless Children B (serving one to four meals) ❑ D (serving one to four meals) 2 List ALL oountles served by this site Denton 3 A Is your site open ®Yes ❑No 8 Is your Sao enrolled? ❑Yes ® No C Site Eligibility Enter the percentage of children eligible for free and/or reduced pace meals for the site (SFSP Handbook, Chapter 11) 22 % 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 & reduced price children ._Cenenc dptn fr� E For enrolled sites, Form 1531 will be used to document eligibility If the enrolled site used school data, list the school used to document the site F What Is the percentage of free or reduced -pace meals for the site? 100 % 4 Did the site participate In previous years, SFSP? (SFSP Handbook, Chapter 11) g ❑Yea ❑No If Yes, give name of contracting organization City of Denton 5 Monitolang Plan (SFSP Handbook, Chapter 111) Enter date of monitoring review to be conducted within A Fkat week of Operation a First Four weeks of Operation C AtltlNonal R be 5 3 96 6 2 7/t7/o� 6 Meal Service Poland Infnrmatinn Ysaao TYPES ER OF CHILDREN MEAL SERVICE TIME SERVED' BEGINNING ENDING Breakfast A M Supplem 37; Lunch12.00 P,m� 1.00PM Supplemp,m, Supper-Irda Ed Irdmmallm is 1 og tib ei tomeal servios jowl /SFSP HarW rh..,., In 7 Do you plan to feed children under one (1) year old? 6 ❑Yes ©No Method of Food Preparation by Contracting Organization (SFSP Handbook Chapter II) See Preparation vended Using School Using Food Service Management using �On Site El Central Kitchen ❑X Faod Authority ❑Company (Includes All Non Profit Year Contracts) ❑ Organlzatlao that Is S Iff-0rep 6 Form 1507IPaoe 2 9 Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook Chapter 11) Cafeeda�style Children are Seated Children Line Up ❑ Other l ❑Meal Service ❑ and are Given Meals 0 and Pick Up MealS 10 List she personnel who will be involved to any extent in the meal service (SFSP SPECIE C F000 Handbook, Chapter CE e11) DUTIES TRLE OF POSITION NO IN POSmON Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up and other duties as assigned 11 Indicate what provisions will be made for meal service during penods of Inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service Service ❑WIIIBeCancelled ❑Other 12 0 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 Elyse ❑No 13 Are meals delivered to the site? 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, Chap II) Site Personnel Will ConW Administrative ❑D fitly Personnel l Will Communicate ®Staff, Who Will Contact Vendor ®Ysa 15 Will delvery be within one hour of the food service period? (SFSP Handbook, Chapter II) If no, describe arrangements within standards prescribed by local health authomies for delivery and holding of meals until time of Service 16 If there is an excess of meals delivered, meals will be (SFSP Handbook, to Chapter III) Stored In Refrigerator Thrown Away Other th N xt De ❑at the She ❑ for Disposal ❑ No ® sand Served e y I certify that it hasEthei capability and facilities for the meal service planed for the numberrrect to the bestOf children anticipated d I know thiat deliberats site has emi representati��onen visited and t°''''II withholding of information may result in prosecution under applicable state anNern@0 slat�utesroW on I r' .��'N-�� -9 City of Denton — ZI APPr�b ❑penied,roason USE Inae C� I usE S_ 3 ONLY &1 �i.�p Datate6 _ ACLU OF VIRGINIA PS" OWU&S MVW) FAX Jaa t i Wom au1covv DATA" ApOl19,1991 M.' . Dense, TX E wept Aw dw Dow& pelt dw (eee ettecJied map), all vita an ioeegd gA r� bkxk its iieee ere the"* �amOlY in 1 Cwmo Curter. M" black Stoup u only 49% but c wms nt d 020601 1e ovar SM o oiols �" :i.;VbiIS41L [s lid —_vm)s�ces3y� ^_ - 0 48= 2 Deane Park 'o . o3 ur ie k�amed is bk�dc Sioap 0208 3, bat oay a few tbet WRY hoer► qwl flfi W blo& 0208 T~ µ^ 0 20i �FeS'7� 1'afa�*!k 0208 4 82�'. 243 lb 24 840 3 M1.K Rec CeoW 0212 = 1028 - gl. �._ 4o-ltLfakor. a ib t '1i% - 77 71t 'M �• f rt.