1997-100AN ORDINANCE OF THE CITY OF DENTON, TEXAS, AUTHORIZING THE CITY
MANAGER TO EXECUTE A CONTRACT WITH THE DENTON INDEPENDENT SCHOOL
DISTRICT ANDALLADDITIONAL DOCUMENTS AND AGREEMENTS, AS REQUIRED,
TO OBTAIN FUNDING FOR THE 1997 SUMMER FOOD SERVICE PROGRAM,
AUTHORIZING THE EXPENDITURE OF FUNDS TO ADMINISTER THE PROGRAM, AND
PROVIDING AN EFFECTIVE DATE
WHEREAS, the City of Denton, Texas will submit an applIcation
for funding under the National School Lunch Act, to the Texas De-
partment of Human Services for the purpose of making meals ava~l-
able to eligible children at the C~ty's Summer Action Site pro-
grams; and
WHEREAS, pursuant to the grant, if received, the City w~ll con-
tract with the Denton Independent School District to provide the
meals at the various sites, NOW, THEREFORE,
THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS
SECTION I, That the City Manager is hereby authorized to
execute, on behalf of the City, an application for funding under
the National School Lunch Act, and if funded, the Summer Food Ser-
vice Program Agreement w~th the Texas Department of Human ServIces,
a copy of which IS attached hereto and incorporated by reference
here~n, along with any other documents and certificates necessary
to obtain such funding
SECTION II That the City Manager ~s hereby authorized to
execute a contract w~th the Denton Independent School D~strlct,
substantially in the form of the contract which is attached to and
made a part of th~s ordinance for all purposes, to provide meals
for eligible lndlv~duals at the various sites, and such other
documents and certifications as are necessary to carry out the 1997
Food Service Program, and to handle all fiscal and administrative
matters relating to the application and the program
SECTION III That the expenditure of funds necessary to
administer the 1997 Summer Food Service Program is hereby
authorized
SECTION IV That this ordinance shall become effective immed-
iately upon ~ts passage and approval
this the /~ day of ~~__, 1997
PASSED AND
APPROVED
ATTEST
JENNIFER WALTERS, CITY SECRETARY
APP~'OVED AS TO LEGAL FORM
HERBERT L PROUTY, CITY ATTORNEY
Page 2
AGREEMENT TO FURNISH FOOD SERVICE
CITY OF DENTON
and
DENTON INDEPENDENT SCHOOL DISTRICT
FOOD SERVICES
TI-HS AGREEMENT Is made and entered into by and between the Denton Independent School
D~stn~ and the ~ Denton Independent School D~stnct agrees to supply umt~zed
meals reclusive of milk and juice to the C~ty_ of Denton Parks and Recrentmn Department_ at the
MLK Recreation Center, Phoemx Park, Demo Park, Civic Center Park, Owsley Neighborhood,
TWU Playhouse Program, Vdlage East Apartments, Borman Elementary Summer School, and
C~nmngs Elementary Summer School, vath and for the rates harem hsted
Breakfasts $0.00 each Lunches $1.55 each
Snacks $0.00 each Supper $0.00 each
It is further agreed that the Denton Ind .e~endent School I~stnct, pursuant to the provisions of the
Summer Food Service Program Regulatmns, a copy ofwhtch is attached as Exlubit "A" and Is
part oftlus agreement, wdl assure that smd meals meet the mimmum reqmrements u to nutnUve
value and content as outhned m the U S D A's Sponsor Meal Preparation Handbook, and vail
maintain full and accurate recordings of such, including the following
1 Menu Records, mcludmg amount of food prepared
2 Meals, including dmly number of meals dehvered by type
These records must be repolted to the restitution promptly at the end of each month Denton
Independent School District a~rees also to retain records requtred under the preceding clause for
a period of three years and 90 days after the end of the contract per~od ffaudlts, claims or
litigation have not been resolved, all records must be retained beyond the required time period
until all issues are resolved in accordance w~th the Summer Food Serwce Program Agreement
between .Tu~sil.~i/l~a and the Texas Department of Human Services
The Denton Independent School District agrees to comply w~th the requirements of the
Inmugration Reform Control Act of 1986 regarding employment verification and retention of
verification forms for any mdtvtduals lured after November 6, 1986 who w~ll perform labor or
sconces under tlus contract
The Denton Independent School District agrees to allow for purposes of audit, exarmnatlon,
excerpt, and transcnpUon, the USDA, the Comptroller of the Umted States, D S and any of their
authorized representatives to have access to any other contractor's books, documents, papers, and
records that are pertinent to the contract
The Denton Independent School Dismct agrees to comply with the required mandatory standards
and policies concermng energy efficiency contmned in the Texas Energy Conservation Plan issued
in comphance w~th the Energy Pohcy and Conservation Act (P L 94-163)
The Denton Independent School District agrees that except for small purchase contracts, it w~ll
comply wath and enforc~ prowsions that allow for adnumstrative, contractual, or legal remedies if
contractors wolate or breach contract terms, and any appropriate sanctions and penalties
The Denton lnde_oendent School D~nct agrees to be m comphance w~th 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 tlus Act, contractors must compute
the wages of mechmucs and laborers on the basis ora standard work day of eight hours and a
standard work week of 40 hours Work that exceeds the standards must be compensated at least
1½ tunes the bastc pay rate for overtune hours worked These requffements do not apply to the
purchase of supphes or matermls ordmartly avadable on the open market or contracts for
transportatton
The Denton Inde_oendent School D~stnct agrees to comply w~th Executive Order 11246 entitled
"Equal Employment Opportumty" as amended by Executive Order 11375 and as supplemented m
Department of Labor regulations (41 CFR, Part 60)
The Denton Independent School D~stnct agrees to comply w~th all other apphcable laws,
mcludmg w~thout hrmtatton, any additional apphcable Federal Laws or regulations contained m
the Summer Food Pro_sram A_ureement between the .C~ and the .T.~Aj~li:~,RL~
If the Denton Inde.nendent School District fads to provide serwces m accordance w~th the
proxqs~ons oftlus contract, the C~ty of Denton may, upon written not,ce of default to the
contractor, tmmed~ately terminate the whole or any part oftlus contract
The ~ agrees to pay Denton Independent School Dtstnct for all meals ordered on a
dmly basts at the rate a~reed upon tn th~s contract
The agreement shall be effective as of ~l.V..2,~.,_l~ It may be terminated by nottce mwnttng
g~ven by any party hereto to the other parttes at least 30 days pnor to the date of ternunatton
IN WITNESS WHEREOF, the part~es hereto have executed th~s agreement as of the dates
xnd~cated below
Agreed to tlus date ,¢/~// ~ Agreed to thls date ~/'~-/C~ ~
Sponsor Offictal .~.~/~r~c~°~-~ Sponsor ~,~
Title CI~ Mana_~er Title DISD School Board President
The locatton of the food preparation stte will be
Borman Elementary
1201 Parvtn
Denton, TX 76205
APPROVED AS TO LEGAL FORM
HERBERT L PROUTY, CITY ATTORNEY
SU~fl~IER FOOD SERVICE PROGRAM
AGREEMENT
STATE OF TEXAS
COUNTY OF TRAVIS
The Texas Department of Human Services, hereinafter reterred to as TDHS,
AND
City of Denton, Texas, A Texas Municipal Corporation
at 215 E McKinney Denton, Texas 76201
hereinafter referred to as the contractor, do hereby make and enter into thru contract, as required by
the National S~hool Lunch Act (Section 13) and the Summer Food Servtce Program, hereafter
referred to as the SFSP, Federal Regulations (7 Code of Federal Regulations [CFR], Pan 225)
MUTUAL AGREEMENTS ' ~
The Parties mutually agree ,~.
If the cOntractor falls to provide services in accordance with the provisions of this contract,
A
the De~artment~ may, upon written nO,lea of default to the contractor, immed,ately term,nate
the whole or any part of this contract and refuse to pay clamm for reimbursement Such
termmaUon and/or refusal to pay cia,ms for reimbursement shall not be excluswe remedy but
shall be in addition to any other richLY; and remedies prey,tied by law or under this contract
B If federal and state laws or other reqmrements are amended or jud,clally interpreted so that
the continued fulfillment of thru contract, on the part of enber party, ~s substantially
unreaso'nable or imposs~ble, or ,f the pames are unable to agree upon any amendment which
would therefore be needed to enable the substanual continuation of the aery,cea contemplated
by thisI contract, then the pamea shall be dmcharged fi.om any further obligattons created
under Lhe terms of this contract, except for the eqmtable settlement of the respective accrued
interest or obhgatlons, including audit findings, recurred up to the date of term,nat,on
C Thru contract may be canceled by mutual consent However. ,f such mutual consent cannot
be attal.ned, then and in that event, e,ther party to this contract may cons,der ,t to be canceled
w,thout cause by giving thirty (30) days notice m wmtmg to the other party and this contract
shall thereupon be canceled upon the expiration of such thirty (30) day per,od Nothing m
thru paragraph shall be construed to prohibit ,mmediate cancellation pursuant to above
paragraphs A and/or B
11.
CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT
The contractor wtll comply wfl. h the SFSP Federal Re~ulatloos (7 CFR, Part 225, as
amended), Umform Federal Assistance Regulatmn (7 CFR, Pa~ 3015, as anmnded), nnd state
pohcaes and procedures as issued and amended by TDHS The contr~'tor further qrse~ to
perform as descrabed m ars apphcataon (including supporting documents and approved
amendments to the applacataon) for partaclpation m the SFSP
The contractor accepts final admimstratlve and financial raspomibdlty for food service
operations at each sate sponsored by the contractor This rasponalbllity Ineludus the
petformancu of. the condit~ons, of,~lement,of-.aay audit.ue~l~tiom or paymant deficiency in
the program and the collection and repayment of any amount paid In exce~ of the proper
claim amount whsch are found after momtormg or auditing by TDHS or the United States
Department of Agrsculture (USDA) Thas responsibility applies to this contract, and all
subcontracts hereunder
The contractor will apply to TDHS for approval of changes to ~ts original application and for
praor authorazataon for field tr~ps ~f meals served on the field trips will be claimed for
reambursement 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 f~ld
trap Contractors wall notafy TDH$ wathm five (5) days of the termination of ~lln apprfi~ed
food service s~te
1II.
SFSP RECORD KI:-I;'~ING
The contractor w~ll keep financaal and supporting documents, stat~ieal records, and any other
records pertaining to the servaces for which a ciMm Is submitted The records nmi documents
wall be kept for at least three (3) years and ninety (90) days efler the t~minatlon of the
contract per~od If any Imgat~on, clanm, or audit revolving these records begins before the
stipulated time per~od expires, the contractor wdl keep the records and documents for not less
than three (3) yea~ and ninety (90) days after the tormsnation of the contr~et period and until
all Imgatson, claims or audit findings are resolved The case ts considered rusolyed when a
final order ~ ~eaued m htlgat~on or a written agreum~nt is signed by TDH$ ~d the
contractor Extensions are constdered as separat, ~ontract p~riods
The contractor and its subcontractors will allow TDH$ and USDA officials ~ other
approprsate officials detarnuned by TDH$ to impect fa~Hitlus and records and to nudat,
examine, and copy records at any reasonable rune This includes aece~ to all records of
costs paad, even in part, by TDH$
Non School Slmneors - Page 2
IV.
