HomeMy WebLinkAboutPR 11695: FOOD SVS APPLICATIONCITY OF PORT'ARTHUR
Stephen B. Fitzgibbons, City Manager
Dr. Albert T. Thigpen, Interim Director ~~
Parks and Recreation
March 25, 2002
Summer Food Service Application Submittal
~S
It is recommended that the City Council adopt Proposed Resolution
No.11695, authorizing the City Manager to allow the Parks and
Recreation Department to submit an application to enter into a
contract with the Texas Department of Human Services Summer Food
Service Program in the City's Summer Recreation Program.
The Texas Department of Human Services (TDHS) funds the Summer Food
Service Program which is designed to provide nutritious meals to
needy children during the summer months when the National School
Lunch and School Breakfast programs are not in operation.
The City of Port Arthur in cooperation with the Port Arthur
Independent School District (PAISD} will operate the summer
Recreation Program at several of the district's elementary schools
and Thomas Edison Middle School during the Z002 summer months. A
majority of the program's participants qualify for the district's
~free lunch" program.
3-25-2002
SFSP Application Submittal
Participation in the TDHS Summer Food Service Program would allow
the city to provide lunches to the program participants at the
elementary schools and the middle school. The City successfully
participated in the program last year. The elementary schools
proposed for this year's program are: Franklin Elementary, Pease
Elementary, Sam Houston Elementary, Travis Elementary, Tyrell
Elementary, Washington Elementary, Wheatley Elementary. Thomas
Edison Middle School, as the site for S~er School this year, will
replace Woodrow Wilson Middle School.
B~OgL'T~RX/FX$CAL r, rr~CT:
T~e Cit~ wiX1 be z~t~mb~ree4 for
pr~gz~ ~nfe~z&tXve goat. Approval of this proposed resolution
will require appropriation of funding in the amount of $166,713.75
which is reimbursable from the Texas Department of Human Services
(TDHS).
The City will be reimbursed by THDS for administrative costs for
operating the program; also, the City will be reimbursed by the
State of Texas for program participation. These reimbursements are
in addition to the reimbursement for each meal served.
ST~:
No extra staffing is needed; personnel ordinarily hired to work the
Summer Recreation Program-will be all that is required.
It is recommended that the City Council adopt Proposed Resolution
No. 11695, which authorizes the City Manager to submit an
Page 3 of 3
3-25-2002
SFSP Application Submittal
application to the Texas Department of Human Services (TDHS) Summer
Food Services Program for the purpose of providing meals to Summer
Recreation Program parti~ipants at the program's designated
schools.
P.R.# 11695
03/25/02 klb
RESOLUTION NO.
A RESOLUTION AUTHORIZING THE CITY MANAGER TO SUBMIT AN
APPLICATION TO THE TEXAS DEPARTMENT OF HUMAN SERVICES
(TDHS) SUMMER FOOD SERVICE PROGRAM FOR THE PURPOSE OF
PROVIDING MEALS TO THE SUMMER RECREATION PROGRAM
PARTICIPANTS AT THE PROGRAMS ELEMENTARY SCHOOLS.
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PORT ARTHUR:
THAT the City Council of the City of Port Arthur hereby
authorizes the City Manager to perform all tasks necessary to
submit an application to the Texas Department of Human Services
Summer Food Service Program for the City of Port Arthur's Summer
Recreation Program to provide meals to the youth participating in
the program at the elementary schools; and
That a copy of said application is attached hereto, made part
of hereof as if set out in its entirety as Exhibit ~A".
THAT a copy of the caption of this Resolution be spread upon
the Minutes of the City Council.
R~AD, ADOPTED AND /%pp~r-~D THIS__ day of
A.D., 2002, at a Regular Meeting of the City Council of the City of
Port Arthur, Texas, by the following vote:
AYES:
MAYOR:
COUNCILMEMBERS
P.R.~ 11695
03/25/02 klb
NOES:
MAYOR
ATTEST:
Acting City Secretary
APPROVED AS TO FORM: ·
Mark Sokolow
City Attorney
APPROVED FOR ADMINISTRATION:
Ste-p~'en B. Fitzglbbons
City Manager
Albert Thigpen
Interim Director Parks & Recreation
EXHIBIT ~Am
TEXAS DEPARTMENT OF HUMAN SERVICES
SPECIAL NUTRITION PROGRAMS
AGREEMENT
STATE oFTEXAS §
COUNTY OF TRAVIS §
The Texas Department of Human Services, hereinafter referred to as TDHS,
THE CITT OF PORT ARTHUR
hereinafter referred to a~ thc ContractOr, do hereby make and ente~ into this contract, as required by thc National School Lunch
Act and the Child Nutrition Act, as amended, and the following program regulations: the National School Lunch Program
(NSLP), 7 Code of Federal Regulations (CFR) Part 210; the Special Milk Program (SMP), 7 CFR Part 215; the School
Brealffast Program (SBP), 7 CFR Part 220; the Summer Food Service Program (SFSP), 7 CFR Part 225; and the Child and
Adult Care Food Program (CACFP) 7 CFR Part 226.