+ 0206022 i70 138 24 6o K s Aa WIM owl IJbm" U" gr Oft N~ U. SlsrJYP�Mk SIrOF �:, JeiarwaA4 YA.13119 ' ` rm. ON 6tFar (leg 66-2M 21 .::-3_ �!PM 0206011 304 N 2$V- A t F cn cn aJ m2 S Ln = V3 V o N uj Wa li4i ► O6u. y Z7 Texas Deparvwt Of Human Services SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION MLK Recreation Center 1300 Wilson Denton, TX 76205 Pend of Operation of Food SON109 (M4daytyr - 4daytyr) From 5/28/96 through 8/9/96 Number of Op May June erotingDays 4 � 20 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Sits Serving Primarily Migrant Children 1 Indicate Type of Site [:1A (serving one to four meals) ❑ C (serving one to four meals) ❑Nonresidential Camp She Serving Primarily Homeless Children B (serving one to four meals) ❑ D (serving one to four meals) 2 List ALL counties served by this site Denton FOR DHS USE I TX slephone No (1n A) ) (817) 566-8125 22 y 7 ©Other Site E (serving one to four meals) 3 A Is your site open ©Yes []No B Is your site enrolled? Dyes ®No C Site Eligibility Enter the percentage of children eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) 31 % 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 dlst to establish percentage of free & reduced price children Census data from TACAA E For enrolled sites, Form 1531 will be used to document eligibility 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 the site? 100 % 4 Did the site participate in previous years, SFSP? (SFSP Handbook, Chapter 11) ❑Yss ❑No If Yes, give name of contracting organization City of Denton 5 Monitoring Plan (SFSP Handbook, Chapter ill) Enter date of monitoring review to be conducted within A Fkst Weak of Oparetlon a Flret Four Weeks of Operetion C Additional gevbws 5/31/96 6/12,196 7/17/96 6 Meal Service Period Informatinn rcrec TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN MEAL SERVICE TIME TO BE SERVED BEGINNING ENDING Breakfast AM Supplement Lunch 90 2 P M Supplement Supper 'fhb infomutdon b Omsk*md by DHS when satlkp ab approved meal servk a level (SFSP H;;=k .n..,., u, 7 Do you plan to feed children under one (1) year old? 8 ❑Yes ©No Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) See ] On Site vended Using School UsingFood Service Management ❑ On Sile ❑Central Kllchen Non Profit ® Food Authority ❑ Comany (Includes All Year Contracts) ❑ Org Using that le seti-Prep 0 Fain 15071Page 2 g Indicate the system to be used for the serving of meals and the supervision of children during meal service period (SFSP Handbook, Chapter II) Cafeteris"atyle Children are Seated Children Line Up ❑ Other Elm"[ Service ❑ and are Given Meals ®and Pick Up Meals 10 List she personnel who will be Involved to any extent in the meal service (SFSP SPEC Handbook. FOOD SERVICE Chapter 11) DUTIES TMX OF POSMON NO IN YVsn,un - - te Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean—up, and other duties as Site Helper/Server I 1 I Assist Supervisor 11 Indicate what provisions will be made for meal service during periods of Inclement weather (SFSP Handbook, Chapter II) Indoor Meal Meal Service Other ®Service ❑WIIIBeCancelled ❑ 12 a the site feeds primarily homeless children, what methods are used to ensure that mney, food stamps, or in kind services are not required for meals? N/A (Dyes ❑No 13 Are meals delivered to the she? ORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM IF YES, COMPLETE ITEMS 14,15, fk 16 IF NO, F 14 Indicate the means of communication with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap II) ®Site Personnel Site,WhoWIII illlContvendor Administrative ❑DlmcgyWithV Vel endor ll Communicate ®Yea ONO 15 Will delivery be within one hour of the food service period? (SFSP h Handbook, nh�eS fo� delivery and holding of meals until time of service If no, describe arrangements within standards prescribed by 16 If there Is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) Thrown Away Returned to Vendor ❑Other Stored In Refrigerator �tor Dlaposal ® and Served the Next Day ❑at the Site 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 r has the CERTIFY that end Inffaciormation for the meal serve 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 aeraostatutesnanizWw ------ _ City of Denton —I Summer Food Coordinator POR Approved ❑penled, reason oNs rae ONi ..