CIVIL RIGHTS POLICY COMPLIANCE
A The contractor agrees to comply with Title VI of ~he Civil Rights Act of 1964 (Public Law
88-352). and all requirements Imposed by the regulations of the Department of Agriculture (7
CFR, Pros 15, 1Sa 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 Rchabilltation Act of 1973 (Public Law 93-112). The Americans with Dl~abilities Act
of 1990 (Pubhc Law 101-336), and all amendments to each, nnd all requirements imposed by
the regulations issued pursuant to these acts In addition, the contractor agre~ to comply
with Title 40, Chapter 73, of the Texas Admunstrauve. Code These provide tn pm that no
persons m the Untied States shall, on the grounds of race, color, national origin, sex. age.
dlsabdtty, political beliefs or religion be excluded from participation In, or denied, any aid,
care, service or other benefits prowded by federal and/or state funding, or otherwise be
subJeCted to dlgcrm~manon under any program or actsvlty for which the contractor reCelvas
federal~ financml assistance from TDHS and USDA and hereby gives assurance that it will
immed!ately 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 con~identiality guidelines regarding AIDS and
C This assurance ts given In consideration of and for the purpose of obtaining any and all
federal, financial assistance, grants and loans of federal fund, remthursable expenditures, grant
or donation of federal property or Interest m such property, the detail of federal personnel,
the sale and lease of, and the permission to use, federal property or Interest m such property
or the furnishing of services without consideration or st s Item;nat consideration, or at a
consideration which Is reduced for the purpose of assisting the reCipient, or tn recognition of
the public Interest to be served by such sale, lease or furntshmg of services to the recipient,
or any improvements made with federal financial ass~staece extended to the contractor by
TDHS This ~ncludes 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 eqmpmant or any other financial assistance extended in rehance
on the 'representation and agreements made irt this assurance
D This aSSurance ts binding on the contractor, its succesanra, transferees, and assignees as long
as it receives assistance or retains possession of any assistance f~om TDHS or USDA
person whose signature appears on this contract* Is authorized to make this assurance on beh~Tf
of the contractor
TDH$ CLAIMS PAYlVlEMr ~ -- ~-
TDHS will, subjeCt to the federal appropriation and availability m TDHS of suffic~ant 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 begmn;ng
effeCtive date of this contract or Co) a later date established by TDH$ based on the date of receipt of a
fully exeCuted copy of this contract
Non School Sponsors Page
Vl.
CERTIFICATIONS
A Immigration Reform and Control Act of 1956 - The contractor agrees to comply with the
reqmrements of the Immtgratlon Reform and Control Act of 19~6 ~'egardin~ ea~ployment
verification and rctent~on of verification forms for any individuals Illted nt~ar November 6,
1986, who will perform any labor or services under this contract
B Regardtng Debarment, Suspension, Ineligibility, or Voluntardy Exclusion For Covered
Contracts - The contractor centfies, by execuuon of this agreement, that neither it nor its
prmctpals ts presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntardy excluded from perttctpatmg m thts contract by any federal deperlment or agency
or by the State of Texas By making this certification the contractor a~'eea to the following
terms
I The above certtficatton ts a material repteaentatton of fact upon which reliance was placed
when this contract wes entered into If it ts later determined that the contractor knowingly
rendered an erroneous cert~ficatton, tn addmon to other remedies avadable to the federal
government, the Department of Health and Human Servtces, Umted States Departmant of
Agriculture or other federal department or agency, or the Texas Department of Human
Serv,ces may pursue available remedies, mcludmg suspension and/or debarment
2 The contractor shall provtde immediate written nottca to the person to whzch thts
centficatton ~s submitted tf at any time the contractor learns that the cectlficat~on was
erroneous when submttted or bes become erroneous by reason of chenged ClfcllmatallCe$
3 The words 'covered contract," 'debarred," 'suspended," 'ineligible,' 'pantclpent,"
"person," 'pnnc~pal," 'proposal,' and "voluntardy excluded,' as used in this certificatton
have meamngs based upon materials ~n the Defimtlons and Coverage sections of fedaral rules
~mplementmg Executtve Order 12549 Usage is as defined m the attachment.
4 The contractor agrees by submtttJng th~s cenlfication that, should the proposed coveted
contract be entered into, It shall not knowingly enter into any subcontract with a person who
ts debarred, suspended, declared mehgtble, or voluntarily excluded from pertlctpatton m th~s
covered tran~actton, unless authortzed by the Depertmant of Health and Human Services,
Umted States Department of Agriculture or other federal depenment or agency, and/or the
Texes Department of Human Servtces, es applicable
5 The contractor further agrees by submtttmg this certlficatton that tt will include TDHS
Form 2046 titled "Certification Regarding Debarment, Suspemton, Ineligibility, and
Voluntar~ Excluston for Covered Contracts' wsthout modification, in all coveted subcontracts
and tn sohcttatlons for all covered subcontracts
6 A contractor may rely upon a cerflficatton of a subcontractor that is not debarred,
suspended, mehgtble, or volunterdy excluded from the covered contract, unless It knows
the certification ts erroneous A contractor must, at a minimum, obtain ce~tiflcatl~l&fTom~lls
covered subcontractors upon each subconttact's Initiation and upon each renewal
Non School Sponsors Page 4
VI
CERTIFICATIONS
(continued)
7 Noth,ng conta,ned m ail the forego,ag shall be construed to requ,re estabhshment of a
system of records ,n order to render ,n good fa,th the ceruficatlon reqmred by this
caruflcatmn document The knowledge and mformauon of a contractor ,s not reqmred m
exceed that wh,ch ~s normally possessed by a prudent person tn the ordinary course of
busmess dealings
8 Except for contracts author,zed under paragraph 4 of these terms. ,f a contractor m a
covered contract know,ngly enters mtoa covered subcontract w,th a person who la suspended,
debarred, mel,g,ble, or voluntar,ly excluded from pamclpatton ,n th,s transactton, ,n add,t,on
to other remedies ava,lable m the federal government, Department of Health and Human
Serv,ces, Umted States Department of Agriculture. or other federal department or agency, as
apphcable, and/or the Texas Department of Human Services may pursue avadable remed,es.
,nctud,ng suspensmn and/or debarment
Regard,ne Federal Lobbying - Th,s curt,float,on appl,es only to th,s contract and ~s a mater,al
representat,on of fact upon which rehance was placed when th,s transacuon was made or
entered mto Subm,ss~on of this cert~ficat,on ,s a prerequisite for makmg or enter,ne into
transaction ~mposed by section 1352, t,tle 31, U $ Code Any person who fails
requ,red cemficat,on shall be subject to a clvd penalty of not less than $10.000 and apt mor~
than $'100,000 for each such t'adure
The contractor curt,ties, to the best ofh,s or her knowledge and behef, that
I No federally appropr,ated funds have been paid or wdl be pa~d. by or on beh;[f of
unders,gned, to any person for mfluenc,ng or attempting to ,nfluence 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 m connect{on w,th the award,ng of any federal contract, the makmg
of any federal grant, the maLmg of any federal loan. the enter,ag ,nfo of any ~.ooperatlve
agreement, or the extens,on, contmuatmn, renewal, amendment, or mod~ficat,on of any
federal contract, grant, loan, or cooperat,ve agreement
2 If any funds other than federally appropr,ated funds have been pa,d or wall be prod to any
person for Influencmg or attemptmg to ,nfluence an officer employee of any agency, a
member oi' congress, an officer or employee of Congress, or an employee of a member of
Congress ,n connect,on w,th this federally funded contract, subcontract, subgrant, or
cooperative agreement, the unders,gned shall complete and submit Standard Form-LLL,
'Disclosure Form to Report Lobbymg," m accordance w,th its instructsons
3 The contractor shall teqmre that the language of th,s cert,ficatlon be ,ncluded in the~award
documents for all covered subawards at all t,urs 0ncludmg subcontracts, subgrams, and
contra~cts under grants, loans, and cooperat,ve agreements) and that all covered subrec,p,ems
shall dert,f7 and d~sclose accordmgly
The contractor certifies that nil Informat,on submitted pursuant to th,s agreement Is true and corr~t
The contractor understands that the deliberate m~srepresentat,on or w,thhold,ng of reformation ,s a
vlolat,on of th~a contract and may result m prosecution under applicable state and federal statutes
VH
EFFECTIVE DATE AND SIGNATURF~
For the faithful performance of the terms of this contract, the parties hereto m their capacmes stated,
affix their slgnature~ and bind themselve.~
City of Denton
Name of the Contracting OrganL'~auon
(please Print or Type)
Original signature of the authorized repreaentatwe
of the contracting otgan~zation
Ted Benavides
Name of the authorteed representative of the
contracting organ~atlon (Please Print or Type)
City Manager
Title
Please print or type, ~n the spaces provided above, the name and tale of the authortzed representative
stgmng thru agreement on behalf of the conuactmg organ~.atlon
TEXAS DEPARTMENT H
Effut~ve Datu ~ ~gh
Rews~ F~m~ 1994
Non School Sp~msom Page 6
CERTIFICATE OF AUTHORITY
Thio Is to sanity that
~ ~ AbU,~,...-J Off~m ~.~.. ~ o~ t~m) T~ity__
Ted Benavtdes Manager
Name si
C:Lt¥ o~ Denton
AOO~ (St~em ¢~ ~ ZTP)
321 E McKinney Denton, TX 76201
The repres4mtatlvs designated above ia authorized off beheff of the oontmctiflg organization to make written agree-
monts with the Texas Ooportmont of Human Sol~loo8 to op4.ats a food program, to sign documents or reports about
the mgroement, and to proooflt etsima for ~oimIoureomont, whon 8ppropflmto, to tho deportment
I
Ted Benavides City Manaser
FOR DEPARTMENT OF HUMAN SERVICE~ U~E ONLY
CERTIFICATE OF AUTHORITY
Thio Ii to certify that
Nicole Fletcher Children's Programs Supervisor
lo deeigrmtod Is the lUthodzod repre~ntmlve of
Nlfltl of C, orttrsctJfl0
City of Denton
321 E McKinney Denton, TX 76201
The mprelefltltlve dellgnltod IbOVe Jl lulhadzod on ~half of the ~ntm~lng orpn~tlon to mike w~efl ig~
~ with t~ Texn ~nt of Hu~n bm~e8 m ~te. f~ ~, to ligfl d~umen~ or m~ o~ut
t~ ~meflt, s~ to prmflt c~ f~ ~Im~mflt, w~n ~p~e, to ~ ~flment
N~ ~ ~ (~ ~ ~ ~t)
Ted Senavides ~ity Manager J
FOR DEPARTMENT OF HUMAN SERVICES USE ONLY:
CERTIFICATE OF AUTHORITY
Thle I~ lo r, erllfy tl~t
~ ~ ~ 0~ ~ ~ ~ ~1) T~ummerS Food Coordinator Il
Paul Tucker
~ ~t~ ~ t~ ~o~ mp~n~e of
T~ NpreN~atlve d~ign~ I~ve b ~ on ~ff of t~ ~m~lng or~n~tion to make w~en
mn~ with t~ Texas h~ment of Huron h~s to ~mte a f~ ~, to ~gn ~uments or m~
t~ ~mment, ~ to preNnt =~m lot mlmbummnt, w~n ~p~e, ~ t~ de~ment
~ ~ ~ ~ ~ ~ ~.t) C ~ity
Ted Benavides Manager
FOR DEPARTMENT O1~ HUMAN SERVICE8 USE ONLY'
SUMMER FOOD SERVICE PROGRAM ~o~ DHS ~rAFF ONLy
APPLICATION FOR PARTICIPATION
NO~ Give as much Jnio~flon ~ po~lble A~ch additional ~h~ ~ ~. ~B~ ~Supp ~Lu~h
please identi~ each a~chment wl~ ~e name of
SECTION ~SPONSOR INFORMA~ON
C~tv of Denton 17560005146015 ( 817 ) 566-8125 (817) 566-8125
Ma,h~ ~ (S~t ~ P O ~ ~ ~m ~
321 E McK~nne~ Denton, TX 76201
...N~cole Fletcher Proframs Supervisor
A Con~a~or Clasmfl~on (Ch~ all ~at app.)