This agreement establishes or continues the rights and responsibilities of TDHS and the Contractor pursuant to thc Contractor's
participation in one or more of the above named programs as stipulated herein. If this agreement continues an existing
agreement, all existing terms, conditions, liabilities and obligations of the parties under the prior agreement remain in full force
and effect, except to the extent that those terms, conditions, liabilities and obligations conflict with this agreement, in which
case~this agreement takes precedence.
By signing this agreement, both parties are bound by its terms and conditions from its beginning effeutive date, or the beginning
effective date of any prior agreement/s continued by this agreement, until terminated in accordance with this agreement.
MUTUAL AGREEMENTS
Thc Parties mutually agree:
A. I fthe Contractor fails to provide services in accordance with the provisions of this contract, TDHS may, up°n written ri°rice
of default to the Contractor, immediately terminate the whole or any part of this contract, including refusal to pay claims
foe reimbursement, and such termination shall not be an exclusive remedy but shall be in addition to any other rights and
remedies provided by law or under this contract.
If federal or state laws or other requirements arc amended or judicially interpreted so that thc continued fulfillment of this
contract, on the part of either party, is substantially unreasonable or inapossible, 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 pc'vied. Nothing
in this paragraph shall be construed to prohibit immediate cancellation pursuant to above paragraphs A and/or B.
II.
CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT
A. The Contractor will comply with the applicable regulations for its designated program, as well as 7 CFR Parts 245 and 250,
as amended, the Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), Audits of State, Local
Governments, and Non-Profit Organizations (7 CFR 3052, as amended)and state policies and procedures as issued and
mended by TDHS. The Contractor further agrees to perform as described in its application (including its Policy statement
and supporting documents, and approved amendments t.o the application) for participation in the designated program.
B. The Contractor accepts final administrative and financial responsibility for food service operations in each schcol, summer
feeding site, and child and/or adult care facility, hereinafter referred to as a site, operated or sponsored by the Contractor.
The responsibility includes uny audit exceptions or payment deficiency in the program covered by this contract, and all
subcontracts hereunder, which are found after monitoring or auditing by TDHS or USDA and will be responsible for the
collections and payback of any amount paid in excess of the proper claim amount.
C. The Contractor submits for TDHS approval only those applications for sites which have delegated the authority for the
administration of food service operations to the Contractor or which have executed subagreements with the Contractor for
the administration of food services operations.
D. Contractors participating in the NSLP agree ~
1. ~ that the official signing the Claim for Reimbursement will be responsible for reviewing and analyzing meal
counts to ensure accuracy and compliance with federal regulations
2. to enter into un agreement to receive donated foods as required by federal regulations, and
3. to price lunch as a unit
E. Contractors participating in the CACFP provide or accept responsibility for the provision oforganized, non-residential child
day care and will immediately report to The Texas Department of Protective and Regulatory Services (TDPRS) Licensing
or Child Protective Services staff, any suspected violations of TDPRS Licensing standards or suspected abuse of children
in sponsored centers or day homes.
III*
RECORD KEEPING
A. The Contractor will keep financial and supporting documents, statistical records, and any other records pertinent to the
services for which a claim was submitted in the manner and detail prescribed by TDHS. The records and documents will
be kept for a minimum of 3 years and 90 days at~er the termination of the federal fiscal year for the relevant program. If
any litigation, claim, or audit involving these records begins before such period expires, the Contractor will keep the records
and documents for not less than 3 years and 90 days and until all litigation, claims or audit findings are resolved. The case
is considered resolved when there is a final order issued in litigation, or a written agreement is entered into between TDHS
and the Contractor. The Contractor will keep records of non-expendable property acquired under the contract for 3 years
and 90 days after final disposition of the property.