� ` � a,vsYn1A1NB �aib ACL U OF VIRGINIA FAX � t� (�ludiaa oowr) TO.- JF WO A oem FROM- Bur cogw DATE.- AM/ /#, Ins M.' . Dew TX IIcsvt for the Dmca Peels eito (eee etemoh navy, SU eiw aee toMW qmw% block 8e� an to the as Dwm oq`ae°ty in 1 Cmc Curter, (the block Brae u oaly 49% but aarus VW 020601 in ovor SM 02o6C�13 P� ci%ii.s 20..s 14; _Ym4a$ss4; - 0 480 2 gams Park e 7Ua site is 0208 3 but 02094, aa)y ' fraen blocs 8=mP a fbw lbet way qud&AM We& 0204 3 = 407 2 -� D4�_` ��-io 0208 4 243 10~7 20t 24 840 3 MIX PAc C40a ` 0212 a _. 94n1i s � to_ qli 18 3e� �Ds<faS�lg4 1028 AwMmr CMIL+a"LWm y/i hr&w 88rJ1reNM S, R/etulord, VA, 23210 flL• Na16i4a021 Fir (88p de-2m s un z� O ^ N s Cu s O 11 vc N wF M 0212 2 - loon 0206011 ._ir 304 11 ro a ZO'�0'= 0 # ui v. on m= Ln GS N U3 vc N N Wr Cu w i CL.1- �1- SUMMER FOOD SERVICE PROGRAM AGREEMENT STATE OF TEXAS 4 City of Denton COUNTY OF TRAVIS § The Texas Department of Human Services, hereinafter referred to as TDHS, AND hereinafter referred to as the contractor, do hereby make and enter into this contract, as required by the National School Lunch Act (Section 13) and the Summer Food Service Program, hereafter referred to as the SFSP, Federal Regulations (7 Code of Federal Regulations (CFR], Part 225) I MUTUAL AGREEMENTS The Parties mutually agree A If the contractor fads to provide services in accordance with the provisions of this contract, the Department may, upon written notice of default to the contractor, immediately terminate the whole or any part of this contract and refuse to pay claims for reimbursement Such termination and/or refusal to pay claims for reimbursement shall not be exclusive remedy but shall be in addition to any other rights and remedies provided by law or under this contract B If federal and state laws or other requirements are amended or judicially interpreted so that the continued fulfillment of this contract, on the part of either party, is substantially unreasonable or impossible, or if the parties are unable to agree upon any amendment which would therefore be needed to enable the substantial continuation of the services contemplated by this contract, then the parties shall be discharged from any further obligations created under the terms of this contract, except for the equitable settlement of the respective accrued interest or obligations, including audit findings, incurred up to the date of termination C This contract may be 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 notwe 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 11 CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT A The contractor will comply with the SFSP Federal Regulations (7 CFR, Part 225, as amended), Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), and state policies and procedures as issued and amended by 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 conditiormof aettlenunt,o&auy audit, exceptions or payment deficiency in the program and the collection and repayment of any amount paid in excess of the proper claim amount which are found after monitormg 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 approved food service site SFSP RECORD KEEPING A The contractor will keep financial and supporting documents, statistical records, and any other records pertaining to the services for which a claim is submitted The records and documents will be kept for at least three (3) years and ninety (90) days after the termination of the contract period If any litigation, claim, or audit involving these records begins before the stipulated time period expires, the contractor will keep the records and documents for not less than three (3) years and ninety (90) days after the termination of the contract period and until all litigation, claims or audit findings are resolved The case is considered resolyed when a final order is issued in 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 access to all records of costs paid, even in part, by TDHS Non School Spmaoia 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 end 15b) Department of Justice (28 CFR, Parts 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 Admuustrative. 