~ Resldential~onmsldentlal
~ Nabonal Youth Spo~ Program ~ Summer ~mp ~ ~ ~t~ ~ ~ dir~ W ~ ~a~
~ ~nflnuoua ~le~ar
~ ~h~l F~ A~hofl~ ~ ~1 Year ~ Pfl~ ~m~
B Is your program a year-round pr~r~?
No
C Type of Con~a~or
-
Public Entl~ (exXon)
Is ~r ag~ ~nslder~ to ~ =re ~? ~:~ ~Ye_~.~ No
~ you de~,t your pr~r~ r.m~ent dirty into ~ ~e T.~u~ ~N[A~Ye~
No
~ you de~s,t your ~ r~m~m rolo a I~ ~ ~ N/A ~Y., ~ No
~ yes, is ~t d~ de.it? ~Yes ~ No
~ Private Nonprofit O~ani~tlo~T~xempt s~s ~blis~ ~ le~ d de~ 0~ ~1 ~ ~ ~pt s~ ~ IRS
you,
If yes, ~ it dlr~ de~t? ~Ye~
· e Summer F~d Se~i~ Progr~ (SFSP)? .. ~Yes ~ NO
If no, wh~ of ~e following ~r~ms~s applies?
~ Se.es Migrant Children ~ Failure to
E1
2 ~es ~e organiza~on re~e ~e ~ $25,~ but le~ ~ $1~,~ in lede~ funds yea~? ~Yes ~No
3 A~a~ a ~py of ~e audit ~vedng ~t ye~s pr~ram
~ndu~ed, ln~uding ~e date ~will ~ ~ndu~ed
~ 1506
SECTION II-BUDGET
A Esbmate all SFSP costs which w~ll be dmmed for reimbursement for th pro~lram ~ear'
. , E~TIMATED OPERAllONAL CO$'r~ CO~T~ E~I~IA3~D ADIalNI~31~A1WE ~
Program Labor 6,273 ,,{Management, Monitor, Cisrk3a0 3,066
Fringe Benefits 627 Fringe Beneflt~ 307
Fo(~d 30,256 Rental o~ Office Spane
Non-food Supplies 500 UtiliZes
Ubhbee Office Suppl~ 200
Rent Office Building Ma/ntonance
Eqmpment Use Fee Equipment Use Fee
Rental of Equipment 2,000 Audit Fees
lrans~rtabon 2 8 2 O0 ~ F~s
TranslXXtatfun ¢
~ob~le ?hone 300
TOTAL 1 39,856 TOTAL 2: 3,873
B Indicate projected income to the food serV, ce from all sources olt~r than SFSP mimbumement Identify exactly the costs this income
cover (Do not Include state or federal funds )
SECTION Ill-MANAGEMENT PLAN ~- -
cooks, Janitors or other personnel revolved in o~-s~ts food smvice )
Director [ Conducts training session, monitors sites,
preDares reports, coordinates food serC~T~ces
Coordinator ! Ass:[.s~:s Direct:or with dut:ie~ ~, ,
Are children charged separately for meals? [~]Yee ~'~No
If yes, see Form 1508, Attachment B
C Do you want to receive advance payments? ['-]Yes E~No
lfyes 1 For Operat~onal Costs? r']Yes ['-~No
2 ForAdmlnmtrathre Costs? [--]Yea n-lNo
D If meaJ service m self-preparation, do you want to receive commodities? [] Yea [] No
If yes, Form 1608, ApplicaUo~ and Agreement for Commod~ias, must be completed
SECTION IV--PROGRAM OPERATION
A. 1 SegmnmgandEndingDatasofMsoJSewice From, Hay 27. 1997
through, August 8. 1997
2 Number of s~tes 10
B List dates and toptcs of SFSP traJn;n,~
5/23/97 Site supervisor and monitor training on S F S P guidelines
and Civil Rights training
C Is the organizatmn plarlnlng to contract wlfh a food service management company
for the preparatmn of unitized meals? ->.. :~ ~-~ o
~J~- C~y.~[] No
If yes, and the contract will exceed $10,000, attach a copy of Ih~ Invitation to bid Also ~llve , r~ == ~-,a..
I OY'- r-l.o '"-
Also,=~?_ch a copy of an 11-day-cycle menu ~ndudmg all specific menus to be used
D Is the organization contracting w~h a year-round food service management company? .~ ,' ~ Yee [] No
If yes, submit a copy of:your procurement procedures, bid, contract, and all amendment~
E Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department nobfymg~-th, em o! ~.~t~lnt to op~te a
Fond Service Program at the s~te(s) indicated on the attached Stte Information sheet (Form 1507) L~J- ,'~ o
SECTION V-ASSURANCES
A Free MeN Policy Statement
1 The contracting organization assures the Texas Department of Human Services (DHS) that all children at the mtos desc.flbed on the
S~to(s) Information Sheets for the Summer Food Service Program, will be offered the same meals w~th no physical segregation of, or other
dmoriminatlon against, any child because of race, color, disability, age, sex, national ongln, religion, or poht~cal behefs No separate cha~ge
w~ll be made for any meal except in accordance with attachment B of th~s appl~cation
2 The contracting organization assures DHS that, if it is sponsoring camps or other enrollment programs
· The contra~ng organization has or will obtain family size and income data about all children whose meals w~ll be reported as h'ee or
reduced-price, and
· The children ctalmed as free or reduced price meet the CU~Tant fatmly size and income standards set by the United States Department
Agriculture, DHS Form 4504, ~tandard$ for Determining Free and Reduced. Price Eligibility
Fern 154)6
3 If t~e contracting oq]anlzation m s~nng a ~mp ~ o~er enmll~nt pr~mm ~at ~ges sepam~N for meals ~e ~n~ng
~aniza~n has read A~ment B ~ ~is ~ph~fl~. 'Add~on~ ~an~s for ~ps ~d ~er Enrollment Pr~rams ~at Ch~e
Sep~ate~ f~ Meals" ~d ~res DHS ~at ~1 r~u~m~n~ ha~ ~n
B Public Rele~e
1 ~ ~n~ng ~an=aaon ~11 ~e effo~
will supp~ ~em wi~ a ne~ mle~e
ff ~e ~n~ng ~n ~ s~dng a ~mp ~ o~er ~l~nt ~. ~ m~e must ~n~in, at a mimmum, a ~st ~ a~l
~pro~d s~s, a I~t ~ ~e ~nt ~nd=ds ~r dete~;ning ~ ~d ~ p~ el~ibd~, ~d ~e f~l~ng ~tement
C~tv of Denton
~e ~m~~) an~u~ ~ ~mhlp of ~e Summer F~ Semite Pr~mm
In.me ellglbll~ will ~ ~ ~ ~ml~ 81~ a~ In~m ~lng ~e S~l ~r ~te~lnl~ F~ a~ R~uc~-P~e
EIIglblll~, pmvld~ by ~ UnE~ S~tes ~e~ of AgH=u~m Meals will
eligible ~ ~dlcl~te In ~e pr~mm must not ~ dl~dml~d against ~u~ of m~, ~lor, national origin, se~ age,
dl~blll~, religion, or ~llfl~l ~llef Anyo~ who ~llev. ~t ~y ~ve ~n dl~Hml~ ~l~t should wdte Imm~
~ Dl~or, Civil Rlgh~ DIvision, MC W-I~, Tex~ ~ent of Human ~w~, P O Box 1~, Austin, Tex~ ~71~
er ~ S~m~W of Ag~u~m, W~hlngton, D C
must ~ mfe~ ~/y ~ ~ DiOr, Civil Rlgh~ Dbls~n, Te~ ~ent ~ Huron ~w~"
F~ ~1 o~r p~ ~e ~n~N mu~ ~nam, at a ~nimum, a ~ of al ~ s~ ~d ~ f~ sate~n~
C~7 of
~e W~~W~) announces ~e s~n~rshlp of the Summer F~ Sewlce Pr~ram M~
will ~ provided at the site(a) listed People who are eligible ~ ~clpate In ~e pr~mm must ~1 ~ discriminated against
~cause of mee, ~lor, natlo~l origin, .x, age, dl~bll~, mllg~n,
dl~Hmlnat~ agal~t s~uld write Imm~ly ~ Dl~or, Civil Rlgh~ DIv~ion, MC W-I~, Te~s De~ent of Huron
~w~es, P O. Box 14~, Ausan, Te~ ~71~ or ~e ~m~W of Agriculture, Washington, D C 2~0 NO~
Dl~Hml~flon ~mplaln~ ~s~ on religion or ~llfl~l ~11~ must ~ mfe~ ~/y ~ ~e Dl~or, Civil Rlgh~ Division, Te~
De~ment of Human ~wl~s"
~is pubhc release ~ or mil ~ published In
~ME ~ M~ O~ DA~ ~ REdE ~ ~ M~ ~ DA~ OF RE~
Denton Record Chronicle 5/1/97 T~ Student Paper 5/1/97
Dallas Morning News 5/1/97 ~TU Radio 5/1/97
UNT Daily 5/1/~7
3 A~ a m~ of ~e ~n~ng ~Uon's ~ic
publidze ~e p~'s av~l~ ~ ~~ ~u~
SEC~ON V~ CER~FICA~ON (~ Fo~ 1~. A~ch~nt
I ~ml~ tha~ ~e Info~atl?n on ~l= appll~tlon
cm~m~ only mr app~v~ meala ~w~ ~ eligible chlMmn duH~
deli~mte mismpmsen~tlon or wl~holdl~ of Info~a~ my ~E In p~l~ under appll~ble a~ and f~eml s~tutes
~cole ~letche~ Ch~id~en's P~og~ams
FOR DHS USE ONLY
APPRO~D DENIED ~ denl~,
date Fo~ 1~8 sent
Human S~n~ces SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FO~ DH~ USE ONLY
SITE INFORMATION TX
Owsley Park (8~7) ~-8125
Stalla Street Denton~ TX 76201
~ M ~ M F~ ~ (~ ~y~)
A~ACH A MAP WffH THE S~ SER~CE AR~ IDE~FIED
~ R~ ~mp S~ ~1~ P~maHly Migrant C~m ~t Sl~
~n~l ~mp Sfle ~wl~ Pflmafl~ ~m~
~ B (~ o~ to ~r. m~) ~ D (~wlng o~ ~ ~r. ~)
2 b~ A~ ~unhes se~ ~ ~ 8~e Denton
3 A Isyourmteo~n ~Y~ ~No
B isyours~te enrolled? ~Y~ ~o
C S,te Ellg~bdi~ Enter ~e ~nm~ ~ ~r~ ehgt~ f~ fr~ ~ r~u~ ~ ~s f~ ~ ~ (SFSP H~ C~ Il) 19 %
D ff o~n sites, submit d~u~n~ suppling ~is ~rmn~ figure (s~ ~ m~ date,
hst ~e s~ls u~d ~ d~nt ~e ellglbili~ ~ f~ u~d by ~1 disL ~ es~l~ ~n~ of f~ & r~ pdm ~ddren
Census da~a ~=o~
E For enroll~ sltes~ Fo~ 1~1 ~11 ~ ~ ~ d~nt e~l~ ~ad~ Y~ S~ ~r~efer ~ SFSP Hand~, C~ter 2 )
Il ~e enroll~ see u~ ~ ~, I~ ~ ~ ~ ~ ~nt ~ ~
F What is ~e ~r~ntage of ~ ~ ~u~pH~ ~Ns ~ ~ ~e? [00 %
4 D~ the s.e paid.pate In pm~us y~' SFSP? (SFSP ~, Ch~ter II) ~;~. Ye~ ~ No
If Yes, g~ve name or ~nW~ o~ City of Denton . -~ '
6 Monttonng Plan (SFSP Ha~k, C~p~r Iff) Enter date ~ ~to~ng ~ ~ ~ ~ ~n
5/30/97 6/20/97 7/25/97
~ Meal Se~ Period Inlo~ab~ SFSP H~d~ Ch~ter II)
Breaker
~M Supplement ,
~n~ 70 [2 00 o.m. [.00