B. The Contractor and its subcontractors will allow TDHS and USDA officials and other appropriate officials determined by
TDHS to inspect facilities and records and to audit, examine, and copy records at any reasonable time. This includes access
to all records 0f costs paid, even in part, by TDHS.
C. The Contractor and its subcontractors will establish a method to secure the confidentiality of records und other information
relating to clients in accordance with the applicable federal law, roles, and regulations, as well as the applicable state law
and regulations. The provision shall not be construed as limiting the Department's right of access to recipient case records
or other information relating to clients served under this contract.
D The Contractor certifies that the goods and/or service(s) covered by this contract are designated to be used prior to, during,
and after calendar year 2000 AD. The goods and/or service(s) will be operated during such time periods without error
relating to date which represents different centuries or more than one century.
IV.
CIVIL RIGHTS POLICY COMPLIANCE
A. Thc Centr:actor agrees to comply with Title VI of the Civil Rights Act of 1964 (Public Law 88-352) and ail requirements
imposed by the regulations of the Department of Agriculture (7 CFR. Part 1 $), Department of Justice (28 CFR. Parts 42 and
50) and FNS directives or regulations issued pursuant to that act and the regulations. Section 504 of the Rehabilitation Act
of 1973 (Public Law 93-112), the Americans with Disabilities Act of 1990 (Public Law 101-336), Title IX of the Education
Amendments of 1972 (7 CFR Part 1 Sa), the Age Discrimination Act of 1975 (Public Law 94-135), and all amendments
each, and all requirements imposed by the regulations issued pursuant to these acts. In addition the contractor agrees
comply with Title 40, Chapter ?3, of the Texas A s, tive .. ese that.no, pe. on in,th,¢ ted
States shall, on thc ground of race, color, national origin, sex, age, disability, pontlcat ocders, or renglon vc excmac~ from
participation in, or denied any aid, care, service or other benefits pmv. ided by federal a?/. or...sta, te ~fun..ding,..? .o~ .c~-w!s,c. be
subjected to discrimination. The contractor also agrees to comply w~th Health and Surety ~oue ~ect~on 5~.1 ~ ~remung
to workplace and confidentiality guidelines regarding AIDS and HIV).
Thc contractor hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement.
· ' · federal financial assistance, grants
B. This assurance is given in consideration of and for the purpose of obtaining any and all
and loans of federal funds, reimbursable expenditures, grant or donation of federal property and interest in property, the
detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or
the furnishing of services without consideration or at a nominal consideration, oi' 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 program applicant
by the TDHS. This includes any federal agreement, arrangement, or other contract which has as one of its purposes the
provision of cash assistance for the purchase of food, and cash assistance for purchase or rental of food service equipment
or any other financial assistance extended in reliance on the representation and agreements made in this assurance.
C. The Contractor agrees to compile data, maintain records, and subnut reports as required, to permit effective enforcement
of the above Acts and permit authorized TDHS, USDA and FNS personnel during normal working hours to review such
· · If there are any violations of this
records, books, and accounts as needed to ascertain comphance with the above Acts.
assurance, TDHS, USDA and FNS have the fight to seek judicial enfomement of this assurance. This assurance is binding
on the Contractor, its successors, transferees, and assignees as long as it receives assistance or retains possession of any
assistance from the department. The person whose signature appears on this contract is authorized to sign this assurance
on the behalf of the Contractor.
D. A religions or charitable organi~'ati°n is eligible t° be a c°ntract°r °n the same basis as any °ther private °rganizati°n' The
contractor retains ~ta independence from State and local governments, mchiding the contractor's control over the definition,
development, practice, and expression of its charitable or religious beliefs. Except as provided by federal law, TDHS shall
not interpret this contract to require a charitable or religious organization to alter its form of internal governance or remove
religious art, icons, scripture, or other symbols. Furthermore, ifa religions or charitable organization segregates the
government funds provided under the contract, then only the financial assistance provided by these funds will be subject
to audit. However, neither TDHS's selection of a charitable or faith-based contractor of services nor the expenditure of
funds under this contract is an endorsement of the contractor's charitable or religious character, practices, or expression.
The purpose of this contract is the provision of services; no State expenditures have as their objective the funding of
sectarian worship, instructions, or proselytization.