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 trom 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 The person whose signature appears on this contract is authorized to make this assurance on behalf of the contractor V TDHS CLAIMS PAYMENT 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 2j J 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 l 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 States Department of Agriculture or other federal department or 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 as 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 contract, unless it knows that the certification is erroneous A contractor must, at a minimum, obtain certifications from its covered subcontractors upon each subcontract's initiation and upon each renewal Non School Sponsors 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 the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure The 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 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 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 3 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 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 Non School Sponsors Page 5 ill VII 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) Ongmal signature of the authorized representative of the contracting organization Ted Benavides Name of the authorized representative of the contracting organization (Please Print or Type) Citv Manager Title Please print or type, in the spaces provided above, the name and title of the authorized representative signing this agreement on behalf of the contracting organization TEXAS DEPARTMENT OF �UMAN:SERVIC�S�'�y� '� Effective Dates M_ % through �r A AC} q.1gCl In By -'� Date ��3 Revised February 1994 Non School Spmwn Page 6 1996 CONTRACT YEAR Texaa Department of Human Ser aces SPECIAL NUTRITION PROGRAMS SINGLE AUDIT IDENTIFICATION DATA Form 1569 November 1995 Contractor Name ontact Person C City of Denton Teresa Milam Address (Street or P O BOX City Safe LP) 321 E. McKinney Denton, Texas 76201 Telephone No Payee 10 No Contract No (817 ) 566-8125 17560005146013 Contractor Fiscal Year ErW (mr vCk4W) Type of Qonvaci 0 9/ 3 0/ 9 6 El For Profit Non Profit IRGavernmental Check the appropriate box(es) to Indicate the type(s) of programs COMMODITY ASSISTANCE PROGRAMS ❑ A — National School Lunch ❑ B — Charitable Institutions C — Area Agency on Aging ❑ G —Summer Camps H — Summer Food Service ❑J —Jails ❑ K — Soup Kitchen ❑ I —TEFAP Commodities amount or env recerai financial See In which you currently participate or for which you are applying CASH REIMBURSEMENT PROGRAMS LJ AD — Adult Day Care BL— National School Lunch/Breakfast ❑ CC — CACFP Center ❑ DH — CACFP Day Home ® SF— Summer Food ❑ SM — Special Milk ❑ TE—TEFAP omer fnan from muse oru9fa9;13 narCu auuvu ❑ SINGLE AUDIT EXEMPTION-1 certify that I am not required to submit an audit under the Single Audit Act for the following reason(s) ❑ I am a for -profit organization ❑ I 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 N An Annual ❑ A Biennial audit as a condition of eligibility to pamcipale in the Special Nutrition Programs and that failure to do so as required could result in adverse action, including the withholding of my claim for reimbursement payments and termination of my contract I also understand that if I am a private non profit organization subject to the requirements of the Single Audit Act and have a financial audit performed annually, I must also obtain a single audit on an annual basis Lj -9 6 Date -Kyle Hogue Summer Food Coordinator 3S Texas Department Form 4508 issu CERTIFICATE OF AUTHORITY This is to certify that Name of Aulhonzed Official (please type or pnnt) Tine