P M Supplement
Super
7 ~ you pl~ m feed ~ldren under ~ (1) year ~d? ~Yee ~ No
8 Me~od of F~ ~rep~aUon ~ Con~ng OrganlzaUon (SFSP Hand~k, Chapmr II)
~ Prep~a~ ' V~ UsI~ ~ ~ Usl~ F~ ~e M~ement
I
~ 0n S,te ~ Canal Kflc~n ~ F~ A~o~ ~ ~mpany ~. NI Yeu
9 Indicate the system to be used Iv the serving of meals and the supewiSlOn of childrefl dudflg meal service per, od (SFSP Handbook, Chapter II)
[-] Cataterin-~tyie ~ Children are Seated ~ Children LI~ Up
M~ ser~k~ I I~M m~ Given Mse~ I x~nd Pk~k Up Me~ [~]0~
10 U,~ s~e personnel who w~il be involved to any extent m ~e me~d service (SFSP Handb~m:~, Chapter II)
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 InPl,~!,* what provisions mil be made for meal service during benods of inctemant weather (SFSP Handbook, Chaplet II)
[] ~Mssl ~ Mssl se~c,
I AIWIII Be Car~elled [~] Other
12. If the rote fm~ ~m~ly h~m~einss c~ddren, what me~ m'~ used to e~,su~e ~ money, f~ ~tamps, ~ ~n.ldm:l ssP,,k:as are no~ required for
~/~
13. Are meals delivered to the ate? ['"f]Yee r"]No
· YGs, coMP,. m rmMs NO, roam ,S com,,_-'m ..XCEPT FO. AT"orroM
m'1 Site Persennd Will Contact Adminlatmtlve I"-1 Site Pe~o~nel Will Communicate [~. ~" II).~
1~ IS~ff, Who Will Conteof Vendo,' I ID ;blcffy With Veadm' ~.~'~'c .- ...*z=
15 WilldelNerybewithlnonehourofthefocxiserwceperlod?(SF Handb~Choplorll) ,.; YI?~[~]No
If no, describe arrangements w~th~n standards presonbed by local beaith authcxl'uas for delivery and hok:hng of mea~t]l time"bfservlce~
r
16 If Ifwe iS an excess of meaJ.1 dativereclo meals will be (SFSP HaJxtoor~ Chapte' Ill)
D Stored in Refrigeretor r"-1 Thrown Away ~ Returned to Vender
I CERTIFY Ihat the inlormat~on on thru form is true and correct to the best of my k~owledge I cerbfy that this site has been wsited and that it
has the cepabllAy a~d facd~bes for ~e meal service planned for the number o~ children anticipated I know that dehharate misrepresentation or
w~hold~g of lnfoj'mat~on~$uit in p~rosecubon under apphcabin state and indere] statutes
~me ~ C~ ~GG~G ~pe G~ ~v~Nieole
I
Fletcher Children's Prosrams Supervisor
H~ ~ ~ SUMMER FOOD SERVICE PR~RAM FOR CHILDREN ~ D~ ~E ~Y
S~E INFORMATION
~y Hu~o~d C,ou~ Denton, ~ 7620T
From 5/27/97 .~,h' 8/8/97 I mMrof °'.., D,.. 4 ~ 2I
A~ACH A MAP W~H THE S~ SER~CE AR~ IDE~FIED
N~n~I ~mp ~ S~ ~wl~ Pflma~ ~m~ Ch~mn
D B (.w~ ~ to ~r. meala) ~ D (.~lng o~ ~ ~r.
2 ~st A~ ~unbes sewed by ~ s~ Denton
3 A Isyourslte open ~Yes ~No
B Is your rote enrolled? ~Yes ~No
C Site Ehg~b~l~ Enter~e~n~ged~renel~i~ef~fr~r~u~sf~e~e(SFSPH~C~ll) 19 %
D If o~n s~tes submit ~u~n~t~ suppling this ~r~n~ figure (s~ ~ m~us date, ~1 data) For o~n ~eSpslng ~ da~
list ~e sch~ls ~ed ~ d~ment ~e ellg~b&h~, a~ fo~u~ u~d by ~1 dwL'~ es~l~ ~r~n~ge og fr~ & ~ pd~ ~ldren
Census data from TAC~
E For enroll~ rotes, Fo~ 1~1 ~11 ~ ~ ~ d~nt e~gi~l~ (Nad~ Y~ S~ P~r~efer ~ SFSP Ha~, Ch~ter 2 )
~ 100 %
4 D~ ~e s,te pam=pate,in ~ ~' SFSP? (SFSP ~ C~ter II) ~ Yes No
If Yes, g~ve nam~l~n~ o~ City of Denton
5 Momtonng Plan (SFS~ Ha~, C~p~r III) Enter da~ ~ ~dng ~ ~ ~ m~u~
5/30/97 6/20/97 7/25/97
E Meal Sew,~ Period Inlo~ab~ SFSP H~d~ Ch~r II)
~ TO BE SER~ BEGIN~G
Breaker
A M Supplement
J PM Supplement
~ Supper .......
7 ~ you pl~ m feed ~ddren under one (1) year ~d? ~Yes ~ No
8 Method of Fo~ Prepsrabon by Con~ng Orgamzabon (SFSP Handb~k, Chapter II)
Se, Prepua~n ' V~ Using ~h~l ~ Using F~ ~wke Ma~gement
~ On $de ~ Central K~c~n~ F~ Autho~ U ~mpany 0~udes All Year Con~) U O~an~don t~l
~ Indicota ~e lysmm to be u~ t~ ~ ~ng of me,is and ~ ~ton
M~M ~ CM~mn a~ ~at~ ~ C~Mmn Lim Up
I0 ~t ~ ~r~nnel ~o ~11 ~ I~ed to any e~ent in ~e ~ .e~iM (S~P H~ ChOler II)
StCe Supe~tso~ ~ Supervise and as~ts~ distribution
and mat~atn meal ~empe~aCu~e~ 8t~e clean-up, and
Site Helpe~/Server ~ ~sstsC Supe~vlso:
11 lad~!~ what provis~ns mil be made for meal serwco dunng penods of inclement w~alher (S, FSP Handbook, Chapter If)
~.] Indoor Meal ~ Meal Service
SmYICe I IWitl I~e Cancelled ]-]Other*
12. If ~ ,ha feeds primarily homeless children, what methods m'e u~ed to ensure that money, food s/anl~, ~ in-kind se~ce~ am not requ~rad foi' mea~?
13 A/e mea~ del,verad to the =re? [~]YI. E]No
IF YES, COMPLETE rT'EMS 14, 15, & 16 IF NO, FORM IS COMPL/c i c EXCEPT FOR CERTIFICATION AT BO'I TOM.
14 Indicate the means o~ communlcabon w~h the vendor which will be iJaed to adjust meaJ deilvel~ (SF..RP Handbook, Chap II)
E~ S~to Personnel Will Contact Admlnls~atlve ~ Site Personnel Will C~
Staff, Who Will Contact Vendm' I lOlmcl~/With Vemtm'
15 WIll do0vmy be within ane hour of the fnod sennce penod? (SFSP Handbook, Chaplin' If) ~ ~l~Iyll~:~] No
If no, ~be mTangemants vAth~n standards prescribed by local haaifh auifxxibe~ fix dot.very and hc~cl~ng of meaJ~. ~1
16 If ~ is an excess of meals delivared, rne~ will be (SFSP Handbook. Chap~e* Ill)
[--i Strand in Refdgerato¢ r'-I Thrown Away ~ Returned ta Vendor
~nd S~ved ~ Nm Day L_l.t tha Sfl. ~L~Jflx D~poMI
I CERTIFY that the infonnaaon on this form is true and correct to the best of my knowledge I cerdy that this site has been ws~ted and that it
has the capabrlm/and tacdmes for the meal service planned for the number of children anac~pated 1 know that delibemta mlsrepresentaifon or
w~thholdin~ of inforr~ation may result m prosecubon under apphcable state and federal statutes
N~me o~ OWoJJ (p~L~ ~pe o~ p~ TWe
I
Nicole Fletcher Children's Pro~rams Supervisor
Tex,u I~t Fe'm
M ,um~ M~ EUMMER FOOD SERVICE PROQRAM FOR CHILDREN F~ ~ ~ ~Y
S~E INFORMATION ~ 0~/-/~ ~ ~R ~u
N~ ~ F~ ~ S~ T~ ~)
Denia Park ' (817) ~6-~125
1001 Parvin Denton, TX
A~ACH A MAP W~H THE 8~ SERVICE AR~ IDE~FIED
ge.~ ~mp ~ Sb ~wl~ Pdml.ly Might Ch~n ~r Sits
H~nbl Camp
List ALL counties sewed by this site Denton
A Is your $~te open [~]Yfl DNo
B is your s~ta enrolled? DYee ~lNo
C S~taEhg~bdriy Ent~r~epercentagedc~i~drenehg~bisf~frseand/~.mducedpncemas~m.tt~e(~FS~H~C~ 64 %
D If open rotes, submit documantat~ supporting this percentage figure (such as census date, school data) For open mtas using school data
list the school~ used to document site ehg~bility; attach formula used by school dist~to estabhsh percentage of free & reduced prtoe cflddren
Census data from TACAA
/
E For enrolled s~tes, From 1531 will be used to document elig~bil;ty (National Youth Sports Program~efer to SFSP Handbook, Chapter 2 )
If the enrolled s~te used school data, list the school used to __doc,__,ment the site '~. ~ ' - ~
F What~stheporcen~ageoffreeorreducod-pncemeaisfotthesita? ~.~ .~ 100='
D~l the sKe pamc~pete m prev~$ years' SFSP? (SFSP Handlxx~q Chapter II) ~ Ye No
IfYes g:ve name of contracting organization City of Denton ~[r ~~ ~
Momtonng man (SFSP Handbook, Chapter III) Enter date of monltonng review to be conducted within
5/30/97 6/20/97 7/2.5/97
Meal Service Penod Informabon SFSP Handbook, Chapter II)
NuaeEe o~ MF.N. S~RVlO=
TYPES OF MEAL~ F. LKUBLE CHILDFIEN
TO BE SERVED' BEG~KG F.~HG
Steeliest
A M Supplement
I.unctn 30 [2 00 p m 1 00 p m
P M Supplement ,
Super
DO you plan to feed ct, ldren under one (1) year old? ["lYes [] No
Method of Food Preparation by Contracting Organizat~an (SFSP Handbook, Chapter 11)
Serf I~'epuaUon V~ Using School ,--, Using Food Scrdce Management ,--, Using Privste NomPmfit
[] On Stte [] Central Kitchen Foo~ Authorit~' U Compan~ ~lnc~udes All Year Conlracts} U O~snczatlon that is Serf-Prep
9 Indc~te ~te lyst~m to be used for the servmg of meals end the lupewf~ion of ~ld~efl dudng meaJ le~e period ($FSP Handbeok. Cha4~ fl)
F-ICOfe~edHIyle F"'t Children ere Seated ~ Children Une Up
~ Sefvk~ I I and am Given Meet. I~1 and Peek Up M~e [] O~
10 List she personnel who will be involved Io any extent In the meal service ($FSP Handbook, C~apler II)'
'm~.E (~ posmoN No I.N PosmoN S~I~CffqC I,O43O S~WC~ P~OGRA/4 IXJI1ES
Site Supervisor ! Supervise and assist dt~tributio~ o~ meals, monitor
a~ maintain meal temperature~ site cle~-up, and
other duties as assigoed.