A charitable or faith-based provider of services under this contract shall reasonably apprise all assisted individuals of the
following: "Neither TDHS's selection ora charitable or faith-based provider of services nor the expenditure of funds under
this contract is an endorsement of the pmvider's charitable or religious character, practices, or expression. No provider of
services may discriminate against you on the basis of religion, a religions belief, or your refusal to participate in a religious
practice. If you object to a particular provider because of its religions character, you may request assignment to a different
provider. If you believe that your rights have been violated, please discuss the complaint with your provider or notify your
local TDHS Special Nutrition Programs office.
Section 104 of The Personal Responsibility and Work Opportunity Reconciliation Act of 1996.42 U.S.C. § 604a, sets forth
certain additional rights and responsibilities for charitable and faith-based providers of services, certain additional rights
of assisted individuals, and certain additional responsibilities of TDHS to these providers and assisted individuals. This
contract is subject to those additional rights and responsibilities.
TDHS CLAIMS PAYMENT
A. TDHS will, subject to the federal appropriation and availability to TDHS of sufficient funds for the applicable
program, make program payment to the Contractor in accordance with the terms of this agreement. No reimbursement
shall be made for performance under this agreement occurring prior to (a) the beginning effective date of this
agreement or (b) a later date established by TDHS based on the date of receipt of a fully executed copy of this
agreement.
B. In accordance with Section 403.055(h) of the Government Code, as added by Act of May 19, 1999, 76th Leg. R.S., ch.
583, Sec. 1, 1999 Tex. Sess. Law Ser. 3125 (Vernon), afiy payments owing to the contractor under this contract will be
applied toward elimination of the contractor's indebtedness to the state, delinquency in payment of taxes to the state, or
delinquency in payment of taxes that the comptroller administers or collects until the indebtedness or delinquency is
paid in full. This elanse does not apply if federal law requires payment to be made to the contractor for goods and
services provided in support of any of the USDA child and adult nutrition programs, and may not apply if federal law
conditions the receipt of the money for these goods or services to the state on the basis of payment being made to the
contractor;
IMMIGRATION
The Contractor agrees to comply with the requirements of the Immigration Reform and Control Act of 1986 regarding
employment Verification and retention of verification forms for any individuals hired after November 6, 1986, who will
perform any labor or services under this contract.
CERTIFICATION
A. Regarding Debarment, Suspension, Ineligibility, or Voluntary Exclusion For Covered Contracts - The contractor
certifies, by execution of this agreement, that neither it nor its principals is presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participating in this contract by any federal department or
agency or by the State of Texas. By making this certification the contractor agrees to the following terms:
1. The above cortification is a material representation of fact upon which reliance was based when this contract was '
entered into. If it is later determined that the contractor knowingly rendered an erroneous certification, in addition
to other remedies available to the federal government, the Department of Health and Human Services, United State
Department of Agriculture or other federal department of agency, or the Texas Department of Haman Serviens may
pursue available remedies, including suspension and/.or debarment.
2. The contractor shall provide immediate written notice to the persnn 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 circomstaeces.
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 Exeentive Order 12549. Usage is defined in the
attachment.
4. The contractor agrees by submitting this certification that, should the proposed covered contract be entered into, it
shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or
voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health
and Human Services, United States Department of Agriculture or other federal department or agency, and/or the
Texas Department of Human Services, as applicable.
VII.
CERTIFICATION
(Continued)
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 all solicitation for all covered subcontracts.
A contractor may rely upon a certification of a subcontractor that it is not debarred, suspended, ineligible, or
voluntarily excluded from the covered contract, unless it knows that the certification is erroneous. A contractor
must, at a minimum, obtain certificates from its covered subcontractor upon each subcontractor's initiation and
upon each renewal.
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.
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 Haman Services, United States Department of Agriculture, or other federal department or agency, as
applicable, and/or the Texas Department of Human Services may pursue available remedies, including suspension
and/or debarment.
'B. Regarding Federal Lobbying - This certification applies only to this contract and is a material representation of fact
upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a
prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than $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:
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.
If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of
Congress, or an employee ora member of Congress in connection with this federally funded contract, subcontract,
subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form
to Report Lobbying," in accordance with its instructions.
The contractor shall require that the language of this certification be included in the award documents for all covered
subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative
agreements) and that all covered subrecipients shall certify and disclose accordingly.