Fed Benavides City Manager .Li -� SignatUre-/UdWriL•zved-Ofr�icial Is designated as the authorized representative of Name of Contracting Organization City of Denton Addreas (Street City State ZIP) 321 East McKinney Denton Texas 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 Sigrarture—Official of contacting Agency Dald Name of Official (phase type or pdM) Title Ted Benavides I City Manager FOR DEPARTMENT OF HUMAN SERVICES USE ONLY y Agreement (. ` t ' ati fiecervetl Data By T1 — J q \ L s� 6 Texas Department Form 4508 of Human Services July 1990 CERTIFICATE OF AUTHORITY This Is to certify that Name of Aulhor z d official (please type or print) Teresa Milam Title Leisure Services Manager Sig tttonzed Oflictat Is designated as the authorized representative of Name of Conlracong Organization City of Denton Address (Street city State ZIP) 321 East McKinney Denton Texas 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, andtopresent claims for reimbursement, when appropriate, to the department SSgreWre-0fWal of Contraclktg Agency Name of official (please type or prka) Title Ted Benavides Cit Manager �12e air ne unuau 000W19-CC 11CP nW1 V. run vcrrsn,..........e.-_� Date S— 2 3 -1 1, Agreement No By TX- J �o 3'1 Texas Department of Human Services Form 4506 July 1990 CERTIFICATE OF AUTHORITY This Is to certify that Name of Aunwnzed Owcial (please type or pent) Title Kyle llo ue Summer Food Coordinator .v Signature—Autlte ed Offcial is designated as the authorized representative of Name of Conlraceng OrgaNzatan City of Denton Address (Street City State ZIP) 321 East McKinney Denton Texas 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 sat -TSrgnature-OIadal of contracting Agency Who Name of official (peaea type or prig Two Ted Benavides City Manager FOR OFPARTMFNT OF HUMAN SERVICES USE ONLY A l - J Red�oate TX- U b Teaaa Department of Human Services I CIVIL RIGHTS ACT OF 1964 Form laaa/AHachment A SUMMER FOOD SERVICE PROGRAM FOR CHILDREN January 1990 CIVIL RIGHTS QUESTIONNAIRE A 1 Estimate, by racial/ethnic group, the number of children that will participate In the program at each site If the program consists of several camp sessions, specify the projected number of children by site and date of session SITE (name of all@, school, camp, etc I AMERICAN INDIAN ALASKAN NATIVE ASIAN/ PACIFIC ISLANDER BLACK HISPANIC WHITE Owslev Park TWU Clubhouse Program 10 10 ) 35 Denia Park 0 Phoenix Park 50 30 10 Civic Center Park l0 0 MLK Recreation Center 60 20 10 Village East Apartments 20 10 20 Rayzor Elementary School 25 3auston Elementary School 10 10 10 2 Describe how this projection was made (I e , based on comparative enrollment in sites, observation of students, student surnames, etc Observation of neighborhoods B Does the organization have specific membership requirements which result in the denial of program benefits to specific groups? ❑ Yes ©No If yes, describe those requirements C What efforts will be made by tfle organization to contact minority and grass roots organizations about the opportunity to participate in the program? Posters displayed in neighborhoods, attend community meetings and public service announcements D What other outreach stops will be taken by the organization to ensure that minorities in the area from which It draws Its attendance will have an equal opportunity to participate in the program? S.F.S.P. information will be printed in spanish E Has any federal agency notified the organization of noncompliance with the Civil Rights act of 1954? ❑ Yes ® No If yes give details including dates, names, and results It REHABILITATION ACT OF 1973 (Section 504) A Does the contracting organization have any policies, practices, or architectural barriers that limit, deny, or discourage participation in the program or employment by the contracting organization because of disability? If yes, explain ❑ Yes ® No Form toga / Attachment A Page 2 B Are there any policies or practices that result in unequal treatment in the delivery of benefits or services to