Site Helper/Server i Assist Supervisor
11 I~d,~-~t,* what provisions mil be made lot meal service dunng periods of inclement weather (~FSP Handbeok, Chaptm' II)
r~lndoo~ Meal r-'l Meal Service
Service I IWlll Se Cancelled [-mother-
12. If the ate feeds p~manly homeless chddren, what methods are used to ensure that m~fley, food stamps, or in-bnd seduces ate no[ required for meals?
13 Am meals delivered to the site? ~"~Ye~ [] No
IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLIETE EXCEPT FOR CERTIFICATION AT BoI'roM
14 ~nd~catethemeans~/c<xT1municatm~w~thevendorwh~chwi~be~-~-ea---to~dju~tmeajde~werlds CSPSPHandboc~.~tlap II).
I ,~1 Stiff, Who Will C4:mtagt Vendor I I Directly WIih V~-.IG,-
15 WIll debve~y be wt6~in o~',e boor of tt~e food se~i~e pertod? (SFSp Handlx3ok, Chapter ii) ,:~-~ Y No
~ no, ~ arrangemeflts wth~n standards presc~bed by ioce] heeJth auth~ fix ~n~ and holding of
16 If lhem is an excess of meals delivered, meals will be (SFSP Handlxmk, Ctmptm' III)
l--]Stored In Refrtgemt~ r-'l Thrown Away ~ Returned to Vemior
I CERTIFY lhat l~e mformat~on on th,s fom~ IS true and correct to the best of my knov~edge I ceF~fy tha~ this site has been v~s~ed and ~ ~t
has the capabd,ty and leal•es for the meal se~,,ce planned for the number of chddre~ anticipated I know that deliberate mlsrepresentalk~i or
wqthhold~/~g of I~lo .mnaao~ may result in prosecubon under applicable state and federaJ statutes
Name ol Othc~J (please type m ~ ~
I
Nico[e
Yle~cher
,Children's ?to§rams Superv±so~ I
o~.--. SUMMER FOO0 SER.CE PR~RAM FOR CHILDREN ~
S~E INFORMATION ~ ~/-/~
~ ~ F~ ~ S~te T~ (~)
Phoenix Park , (817} 566-8125
Wood Street Denton, TX 76201
From 5/27/97 .gh: 8/8/97 I~m"r°fO',.,Day, ~ ~1 ~2
A~ACH A MAP W~H THE S~ SERVICE AR~ IDE~FIED
~ Re~ ~mp ~ S~ ~l~ P~mad~ Might C~ ~ Si~
~n~l Camp ~ S~ ~i~ Pdma~ ~ ~mn
Ust A~ ~unhes se~ed ~ ~ s~ Denton
A Is your s;~ open
B Is your site enrolled? ~Yes ~ No
C S~te Ehg,bdi~ Enter~e~nmged~ren~f~fr~~sf~(SFSPH~rll) 31 %
D If o~n sites, submK ~n~ suppling ~is ~r~n~ figure (s~ ~ ~ date, ~1 data) For o~
hst ~e sch~ls used ~ d~nt ~ ehg~bih~ a~ f~u~ u~d by ~1 d~b ~ es~l~h ~r~n~ ~ fr~ & ~ prim ~ddren
Census da~e ~oa TkC~
E For enroll~ s~tes, Fo~ 1~1 ~11 ~ u~ ~ d~nt e~iMl~ (Na~ Y~ S~ P~efer ~ SFSP Ha~, C~ter 2 )
If ~e enmll~ site u~ ~ ~t~. I~ ~ ~1 ~ ~ ~nt ~ ~ '~
F What is ~ ~r~n~e of ~ ~ ~u~p~ ~s f~ ~ ~? ~
D~ the s,te p~=pate'in ~s ~' SFSP? (SFSP H~ C~ter II) ~:. Ye No
IfYes, g~venameof~n~o~. City of Denton <~
Momtonng Plan (SFSp Ha~k, C~p~r III) Enter da~ ~ ~ng ~ ~ ~ m~ ~ffitn
~ F~[ W~ ~ ~r~n ~ ~F~W~ C ~~
5/30/97 6/[2/97 7/25/97
Meal Se~ Period Info~a~ ~FSP H~d~ Ch~r II)
N~BER ~ ~ ~R~E
~PE$ OF MEALS ~ C~
~ BE ~R~ B~GIN~
Brea~t
A M Supplement
~n~ 90 12 00 p m 1~00 p m
P M Supplemem
Supper
~ you plan m feed ~ddren under ~e (1) year ~d? ~Ye; ~ No
Method of F~ Pre,aragon by Con~hg Orgamza~on {SFSP Hamdb~k, Chapter H)
Se~ p;ep~n v~ Using ~h~ ~ U~lng F~ ~w~e Ma~gement ~ ~1~ P~wte
~ On Sde ~ Central Kdc~n ~ F~ Autho~ ~ ~mpany O~es All Ye~ Con~) ~ O~an~llon t~t
9 Indcale the ly~tem ~ ~ ~ f~ ~ ~ng of meals a~
~ ~ ~ ~ ~ Given ~
10 ~ ~ ~r~nnel ~o ~11 ~ I~d to any e~ent in ~e ~ lewi~ (SFSP HaM~ ~ter II)
~t~e Supe~vtao~ [ Supegvlae a~d ass~s~ ~ts~tbu~to~ o~ mea[a, mo~tEog
o~he~ ~u~tes
StYe Heipe~/Se~ve~ [ As;ts~ Supegvtso~
11 I~ ~ pr~ ~ll ~ ~e for ~al ~wi~ duH~ ~s of In~e~nt ~r (~FSP ~ ~ II)
~ ~Ue.I ~ Meal
~11 h ~ell~ ~e~
~/~
13 ~ ~ deli~r~ m ~ ~e? ~Y" D No
· YES, COMP~'I~ ~MS 14, 15, & 16 IF NO, FORM ~ COMP~ ~CE~ FOR CER~FICA~ON AT BOSOM
14 I~ ~ ~s ~ ~n~ ~ ~ ~der ~ ~11 ~ ~ ~ ~ ~ ~. ~SP H~ I~
16 If the~ is an excess of meals belivered, meals will be ($FSP Handbe~ Chaptel' lit)
i.-.,1 Sto~ in Refrigerator I-'lThr°wn Away ~ Ret~ to Vefldor
I CERTIFY that the informabon o~ this form is true and con'ect to the best of my knowledge I certify that this site has been vis,ted and that it
has the capabddy and facilities for the meal service planned for the number Of children anac~pated I know that deliberate rnisrepreseNation or
wdhho~d/~g ot inf~)rmation may result in prosecution under applicable state and federal statutes
~m~M~'{~e-~n~Nzcole Fletcher
, Children's Programs Supervisor
Signaaze--~ Rel~e~e~a~v~ DUe
HU~n ~ ~UMMER FOOD SERVICE PR~RAM FOR CHILDREN ~ ~ ~E ~y
S~E INFORMATION ~ ~/- Io0~I ~R ~u
321 E McKinney Denton, TX 76201
From 5/27/97I ~h, 8/8/97 I~m"r'O'..,D., 4 21 ~2 6
A~ACH A MAP W~H THE ~ SER~CE AR~ IDE~FIED
~ Res~ ~mp ~ S~ ~wlng P~ma~ly Might C~~ ~r Si~
B
(~w~ o~ to turk m~ls) ~ D (~wlng o~ ~ mr~ meab)
2 Ust ALL ~uflhes sew~ ~ ~ s~ Denton
3 A Is your s,te open ~Yee ~No
B Is your s~te enrofled? ~Ye* ~No
C S~te Ehg~bd~-Enter~e~nm~renel~f~fr~~sf~(SFSPH~HI) 22
D It o~n sites, submit ~n~ suppling this ~n~ figure (s~ ~ ~us date ~1 da~) For o~n s~ using ~ da~
hst ~e sch~ls u~d ~ d~nt ~e ehg~bih~, a~ fo~ u~d by ~i d~sL' ~ es~lmh ~n~ge o~ fr~ & ~ ~ ~ddren
Census da~e ~=om ~C~
E For enroll~ rotes Fo~ 1~1 ~11 ~ ~ m d~nt elig~l~ (Na~ Y~ S~ P~eler ~ SFSP Ha~, Chafer 2 )
F What m ~ ~r~nmge of ~ ~ ~u~pdm ~ f~ ~? ,~ ~[00 %
the rote pa~patelln
4 D~d ~e~s ~' SFSP? (SFSP ~ Ch~ter II) ~ ,~ Y~ No
IfYes grvenameof~n~o~ City of Denton
5 Momtormg Plan (SFSP Ha~k, C~r iff) Enter date ~ ~ng ~ ~ ~ m~ ~n
6/~2/97 7/25/97 ~ ~ I
~ Meal Se~l~ Period lnfo~a~ SFSP H~d~ Ch~r II)
~ N~BER ~
~PES OF MEALS ~LE C~R~
Breaker
A M Supplement
~n~ 40 12 00 ~ m 1 00 ~ m
~ P M Supplement
~ Super
7 ~ you pl~ ~ feed ~ddren under ~e (1) year old? ~Yee ~ No
8 Method of F~ Prepsra~n by Con~ng Orgamzabon (SFSP Handb~k, Chapter II)
1 Se~ Prep~a~n ~ V~ Ualng ~h~ ~ Using F~ ~wke Ma~ge~nt
~ 0n S,te ~ Ceniml K~c~n ~ F~ Au~o~ U ~m~ny O~ud. All Yeu Con~)
g Incl-~_,. the system to be used lot the sen, lng of meals and the supe~'lsion of c:~b~'en during mee] service pm'led (SFSP Hanclbeolc. ~ II)
r.-]C~eteda-ityle r-~ Chifd~n ~re Seated ~ Children Ltno Up
Me~ L...I Ired ~m Given Maal~ ~L.~J mid Pick Up Me~ I~lOth~
10 list site personnel who will be involved to any extent Iff the mea~ service (SFSP Handbook, Chapter II)
1~rcE O~' pC*S,~C~ KO ~N PosmoN ~-,~C~FIC ~,000 SimWCE ~'nOG~J,~ 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 Indicata what provimons will be made for meal service dunng panods of inclement weather (S~FSP Handbook, Chapter Ii)
I.~1 ~Meal r-.-i Meal Service
I IWill Be Cancelled [] Other
12 If the site feeds p~me~ly Ix~meless chddren, what methods am used ~o encure that monoy, focal stamp~, or in-kl~l se~ce~ are not redu~md fa- meals?