C. The contractor certifies that if it is a corporation, it is either a for-profit corporation that is not delinquent in its
franchise tax payments to the State of Texas, or is a non-profit corporation or is otherwise not subject to payment of
franchise taxes to the State of Texas.
D. The contractor certifies that all information submitted pursuant to this agreement is true and correct. The contractor
understands that the deliberate misrepresentation or withholding of information is a violation of this contract and may
result in prosecution under applicable state and federal statutes.
E. Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in
this contract, bid, or application is not ineligible to receive the specified grant, loan, or payment and acknowledges that
this contract may be terminated and payment may be withheld if this certification is inaccurate.
VIII.
EFFECTIVE DATE AND SIGNATURES
The parties hereto in their capacities stated, affix their signat~es and bind themselves for the faithful performance of the
terms of this contract pursuant to participation in the following program or programs:
National School Lunch Program
School; Breakfast Program
Special Milk Program
Child and Adult Care Food Program
Summer Food Service Program
Name of Contracting Organization
(Please print or type)
Signature of chairman of the board of directors
or other official who has been authorized to sign
contracts on behalf of the contracting organization.
Name of Official Signing
(Please print or type)
Title of Official
(Please print or type)
TEXAS DEPARTMENT OF H1JMAN SERVICES
Effective from
By:
TDHSRepresentative
until terminated.
Date:
Approved for Form by OGC: ~
Revised May 2001
SUMMER FOOD SERVICE pROGRAM
APPLICATION FOR PARTICIPATION
Give as much information as possible. Attach
additional sheets if needed; identify each
attachment with the name of the contracting
organization. ~
E:]A.H. Supp. E:lLun:h E:]P...supp. [:]S.pp.r []Al,
SECT]ON -SPQNSOR INFORMATION
CITY OF PORT ARTHUR, TEXAS
Mailing Address (Street or P.O. Box, City, State, ZJP)
444 4th STREET P.O. BOX 1089
Texas ID NO. Telephone No,
1-74-6001889-00~ 40g) 983-8210
PORT ARTHUR, TX 77641
Ho~i~.) 983--~619
81 th I ~lpenlportar thur - net
1368 9th AVENUE PORT ARTHURr TX 77642
OR. ALBERT T. THIGPEH
CITY MANAGER
(409) 983-8210, 983-~619
A. Contractor Classification (Check alt'that:a~3ply):
r~l ResidentJafiNonrssidential ~ Unit of Govemmset-Contractar certifies that all food
[~ National Youth Spots Program I I Summer Camp IXJ service sites are operated directly by the contractor.
~ Continuous Calendar
[] SchOol Food Authority U School Year [] Private Non-profit
S. Is your 15rogram a year-round prograph? ...... ~.~';:~.-~-~-- ............................................................. E~]Yes r'~No
C. Type~-c~f Contracto . * · ~ ~ ' ~":
[] Public Entity
is y?ur agency considered to be stale owne~operated? ................................................................ [--~Yes [~]No
DO you depo;it your program reimbursement directly into the State Treesur¥? ................................... [] N/A r~JYes [] No
Do you deposit your program reimbursement in~ a local bank? ................................................ [] N/A [~]Yes [] No
· Ifyes, is it direct deposit? ......................... ~--'.-~ ......... L.~ ......... ": .................. ~ ............. []Yes ['--~No
[] Private Nonprofit Organization-Tax-exempt status established. Attach ?tter of determination (iRS 501-30) of tax-exempt sta[us from IRS.
Do yo'u deposlt your program reimbursement into a local bank? .............................................. ~.[]N/A []Yes r--]No
If yes, is it direct deposit? .................................................................... ;~ ........ ~ ........ E~Yes r--~No
D. Does the organization provide ar~ ohgoing year-rbund servic~ to the community that is to be served by : ~ [] No
the Summer Food Service Program (SFSP)? .............................................. ,- ........................... Yes
~. If rl?.which of ~ following circumstances appl!es?, ~ ~ F ~ ~
[] Residential Camp [] Failure to operate would deny program to a poor area
[] Serves Migrant Children [] Failure to operate would deny a significant number of children access to program
E. Does the organization expend $300,000 or more in federal funds yeaAy? ........................................... [-J~Yes [] No
Attach a copy Of the audit covering last year's program o~eretion or documentation that an audit conforming with SFSP policy will
be conducted, including the date it will be conducted.
SECTION II-BUDGET
A Estima e ail SEeP costs which w~ll be claimed fo~' reimt~rsement for t~e program year:.