participants, applicants, or employees according to disability? If Yes, explain C Does the contracting organization employ 15 or more people? If yes 1 ® Yes ❑ No Enter the name and title of the coordinator who will work with DHS to ensure that Section 504 requirements are met Name Title Leisure Services Manager 2 Has the organization established grievance procedures that Incorporate appropriate due process standards? © Yes ❑ No If yes, do these procedures provide for the prompt and equitable resolution of complaints that allege an action prohibited by Section 504 of the Rehabilitation Act of 1973? © Yes ❑ No 3 Has the contracting organization Informed the public of the right to file a complaint and of the filing procedure? © Yes ❑ No If yes, briefly describe how the public was informed 'There are posters and flvers Posted throuqhout the City of Denton wnicn acKnowledges the Citv's compliance with the guidelins set by the EEOC, ADA, and the Civil Rights Act. These posters give instructions for filing a complaint D Has the organizaton taken steps to notify employees, participants, and applicants that the organization does not discriminate on the basis of disability? ® Yes ❑ No If yes, do the people notified Include those with Impaired vision or hearing and members of unions or professional organizations holding collective bargaining or professional agreements with the contracting organization? ® Yes ❑ No If yes, briefly describe how they are notified The visually or hearing impaired are notified thrnnah_radio and television advertisement. Also flvers, announcements, etc. are mailed E Do all organization forms, publications, and recruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the organizationdoes not discriminate on the basis of disability? ❑ Yes ❑ No If no, indicate steps being taken to comply with this requirement F Does the organization have a procedure to ensure that the remedial or corrective action has been or will be taken If noncompliance with non discriminaiton requirements is found by DHS. USDA, or the contracting organization itself? ® Yes ❑ No If yes, explain If not handled within the denartme nt -n question, the City generally cha nels all complaints through the Legal Department. PUBLIC SERVICE ANNOUNCEMENT FOR NON -ENROLLED SITE The Denton Parks and Recreation Department announces the sponsorship of the 1996 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-106, Texas Department of Human Services, P 0 Box 149030, Austm, 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 Dates Sites May 28-Aug 9 Civic Center Park May 28-Aug 9 Dema Park May 28-Aug 9 MLK Rec Center May 28-Aug 9 Owsley Neighborhood May 28-Aug 9 Phoenix Park May 28-Aug 9 TWU Playhouse Program May 28-Aug 9 Village East Apartments Addres Time 321 E McKinney 12pm-lpm 1001 Parvin 12pm-ipm 1300 Wilson 12pm-ipm Stella St 12pm-lpm 308 S Ruddell 12pm-Ipm Mary Hufford Court 12pm-lpm 1700 Village East 12pm-lpm 4.1 o PUBLIC ERVI E ANNOUNCEMENT FOR THE ENROLLED SITE The Denton Parks and Recreation Department announces the sponsorship of the 1996 Summer Food ServiceProgram Income Ehgibihty wdl 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 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-106, Texas Department of Human Services, P 0 Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington, D C 20250 Note Discnmination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services Dates Sites June 3-28 Houston Elementary June 3-28 Rayzor Elementary Address 3100 Teasley Lane 1400 Malone Time 11 45am-12 45pm 11 30am-12 30pm 4I ***NOTICE*** The 1996 Summer Food Service Program is sponsored by the City of Denton, Parks and Recreation Department, and is offered through a federal grant which requires that sponsors apply each year to retain eligibility to offer the program. It is therefore, our declaration that the SFSP will be offered this summer, from May 28th through August 9th, strictly as a PILOT PROGRAM, and that the City of Denton PARR, is in no way directly liable or responsible