N/A
13 Am meals ~hvered to the mto? I'~Ye~ F"]No
IF YES, COMPL.~ i" ITEMS 14, 1 S, & I S IF NO, FORM IS COMPLY: f u. EXCEPT FOR CERTIFICATION AT BOTTOM
14 InP ~,c~_~_ the means o~ communication we~ the vendor which w~ll be ,__,~ed__ to adjust meal deifvede~. (SFSP Handbo~ Ct~p Il)
~.] Site Personnel Will Contact Aclminlstmifve ~...t Site Pemmmel Will ca~
Staff, Who Will Contact Vandm' I IDir~gify With Vends- r~*-
15 Will delivery be within o~e hour of the fcod se~ beriod? ($FSp Handbook, Cha~ II)
16 If them is an ex_re_~ of meals dohvm'ed, meals wdl be (SFSP Handbook, Chapter Iii)
i,~1St~ In Refr;geratm' r-,1Thrown Away ~ Returned to VI~do~
am:l Sewed the Next Day I._Jat the Site I.~.J for Disposal ~]Other'
I CERTIFY that the ~flformat,o~ on thru form m Irue and correct to the best of my know,rigs I Ce~y that th~s site has been ws~tad and that
has the capability and fac~htles for l~s meal service planned for the number of chddmn anl~c3patod I know that dehberata ITaSrepr~sefltaltofl or
w~thholding, of mformatmn ma)' result in prosecobon under apphcabie state and federal statutes
( lzc c tcf , V/71q7 I cityof Denton
N~me~Ot~d~e~pe~p~Nicole Fletcher rme
Children's Programs Supervisor
H~ ~= SUMMER FOOD SERVICE PR~RAM FOR CHI~REN ~ D~ ~E ~Y
MLK Recreation Center (817) 566-8125
1300 Wilson Denton, TX 76205
A~ACH A MAP W~H THE S~ ~E~E AM~ IDE~MIED
~ N~n~l Camp S~e ~wl~ P~mad~ ~mebu
~st A~ ~unbes sew~ by ~b s~
A Is your s;te open ~Ye,
B Is your rote e~mlled? ~Yes
C S~te Ehg~bd~ Enter~e~nmge~MrenehG~f~f~.~~f~(SFSPH~rll) 31
D If o~n s~tes subm~{ d~u~n~ suppling ~ls ~n~ figure (s~ ~ m~ date, ~1 da~) For o~n s~s using ~ da~
hst ~e s~ls u~d ~ d~nt ~ ehg~bdl~, a~ fo~u~ u~d by ~1 d~b ~ es~l=h ~n~ ol f~ & r~ p~ ~ddren
Census data, from TAC~ /~
D~d the rote pamopate m pm~s ~' SFSP? (SFSP ~ C~ter II) n . ~ ~Y~ No
If Yes, g~ve name of ~n~
Mondormg Plan (SFSP Ha~, C~p~r 111) Enter date ~ ~flflg ~ ~ ~ ~ ~n
5/30/97 6/[2/97 7/25/97
Meal Se~ Penoe Info~a~ IFSP H~d~ ~r II)
~PES ~ MEALS ~LE
TO BE ~R~ BEGIN~
Breaker
A M Supplement
P M Supplement
Super
~ you plan ~ fe~ ~ddren under ~e (1) year ~d? ~Yes ~ No
Method of Fo~ Pre~arabon by Con~ng Orgamza~on (SFSP Hand.k, Chapter 10
Se~ Pre;~a~n V~ Using ~h~l Uslng F~ ~w~e Ma~gement ~ Usi~ PHvmte ~Pm~
~ 0n S,te ~ Central K~c~n ~ F~ Autho~ ~ ~mpan~ ~udes All Ye~ Con~) U O~an~Uon t~t
g Indicate the system to ~ used tor the serving of meals and the lupenaslon of ehlk~en du~ng meaJ levee perkxl ($FSP Handbook, C~ II)
i-..iCafm~a-tt¥1e ~ Chtld~n are Seated ~ Children Une Up
Ikof ~m~kle L...J and art Given Meale I xz Ind Pk~k Up Meals D Other
10 List ~ personnel who vdll be involved to any exlent In the mea/service ($FSP Handbook, G'~iloter II)
'r'~LE O~ Posmoa No ~s POSmON 8PI;C~C Fooo ~*avlc~ ~ROG~AM DU~E$
$±te Superviaor ] Supervise and assist distribution o£ meals, moni:o:
and mainta:;_n meal temperatu:e~ site cle~n-up, and other
duties as assigned
Site Helper/Server 1 Assist Supervisor
11 Incl _,~_te what provisions mil be made for meal sew~ce dunng periods of inclement weather (~FSP Handbook, Chapter II)
[~lndeor Meal r-..~ Meal Service
Sewfoe I IWill Be Cancelled DOther
12 If the site feeds ~madly hemeless chddmn, what mee~ods are used to ensure ~at mo~ey, food stamps, o~ in kind sewic~ are not reqLamd for mesh?
N/A
13 Am meals dehvered to tha site? [ '-JYe8 Dso
IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPI~ I1= EXCEPT FOR CERTIFICATION AT BOTrOM.
14 Indicate the means of communicat~:~ w~l~ the vendor wh~c~ will be ,_,__~d_ to a~ju~t meaJ delive~ (~FSP Hal~ldoo~ Ct~a~ II)
Stiff, Wbe Will Ceate~ Vendar I I I~e~ly With Wla~ar
15 W~II bebve~y be wtthl~ o~e hour of the food sewioe penod? (SFSP Ha~llx3ok, Ch~ II) r yee r-I.o
If no, de~c~be a~angemants w~thln standards prescribed by IocaJ health at.,thoiftm~ f~' betivefy and holding of meals unbl ~ime of se~ce
16 If them is an excass of mea~s delivered, meats w~ll be (SFSPHandbook. Cha~lll)
1~1Stoced la Refrtgarato~ I--'lThmwn Away ~ Returned to Vendm'
am:l Sewed lbe Next Day Ilat theSlte I~ Ifix Dl~m~al
I CERTIFY that the ~nformauon on thru form is true and correct to the best of my knov~edge I cor~fy that this s~te has been visited
has the capabit~ty and fac~hbes for the meal service planned for Ifle number of chddran anl~c3patecl I krtow that deliberate misrepreseNatio~ or
w~l~.oldir~l of lnlormahon may~result in prosecubon under applicable state and federaJ statutes
City o£ Denton
Name ~ OIf~aJ (p4e~ type or pm~
I
N~_cole Fletcher Ch~_ldren's Programs Supervisor
Hum~ S*n~m. SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FO~ m4s usa ONCy
S~E INFORMATION ~ ~/-/0~ ~ ~ ~U
Village East Apartments (817) 566-8125
~ M S~ (S~ ~, S~ ~P)
1700 Village gae~ De~to~, TX 7620[
From 5/27/97 ~h' 8/8/97 i~ Da~ 6
A~ACH A MAP W~H TNE 5~ SERVICE A~ IDE~FIED
3 A ts your s~te open ~Yee ~No
B ts your rote enrolled? ~Yes ~No
C S~te Ehg~b~h~ Enter~e~n~ge~renel~i~fulr~~f~(SFSPH~rll) [00
D If o~n rotes submit ~u~n~ suppling thru ~r~n~ figure (s~ ~ ~ date. ~1 da~) For o~n
hat ~e sch~ls u~ ~ d~nt ~e ehg~bdl~, a~ Io~u~ u~d by ~1 dlsL'~ es~l~h ~r~nmge ~ fr~ & r~ p~m ~ddren
Census daLa ~om ~AC~
E For enroll~ rotes, F~ 1~1 ~11 ~ ~ ~ d~nt el~i~l~ (Na~ Y~ ~ ~efer to SFSP Ha~. Ch~ter 2 )
If ~e enroll~ rote u~ ~1 ~. I~ ~ ~ ~ ~ ~nt ~ ~
F What is ~ ~r~n~ of ~ ~ ~u~-pd~ ~s ~ ~ ~e? ~
4 O,d the s~te p~pate in ~s ~' SFSP? (SFSP H~ C~ter II) ~ ~ Ye~ No
If Yes give name of ~n~ o~ Cit~ of Denton~,~ ,
5 Monitoring Plan (SFSP He~k, C~p~r Ifi) Enter da~ of ~ng ~ ~ ~ m~ ~ln ~
5/30/97 6/20/97 7/25/97
~ Meal Se~,~ Penod Inlo~a~ 8FSP H~d~ Chafer II)
I ~ER ~ ~ ~E
~PES O~EA~ ~WLE C~
I TO BE SER~' BEGI~NG
Brea~ast
A M Supplement
~n~ ~0 ]2 00 p ~ 1 O0 p
; PM Supplement
I Super
7 ~ you plan m feed ~lldren under ~e (1) year old? ~Yee ~No
8 Method of F~ Prepara~on by Con~ng Orgamzabon (SFSP Handb~k, Chapter II)
~ Prepua~n V~ Using ~h~l ~ Using F~ ~e MaMge~nt ~ ~1~ Pflv~e
~ On Sde ~ Central KAc~n ~ F~ Autho~ ~ ~m~ny ~es All Ya~ Con~) ~ O~an=tlon t~t
g ind,,"~ the system to be used lot the serving of meals and the supewlsion O/~ clultng meal servloe period (SFSP Hanclhook, Cl'mptor it)
[-..] C~eter~tyle ~ Children are Seated ~ Children Une Up
Ikei ~ I I ~nd I~ Given MeaLs L.~ iml PWk Up M#JI [] Othlr
10 List s~te personnel who will be Involved to any extent in the meal sen/ice, ($F~P Handbook, Chapter I1)
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 Im~ _ic~_!e whal provisions will be mede fo~ meal se~ce dunng perm<Is of inc~ement weather (~F~P Handbook, Chapter II)
r~lndoor Meal r-.1Meal Service
Sang, se I IWIII Be Cancelled I--~Other
12 If the ~ feeds Immadly homeless children, what me~ods ue used to ensure that mo~ey, food stature, e' ~n kir~ semica~ mm not reqWmd fo~ me~?