EST~MA'~ED OPE~FtONAL COSTS · COaTa
drain sb'ative Labor
Program Labor [ [(Management, Monitor, Clerical)
Fringe Benefits ~ Fdnge Benefits
Food
Non-food Supplies
UtU~ties
Rent '
Equipment Use Fee
TransportatJ0n
Rate per rfile
Office Supplies -
Offce Building Maintenance , ,-
IEquipment Use Fee - ; ·
Naade~fe4. y SFSP Conference
] Legal Fees
~ (s~):
Outreecb/A4wertlsl ag
her
Te I
S 9,116.00
4~.46~.00
~ 2.000.00
I 't ~00-00
800.00
! °242.00
I ,600.00
TOTAL 2: S 2t ,924.00
DIRECTOR ~
PROGRAM/SITE MONITOR
SECRETARY ~
POSITION
!
t
PROGRAM AND SITE MANAGEMENT ~--
PROGRA# AND SITE MONITORING ~
MAINTAINING FILES, RECORDS, CORRESPONDENCE
TOTAL 1:
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 f~nds.}
SECTION IIF-MANAGEMENT pLAN
A. List administrati'~'e level personnel who will be responsible for management and monitoring of the SFSP. (Do not inctude site
cooks 'anitors or other personnel involved in or.site food service.) ~
supervisors, , ] ~ ~
B. Are children charged separately for meals? ................................. - .......... E~Yes [] No
If yes, complete Form 1506, Attachment A (page 2), and submit with this app[ice§?n.
C. Do you want to receive advance payments?
Fo Opera.o.a, Oosta? r;-IYea [].o For ^dm nistrativa Costs? []yes [].o
..
D. If meal so.ica is self-preparation, do you ~nt to re.lye ~mm~!tles ..............................................
If yes, Fo~ 1608, ~pfi~tion and Agreement for Comm~ities, must be ~mplet~ and re~med with your SFSP appli~tion.
SECTION tV-PROGRAM OPERATION
I A. 1. Beginning and Ending Dates of Meal Service .e C Iosed Ju I y 4, 2002 ~A.2. Number of Sites
FROM: June .~, 2002 TO: August 9, 2002
H
B.
List dates and topics of SFSP training:
TOPICa
DATES
June 7, 2002 ~lvll Rights
Is the:or anization current y contracting with a year,.round food service management company?.~. -: .................... [] Yes [] No
C If ye~; ~ugbmit a copy of your procurement procedures, b~d, contract, and all amendments, skip Item D If no, complete Item D
D. Is the organization planning to contract with a food service management company? ................................... ~'~Yes [] No
If yes, and the contract wtil exceed $10,000, attach a copy of the invitation to bid. Also give:
Date of Bid Publication Place of Publica~on Date of aid Opening Time of Bid Opening
I · .... ~ ~nfl~ Port Arthur
is~iciexpectecqtobe$100,00Oormore? .ifyes, giveplaceolbidoPefling: 444 4th ST. l
[~]Yes [ iN0 ~ 5th Floor Council Chambers, City Hall Hain Tover Port Arthur T~
^]so, attach a 'copy of a minimum 11 -day-cycle menu including ati specific menus to be used.
E, Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department notifying them of intent to
operate a Food Service Program at the site(s) indicated on the attached Site Information sheet (Form 1507).
F. Are you implementing the option to allow off-site consumption of food? ............... [] NI Sites [] Some Sites [] No Sites
SECTION V-ASSURANCES
A. Free Meal Policy Statement
I, The conb'acti~g or~an~.atiO-n assures the Texas Department of Human Services (DHS) that ali children a the sites described on the
Site(s} Information Sheets for the Summer Fond Service Program, will be offered the same meats with no ~)hysical segregation of, or
other discrimination against, any child because of race, color, disability, age, sex, national origin, religion, or political beliefs. No
separate charge will be made for any meal except in accordance with attachment A of this application.
2.TNB 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 chlldren whose meals witi be reported as f~*ea
or reduced~pHce; and
· The children claimed as free or reduced-price meet the current family size and income standards set by the United States
Depar?~ent of Agriculture, DHS Form 4504, Standards for Determining Free and Reduced-Price Eligibility.