for the continuance of the program in the future. BUMMER FOOD SERVICE PROGRAM BUDGET 1990 Personnel Staff Rsts Hour Tad Amkdeaathre 9024-Btpervlea 1 $12 91 98 41 208 18 9028-CoarGnala 1 40 10 300 41 84800 Owed" Admin $311318 9028.8Re Leaders 9 t6 00 75 t3 379 00 9028•Van Driver 1 4500 170 $850 00 Operat t4 225 00 Wei FICA AdmWWa0vo 0078E Adnin $23810 Opersllanal Operst 432321 0064-WORK COMP Ay 6dotrative 00234 Adnin $72 86 Opera0onal Operal $98 97 8101-018ae Supples 8000 Tan1 49 071 20 hWoaOensar $200 00 8112 Reaeatlon Supp9ee Mfsawaneae 11 600 00 8100 TRAY $1,700 00 8602-Spear Sarvlcss Food Avg Defy DM Pries Lunchw 326 83 41 66 $20 098 75 Mab9e Phons $300 00 Tranepartatlen Van Rental t2 500 00 Ml~ M9ee Dep Rate 30 63 028 i446 20 8500 Tent $29 943 86 **Difference of $1.85 is due to rounding Budget Tabd * 718 21 -a rl } � I Iµl � I, "- �ct 0 a� SUMMER FOOD SERVICE PROGRAM APPROVAL DOCUMENTS 'g`�//�A� i' a§ f9..2�'° Hnd 4 L 3, a4e,. ttt pL`yy,yp s nay aa.ao ba g8Y yy<,''''.<�#+ ° gC.'VTF.. 3 �s�a SFSP Agreement 1 Retain for your agencies SFSP files 1506 Application for Participation, A, B, 1 Retain for your agencies SFSP files &C 1507 Site Information 1 Retain for your agencies SFSP files PROGRAM OPERATIONS FORMS Al <y`y o$>y¢°y�'QVt]Y�y^:yNd b> gtr� 16 rW c(°:y$°„}Q nj�`rxa ,t,./ary u`N��p8 tSt `tp�LL . �i�r �>°d`�� Claim for Reimbursement °`y o°b AY�III��l.b '4 �^3�5'�i'! 1513 4 Submit completed claims to Financial Services, Y-906 1514 Claim for Reimbursement 4 Complete for each claim submitted Worksheet Retain on file 1557 Monitoring Site Review (Vended 3 Complete one form per site Sponsor Programs) maintains forms for review by TDHS and USDA 1558 Monitoring Site (On -Site 3 Complete one form per site Sponsor Preparation) maintains form for review by TDHS and USDA 1566 Monitoring Program 3 Completion required Sponsor maintains form for review by TDHS and USDA 1568 Record of Recycled Food 3 Completion required Sponsor maintains forms for review by TDHS and USDA 1601 Beneficiary Ethnicity Data 3 Completion required Completed form maintained by sponsor Crvd Right Posters "And Justice 1 poster of Required posting of all 3 posters at for All", Liberty Bell - English, each per site each site Liberty Bell - Spanish Weekly Call -In Report, 16 Completion required Worksheet Follow enclosed instructions Submit or make verbal report to Financial Services Budget Amendment 3 Submit to contract manager prior to significant changes inbudgeted cost 1.1 q SUMMER FOOD SERVICE PROGRAM APPROVAL DOCUMENTS Page Two ADDITIONAL FORMS FOR FNRAI I Fn artnr.RAsec niuu v ` NK to J i ):.� p�. igk'3`:.yt <.V Yy aoS4di� >ou4 <i oiy�, b<i`R <� ti y •` b " Y''Y` b n P V JY 1�Y{ g�W�J✓< bi k t n G 4 �^x 's J �o/ '�<�j� G kjS�iy#Y.o �Y S ��`d�C tl §o }b'i�gJRff3�3S�fb^Rx �N� Y 'i > S y?�b"� k.§�' y{` xn$ESu JES BJS' �^.TI . ��Fl�M ITj'TJj Y%RiT�xn$�� 1513 Claim for Reimbursement for Camp 4 Submit completed claims to Financial Attach- Enrollment Report Services, Y-906 (Required form for ment A Camp Enrollment only ) 1531 Child Nutrition Program Application 2 Retain for use (Enrolled Programs Only ) 1625 Letter to Parents (Charge 2 Retain for use (Enrolled Programs Separately) Only 1 1625-A Income Standards for Determining 2 Retain for use (Enrolled Programs Child Nutrition Program Eligibility 1626 Letter to Parents 2 -.Only Retain for use (Enrolled Programs Only 1 L4504 Standards for Determining Free 2 Retain for use (Enrolled Programs Reduced -Price Eligibility (for Only 1 Facilit Use) PROGRAM REFERENCE DOCUMENTS $o,T0'"7 >S'y'yfhSYar Pk-Y(.Rkk .ijYvbYRUMo�, 1rJ ZL o Pr° }> Sio�4xy' Div N II BE k ob �o 'iib �� �`y'�.ijY�r(S�21 5 SIR' > 4 oa .iZ <o��`y�YL ���hY Y T�M�7MR Y � IR' f Contract Appeals, Fair Hearing, Fraud, and Civil Rights 1 Reference Information regarding procedures for Contract Appeals Policy Alert SFSP 96-3 Single Audit Documentation 1 Reference for your Information and use and Compliance Requirement Policy Alert SFSP 96-4 SFSP Reimbursement 1 Reference for your information and use