N/A
13 Are meals delivered to the ~te? [ ]Yel •No
IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPL~ I c EXCEPT FOR CER'FIFICAllON AT BOTTOM
14 Ind _~_~ the means o~ communication w~th the vendor wh;ct; will be u~ed to adjust msoJ dal~ede~ (SFSP Handbook, C~ap II)
r.~l s~to Personnel Wilt Contoct/~lminLstratlve r.-1 Site Pef-onnal Will camamltiseto
Staff, Who Will Coninat Vend~ I I~;m~ly With
15 .?1 doiJveado~,i~'e~,_~..~.l~¥] ho within one hoor of the fsod service penod? ($FSp Handhooig Chaptor ii)
16 Ifthee'~manexc'*__,~_<of .~e-___L'~belivered, meaisw~lbe (SFSPHandlxx:~k. Chaptm, lll) ~ ~-
i---i Stored in Refrigerator r-'lThr°wn Away ~ Returned to Vlnd~
I CERTIFY that the i~lom~at~on on Ibm form m true and com'ect to the best of my knowledge I ce~fy that this ~te has been wslted
has the capabiltty and facditms for the meal service planned for the number of chddran anl;c~pated I know that dol~perate misrepresentation or
w~thhold~r~l ol' mformslton may result ~n prosecution under appl~..abie state and federal statutes
- -'~,c~Co~O~amx. a~,o. ~ , -
~o~~.~N~cole Fletcher
, Children's Pro~rams Supervisor
Tix~I Deplcmem
~ ~s SUMMER FOOD SER~CE PR~RAM FOR CHILDREN ~ F~ o~ ~ ~Y
S~E INFORMATION
Fred Moore Learning Center (817) 566-8125
~u ~ ~ {~ C~ ~ ~P)
Prom ~/2/~7 ~h' ~/~/~7 I
e~ Oi~ 0 ~ ~ 22 6
A~ACM A MAP W~M THE $~ $ER~CE AR~
~ R~ ~mp ~ S~ ~wlng Pdmld~ Migrant C~ ~r SI~
1 Ind~teTy~o~S~te ~(~~) ~C(~l~m~)
N~en~l Camp ~ S~ ~wl~ P~aH~ ~meb~ ~n
2 ~st ALL munbes sew~ W ~b s~
3 A ts your mte open ~ ~o
B ts your s~te enrolled? DYes ~No
C Site Ehglblh~ Enter ~e ~n~ d ~ren ehgi~e f~ fr~ ~ ~
D If o~n rotes subm{t d~u~n~ suppling ~s ~r~na~ figure (s~ ~ ~ date, ~1 da~) For o~n s~es using ~ da~
hst ~e sch~ls used ~ d~nt ~ el~g~b~h~ a~ f~u~ u~d by ~1 d~L, ~ es~l=h ~nmge el fr~ & ~ p~m ~ldren
E For enrolled s~tes, F~ 1~1 ~11 ~ u~ ~ d~nt elig~l~ (Na~on~ Yo~ S~ P~r~eler ~ SFSP Hand~, Choler 2 )
If ~e enroll~ s~le u~ ~ ~, ~ ~ ~1 ~ ~ ~nt
F What is ~ ~r~ntage of ~ ~ ~u~-~m mens f~ ~ ~e? 1 O0 %
4 D~ the rote pa~=pate ~n pre~ ~' SFSP? (SFSP ~, Choler II) DY. No
If Yes g~ve name of ~n~ o~
5 Momtonng Plan (SFSP H~k, C~pmr fil) Enter date ~ ~odng ~
I,.,
6/6/97 6/27/97 7/25/97 n~-~; ~ '~m
E Meal Se~ Peno~ Info~a:~ 8FSP H~d~ Ch~mr II)
~ER ~ ~ ~R~E ~ME ~1 ~,,
~ TO BE ~R~' BEGI~NG
Breaker
A M Supplem~t
~n~ 7~ 12 00
~ P M Supplement
~ Super
-~ ~o~1.~ ~~~~ (8FSP ~ ~ II)
7 ~ you plan ~ fe~ ~lldren under ~e (1) year ~d? ~Yes ~ No
8 Method of F~ Prepara~on by Con~ng Organiza~on (SFSP Handb~k, Chapter II)
' Se~ Pre,sawn V~ Using ~h~l Using F~
t ~ On S,te ~ Central Kdc~n ~ F~ lutho~ ~ ~mpan~ 0~e* AIl Year Con~) U O~anmfion t~t ~ ~ff~rep
9 Ind _,c~ the system to be used Io~ the sewing of meals aM the lupewLslon of children during meaJ ~en4ee pe~xl (SFSP Handbeok, Chapter II)
r...~Cafeterla~tyl~ r'"'t Children are Seated ~ Children Uns Up
M~al ~efvlee I I ~nd ~w Given Meal~ I "1 ~nd Pk~k Up Meale D Othar:
10 LJat site personnel who will be involved to any extent iff the men sotvice ($FSP Handbook, ChKoter II)
1111.E OF ~OS~C,~ I NO ~N Posmo~ ~-EClFIC Fo00 ~EI~VtCE P~O~RAla IX/TIES
Site Supervisor i 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 Ind _,~__te what provisions mil be made lot meal se~ce during penods of inclement weather (~FSP Handbook, Chapter Il)
[:~] Indoo~ Meal r-,1 Meal Service
Service I IWill Be Cancelled r'-lOther
12. If the site feeds I~manly homeless ~ddren, what methods are used to ensure ~at mmey, food stamp, o~ in.kind sewices are not required f~ melds?
13 Are meals delivered to the rote? I~']Yoi DNo
IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICA'TION AT BOTTOM
14 Indicate the means of commun&cabo~ vath the vendor which will be used to I~just meal d(d~,e~ ($FSP Handbook, Chap Il)
~-.~ Site Pe~onnel Will Contact Administrative r..~ Site Parsonnef Will ~ ~.~
Stiff, Wbe Will caatect Vendor I IDIre~y With Verl~kx' -~
15 Will dehver/ be within o~e hour of the fcod sewice penod? (SFSP Handbook, ChalXerll) ~.:~ ~]Y~ [~No
If no, ~ arrangements w~thm standards presc~bed by local health autl~ for deliver/end haid,ng of meals ~t~t0ime ~cO~rvlno
18 Htha~'e~anex~em~ofmea~sdehvemd, mea~wdlbe ($FSPHandbcok`C~lll)
r-]stored in Refrigerator r--i Thrown Away ~ Beten~l to Vendor
I CERTIFY that the inlormabon on this form is true and correct to the best of my knowledge I ceridy that b~l$ site has been wsited and that it
has the capabilffy and factilhas for the meal service planned for the number of chddrefl antxc~patad I know that deliberate n~srepre~efltaUon or
w~hold~r~ of lniorff~bon ma~.,~uit in prosecubon under appi~bie state and federa] statutes
U,:. ,
City of Denton
I
Name ~ O~ ~e~ ~e u ~ Tee
Nlcole Fletcher Children's Programs Supervisor
~ ~:q~'OVed [-'1 canted, rsesen
~ ~; SUMMER FOOD SER~CE PR~RAM FOR CHILDREN ~ F~ ~4 ~; ~y
Borman Elementary School ~ (817) 566-8125
I201 Parvin Denton, TX 76205
A~ACH A MAP W~H THE S~ SERVICE AR~ IDE~FIED
~ Re~ ~mp ~ S~ ~1~ P~maflly Mlg~t C~ ~r
N~fl~l Camp ~ S~ ~wfq Pdmad~ ~m~M
~ B (ff~ oM ~ ~fff meal;) ~ D (a~lng oM ~ ~rff
Ust A~ ~unbes sew~ by ~ s~ Denton
A Is your mte open ~Yee ~No
B Is your site enrolled? ~Yes ~No
C S~te Ellglbdl~ Enter~e~n~ed~renel~f~fr~u~Nsf~(SFSPH~C~rll) 64
D If o~n s3es, subm;t d~u~n~ suppling ~is ~r~na~ figure (s~ ~ m~ date, ~1 daa) For o~n s~e~ using ~
hst ~e sch~ls u~d ~ d~nt ~e ehg~bfli~ ~ fo~u~ u~d by ~1 d~ ~ es~l=h ~r~n~ o~ fr~ & ~ prim ~dren
~n~ ~ f~nm ~A~AA
E For enroll~ s~tes, Fo~ 1~1 ~11 ~ ~ ~ ~nt elig~lW (Native Y~ S~ P~efer ~ SFSP Ha~, Ch~ter 2 )
If ~e enroll~ rote u~ ~1 ~, ~ ~ ~ ~ ~ ~nt ~ ~ ~ ~
DM the s3e p~opate in ~S ~' SFSP? (SFSP ~ C~ter II)r~: ~' Yes J~
If Yes gtve name of ~n~ o~
Momtonng Plan (SFSP Ha~k, C~r III) Enter date M ~ng ~ = ~ m~ ~ffim
6/6/97 6/[3/97
Meal Sew[~ Period Inlo~aa~ SFSP H~d~ Ch~r II)
N~BER ~ ~ ~cE
~PiS ~ MEA~S ~m~ C~R~
A M Supplement >~
~n~ TS0 1T 30 a m 1~30 p ~
P M Supplement '- ~ ~ ~ ~
Super '; ~ '~-
~ you pl~ ~ feed ~ildren under one (1) year old? ~Yee ~No
Me.od of F~ Pre~aaon by Con~ng Org~iza~on (SFSP Handb~k, Chapter II)
Se~ ~ep~a~n V~ Using ~h~l Using F~ ~w~e MaMgemen~ ~ Usi~ Private
I
~ On S,te ~ Cefltml K~c~n~ F~ AMho~ ~ ~mpany O~udea All Yeu ~fl~) ~ O~an~fion ~l ~ ~mp
9 In~,~,!,, the system to be u~ed to~ the se~ng of meals and the lupan~mian o~ children dudng meaJ san~ce bed~xl (SFSP HandboOk, Cheerer II)
[:::::] Catetan'e.~tyld ~ Children ere Seated ~ CMIdren Une Up
MM Sen~ L-J .~d I~ (31yen Meel. I~1 ind Plak Up MeW [] Other
10 List rote personnel who will be involved to any extent in the maai service, (SFiP Handbook, ChKater II)
~TT~E O~ Poimo~ NO IN PoSmON ~ECII~C PO(~ $~'RV~E RRO~3RAM DUTIES
Supervisor 1 Supervise and assist distribution of meals, monitor
and maintain meal temperature, site clean-up, and
other duties as assifined
Site Helper/Server 1 Assist Supervisor
11 thd,cate what provismns will be made for meal se~ce dunng pesods of inctemant weather (SFSP Handbook, Chapter II)
i-.~llndcor Meel ~ Meel Sen4ce
Servic~ I IWill Be Cancelled DOther
12. If the site feeds I~manly homeless children, what methods are used to ensure ~ mmley, food stamps, 0r fn~nd ser/ces are no( redutred for meals?