3. if the contracting organization is sponsoring a camp or other enrollment program that charges separately for meals, the contracting
organization has read Atlachment A 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 organizalion will make efforts to ensure that the local news media will make a public announcement of the program
and w~[I supply them with a news release:
If the contracting organizalion is sponsoring a camp or other enrollment program, t~is role'asa must contain, at a minimum, a list of all
approved sites, a list of the current standards for determining free and reduced pdce eligibility, and the following statement:
"The (Nameofthecentra~ngorganizafion) 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-206, Texas Deparb'nent 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 ali other programs the announcement must contain, at a mthimum;a list of ail approved sites and the following statement:
(Nam®°ftheccmtradang°n2an[za~°n) announces the sponsorship of the Summer Food Service Program.
Meals will be provided at the site(s) listed. People who are alii]ibis to participate in the program must not be discriminated
against because of race, color, national origin, sex, age, disability, religion, bT Political belief. Anyone who believes that
they have been discriminated against should ~n'ite immediately to.' Director, Civil Rights Division, MC W-206, Texas
Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington,
D.C. 20250. NOTE: Discrimination complaints based on religion or political beliefs must be referred only to the Director,
Civil Rights Division, Texas Department of Human Services."
2. This ~ ~ublic release was or will be published in the following news media outlet(s):~ ~; ~ ~'
NAME OF MEDIA OUT~T DATE OF RELEASE
~/ZO 6/02
The Purer Arthur NeMS ~/ne
Local Governlent Channel 05/01/02
Locul.-School District Cbuaae Oi/nl/a~
NAME OF MEDIA CUTLET DATE OF RELEASE
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 availabliily and nondiscrimination redu[rements.
SECTION VI-WAIVER REQUESTS (Check all for which yea are appiythg, auhmE appropriate waiver request form and documentation.
[] Waiver to operate more than 25 sites (Nonprofit organizations only.)
r~ Waiver Of the time restrictions for meal service at migrant sites. _.
[] W;iVa, ofthe 15,0~lSscufi~e school day requirement for year-rsund sch. ool program sites.
]Waiver of the first-week site visit requirement (School Food Authorities only).
SECTION VII- CERTIFICATION (see Form 1506, Attachment B)
I certify that the i'nforma{ion on this application ia t~l. le and correct to t~e 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.
Name (pl~ type or pd~t)
Dr. Albert T. Thl~pen
FOR DHS USE ONLY
Dlrector of Purks end Recreut on
['"'~ APPROVED r-}DENIED (reason):
SUMMER FOOD SERVICE PROGRAM FOR CHILDREN
CRIMINAL PROVISIONS AND PENALTIES
1. Whoever, in connection with a-~ly 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 materia{ fact, or makes any false, fictitious or fraudulent statements or whoever in
connection with the program knowingly makes an opportunity for any person to defraud the United States or does or
omits to do any act with intent to enable any person to defraud the United States, shall be fined not more than $10,000
or imprisioned not more than five years.
2. Whoever being ~ partner, officer, d[ractor, or managing agent connected in any capacity with any partnership,
association, cooperation, business, or organization, either public or private, embezzles, misapplies, steals, or obtains
by fraud, false statement or forgery, any benefit provided by the program, or any money, funds, assets, or property
derived from benefits provided by this program, shall be fined not more than $10,000 or imprisoned for not more than
five years or both. If the benefits, money, funds, assets, or property involved is not over $200, then the penalty shall be
a fine of not more than $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 is a list cf deficiencies that ara grounds for termination. Grounds far termination, however, are not limited to this list.
1. Non.compliance with applicable bid procedures and contract requirements of Federal Child Nutrition regulations.
2. The submission of false information to the Texas Dopartm ant of Human Services.
:3. Program violations at a significant proportion of the sponsor's sites. Such violations include, but are not limited to the following:
A. Non-compliance with the meal service time restrictions.
B. Fa}lure to maintain accurate records.
C. Failures to adjust meal orders to conform to the variations in the number of participating children.
D.The simultaneous service of more than one meal to any' child.
E. Service of a significant number of meals which do not include required quantities of all meal components.
F. The claiming of program payments for meals not served to participating children.
G.Excessive instances of off-sita meal c~nsumption.
H. Continued use of food service management companies that are in violation of health codes.
ATTACHI~ENT
SUMMER FOOD SERVICE PROGRAM (SFSP) APPLICATION
OUTREACH PLAN FOR OPEN AND RESTRICTED OPEN SITES
If you operate open sites or restricted open sites, indicate your plans for conducting
outreach to inform persons about the operation of the SFSP at your sites and promote
participation at your sites. Check all that apply,
~ Make television announcements.