H/A
13 Am meats delivered to the ate? El]Yes DNo
IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPI ,- it: EXCEPT FOR CERTIFICATION AT BC~OM
r~ ,1ira Personnel Will Conta~ ~lminbtraflve r"-'l Site Pemonnel Will Commlmiolte
Slaff, Who Will CantiGt Yendm' I IDireGtly With Vendm'
15 Will deiNee/be wdhin one hour of the fcod sendce period? (SFSP Handbcok, C.l~ II}
If no, ~be arrangements within standards prescribed by local health authodtms f(x detlv~y and holding of meal~nlil time~mn~.l;7-
~..
ec=C
16 If tbe~e is an ex_ce?__~ of meaJs delivered, n~)ais will be ($FiP Handbcok, Chapter Iff)
D StMed In Refrigerate' r--iThrown Away ~ Retu~md to Vendo~
I CERTIFY that the mformaaon on thru form is true and correct to the best of my knowledge I coddy that th~s
has the capabddy and faaltaes for the meal service planned for the number of chddren ant]c~patad I know that detWerate mmrepres~Llbon
w,thholdlng o~ mformabon may result tn prosec~JbOn under applicable State and federal statutes,
Nzcole Fletcher Children's Programs Supervisor
S~gnature--OH~ Re~e~ta~ve DUe
H~ ~ SUMMER POOD SER~CE PROGRAM FOR CHILDREN F~ D~ ~ ~y
S~E INFORMATION
Ginnin~s Elementar~ School J (817) 566-8125
820 Sun Valle~ Denton, TX 76~01
~ 6/2/97 ~ 6/27/97 ~ ~ 0
A~ACH A MAP W~H THE 8~ 8ER~CE AR~ IDE~FIED
Indi~e Ty~ of S~te ~ ~(~ ~ ~ ~) ~ C (~w~ ~ m~) ~ E (~~)
~st ALL ~unbes sew~ by ~ a~ De~Co~
A Is your rote o~n
B Is your s:te enrolled? ~Yes ~Ho
C S~te Ehg~bmh~ Enter~e~nm~renel~i~ef~fr.~u~sf~(SFSPH~C~ll) 0
D If o~n s~tes submit d~u~n~ suppling ~s ~r~n~ figure (s~ u ~ date, ~1 da~} For o~n S~ using ~ da~
hst ~e sch~ls used ~ d~nt ~e ehg~bih~, a~ fo~u~ ~d by ~1 dish ~ es~l~h ~r~n~ge ~ fr~ & r~ pd~ ~ddren
E For enroll~ rotes, Fo~ 1~1 ~11 ~ u~ ~ d~nt e~glUl~ (NaU~ Y~ S~ ~efer ~ SFSP Hand~, Ch~ter 2 )
If ~e enroll~ s~te u~ ~1 ~ I~ ~ ~1 ~ ~ ~nt
F What ~s ~ ~r~n~ of ~ ~ ~-pn~ ~s f~ ~ ~? I00 %
D~ ~e site pa~=pate in ~e~us ~' SFSP? (SFSP ~ ~ter II) DY- ~ No
If Yes, grove name of ~n~ o~
Momtonng Plan (SFSP Ha~, C~p~r III) Enter da~ ~ ~nng ~
6/6/97 6/13/97
~ea~ ~e~ Penod Info~a~ BFSP H~d~ Ch~te~ II)
~PES OF MEA~ ~LE C~R~
~ BE SER~ BE~NG
Brea~ut
A M Supplemeflt
P M Supplement
Super
~ you plan ~ ~eed ~ddren under ~e (1) year old? ~Yee ~ No
Method of F~ PreparaUon by Con~ng Organiza~on (SFSP Handb~k, Chapter II)
~ ~epua~n V~ Using ~h~l Using F~ ~ke Ma~gement
I
9 Ind~am the ~ystem t~ be used fo~ ~ ~wing of meal= a~ ~ ~ion ~ ~ du~ ~ ~ ~ (SF~P H~k, ~ II)
10 ~ ~ ~r~nnel ~o ~[I ~ i~bed to any e~ent In ~e ~a ~ewim (SFSP H~ ~ter II)
~E ~'Posm~ NO m ~S~N I
Site Supervisor 1 Supervise and assiat distribution of meals~ monitor
and maintain meal temperature~ site clean-up~ and
other duties as assi8ned.
Site Helper/Server 1 Assist Supervisor
~ ~Me,I ~Meal Se~[ce
N/A
13 ~dehver~te? ~Y~ ~No
F YES, COMPS'lC ~MS 14, 15, & 16 IF NO, FORM ~ COMP~ ~CEPT F~ CER~FICA~ON AT BOSOM,
h~ ~e ~1~ ~d fa~haes for ~e meal sew~ pl~ned for
w~dl~ of ~f~a~on ~y resu~ m pros~flon under ~M
~ , V 7 City of Denton
Nicole Fletcher Children's Pro~rams Supervisor I
~ ~ SPECIAL NUTRI~ON PROGRAMS
SINGLE AUDIT IDENTIFICATION DATA
City of Denton Nicole Fletcher
321 E McKinney Denton, TX 76201
817 ) 566-8125 175600051~601~
[OOZ
09/30/97
Check the appropriate box(es) to Indicate the type(a) of program~ in which you currently participate or for which you are applying
COMMOD~'Y ASSISTANCE PROGRAMS CASH REIMBURSEMENT PROGRAMS
[] A - National Schoo~ Lunch [] AD - Adult Da~, Care
[] B - Charitable Instit~ona [:~ BL- National School
[] C - A~ea Agency on Aging [] CC - CACFP Center
[] G - Summer Camps -1 DH - CACFP Da,/Home
[] H - Summer Food Service [] SF- Summer Food
[] J - Jails [] SM. Special M~lk
[] K - Soup K~tchen [] ,TE - TEFAP
[] I - TEFAP Commodities
Give the source and! / federal financial assistance that, __. _~_.._~ ~ecelvea other than from those ~,,,,~rams listed above
See attached
--]SINGLE AUD~ EXEMP~ON-I ~ ~at I ~ not ~ulr~ ~ sub~ ~ ~ u~ ~e Single ~dlt ~ f~ ~e f~ng m~(s)
I ~ I am a f°r'pr°flt °~an~tl°n ~ I r~lve ~" than $25'~0 'nnually In t°~l f~e~l funding
~ SINGLE AUD~ ASSUR~CE-I under=nd ~at ~ I ~et ~e requ;remen= of ~e Stogie Audit A~ I w;;l agr~ ~ ~bm~L
~ An Annual ~ A Biennial audit ~ a ~ndltion o; el~g~b~l~ to p=~=pate ~n
fmlure to do so as requ~rad ~uld result m adve~e a~on, in~ud~ng ~e w~hold,ng of my ~mm for re~bu~e~nt paten= and
re.mst;on o; my ~n~a~ I also unders=nd ~at ~ I ~ a p~ate non proht org~zat~on suble= to ~e mqu~re~n= of ~e Stogie
Aud~{ A= and h~v~ a finan=~ audit peHo~ed ~nual~, I must a~o ob~n a angle audit on an ~nual
N~ ~ ~ ~t) I T~
Nicole
Fletcher
HISTORICALLY UNDERLrI~I.~z~J BUSENF.$S (HU8I
SUBCONTRACT CERTIFICATION
The Texas Department of Human Serwcas (DHS) wtll make a good faith effo~t to ensure that HUBs receive their respective
share of the total value Of all contracts it awards each hscal year whrch begins Septemper 1 and ends August 31 Based on
the 1994 Texas D~sparlty Study, and m accordance w~th the Texas General Serwcas Commission (GSC) rules, DHS has
estabhshed the followfng m~n~mum HUB goals
* Commodities include equipment, furniture, software, supplies, vehicles, food, fuel chemicals, and lubricants 12 6%
· Heavy ConstructioEI Includes h~ghway, street, bndge, tunnel, water, sewer, and power hne construchon 11 9%
* Building Consttuctloa ~ncludes residential, ~ndustnel, end other nonres~denaal building construction 26 1%
· Special Trade Construction1 includes plumbing, heating, a~r conditioning, painting etec.ncal, masonry,
dry wall carpentry, floor laying, roohng s~dmg, concrete, excavation, and demohtlon work 57 2%
· Professienal Serv c~ include erch~tecture, engmeenng, financial and accotmtmg services, medical serwces
and surveymg
20 0%
· Other Ssrwces ~nclude computer programming, consulting, legal, maintenance end repair and other
mIscellaneous selvlces ' 33 0%
GOOD FAITH El:FO T COMPLIANCE By ~mplementmg the following procedures a contractor shall be presumed to have
made a good faith effort when subcontracting
1 To the extent consistent w~th prudent ~ndustry practice, dlwde the contracl work into the smallest reasonable lots
2 Not;fy HUBs of the work the Contractor intends to subcontract The not;ce shall be ~n writing The not,ce shall include a
deecrffptmn of the~ubcontractmg opportunities and identify the location to review contract specifications The notice shelf
be provided to p(~tentl81 subcontractors prior to submission of the contractor bid
3 The Contractor shall send such not;ce to at least five HUB hrms m the GSC master b~dders hat and HUB d~rectory that
perform the type of work required If the GSC master bIdders hat and HUB d~rectory do not have at least bye businesses
then the Contractor shall send the required notice to HUBs on lists of m~nonty and women-owned businesses maintains0
by other gove.nm~nt agaric;as or orgamzatlons If the Contractor uses sources other than the GSC master b;dders I;st and
HUB d~recto,'y th~ selected HUB subcontractor must become cart;had by GSC m accordance wpth GSC procedures
4. If e non-HUB subcontractor ~s selected through means other than com0e~we b~ddmg, or a HUB b;d is the towest price
responsive 13~c~de~to a competlt;ve b;d, but not selected, the Contracto~ w~ll be recluireq to document the selectmn
procedures /
5 Maintain recoros ~ocumentlng HUB compliance for aud~'( purposes Quarterly reports MAY BE required by the ~;~_e_ ncy, and
the contractor will be given sufficient notification if required to reporl
When the contracto~ is a HUB, ;t may satisfy the good faith effort requirement by performing at least 25% of th~ contrac!~
,york w~th ~ts emploYees as defined by the Internal Revenue Service (IRS) The HUB Contractor may also be reouire'~Jto repo~,t
Quarterly to the agency
Please It~lWar the following (lualtlo~e
1 Are you a cart,fled HUB? ~ YII ~
If yes, please prowde your GSC HUB Cemflcat,on No
2 Do you plan to mfl,ze a s~contractor, suppher, or materml provider for all or any ~on of t~ contract~ ~ YII ~ No
If yes. describe the scope of work t~ subcontractor(..) wdl do
Approximately what percentage of the total contract award wtll be sul~contracted?
Ao~rox~mately w~at ~e~cemage of t~ total contract award w~fl
CSty of Denton NScole Fletcher 061-1002
HUB .ubc~ g~ ~ ~ DHS