[] Make radio announcements.
[] Send letters to potential participants.
[] Distribute flyers to potential participants.
[~ Display posters at locations visited by potential participants.
[] Offer activities other than meals at sites.
[] Partner with other organizations to advertise and promote the program.
[] Other. Explain: .
Janum3', 2002
SUMMER FOOD SERVICE PROGRAM FOR CHILDREN
COLLECTION OF PAYMENT OPTIONS
FOR PROGRAMS THAT CHARGE SEPARATELY FOR MEALS
(camps and Other Enrollment Programs Only)
NOTE: Check the Collection Procedure that you will use:
[I-~ 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
service 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 the
office for accounting purposes. This method works only in a small site whet6 the staff member knows all the children.
r-~ COLLECTION PROCEDURE 3
The site supervisor gives each child an envelope for daily, weekly, session or monthly payments. Children return the
envelopes with the payment 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
Parents pay In advance by the month or session. Each sits supervisor receives a list of those children who have pald.
The site supervisor mar~s 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 sends the records to the
office for accounting purposes.
~---] COLLECTION PROCEDURE $
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
secrets~/distributes Identical tickets labeled only with the children's names. Since the parents may make payments,
even chi~ldren who receive free meals may not know whether their meals are free or paid.
E~ COLLECTION PROCEDURE 6
Parents are billed monthly or by session for paid meals their children are served. Parents mall in all payments. All
participating children receive a coded ticket each month, which is punched at each meal service. At the end of the
month, the tickets are collected and a cler~ calculates the amount to be billed,
COLLECTION PROCEDURE 7
F-"] Other:. Explain in detail; use an attachment if more space s required.
NOTE: The contractor must ensure that this method prevents the overt identification of children receiving free meals.
SITE INFORMATION
FRA#ICLIH ELENE#TAR¥ SCHOOL
lO00 lOth STREET PORT ARTHUR TX 77640
](409 ) 98~-2~ 7:~'
From: June 10. 02through:Aug. 9. 02I eratingDsys:
Y
A'J-TAC H A MAP WITH THE SITE SERWCE AREA IDEN~FIED
Reside~al Camp
1. Indi~[a Ty~ of Site: ~ (seeing one ~ three meal~}
Honre~denEal ~mp
~ (se~ing one ~ three meals)
2. Lis[ ALL ~unties sewed by ~is si[e: Jef fe~son
r-lsRa se~ing Pdman'ly Migrant Children
(se~ng one to three meals}
[~] OUler 5it~
(serving one or ~o meals)
3, A. is your site an open or restricted open site? ........................................................ ['~Yes ['-'~ No
B. Is your site enrolled? .......................................................................... ['~Yes
C. Site Eligibitity: Enter He percentage of children eligible for free and/or
reduced price meals for the site (SFSP Handbook, Section 2) ............ .C.E.#$ .0.~..T.R..A.C.T...6.1 ............ 72.82
D. if opeNresthcted open sites, submit documentation supl:~dJng this percenLage t~gure (such as census data, school data). For oper',/resthcted
open sites using school data, tist the schools used to document site e]igibilib/; attach formula used by school dist. to establish percentage or [res
& reduced pdce children.
E. For eer~o~l~d sites, Forms 1531 wilt be used to document eligibility. (NaUonal Youth Sports Program-re[er to SFSP Handbook. Section 2.)
If the enrolled site used school data, llst the school used to document Ihs site:
F. What is the percentage of free and reduced-price meals for the site? ..................................... 84 %
4. Did the site partJclpate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ [~'~Yes [] No
if yes, Give name of contracting organization:, C I TY OF PORT ARTHUR
5. Monitoring Plan (SFSP Handbook, Section 4)- Enter date of monRodng review to be conducted within:
6. Meal Service Period Information SFSP Handbook, Section 2):
Breakfast
.:
A.M. Supplement
Lunch 400 I1:00 A.M. 12:00 A.M.
P.M. Supplement
Supper
7. Do you plan lo feed children under one (1) year old? ................................................................. E--~_~Yes [] No
8. Ms~hod of Fo~d Preparation by Contracting Organization (SFSP Handbook, Section 2)
9. A. ]ndica~e the system ~o be used for the se~ying cf meals and the supervision of childran during meaI service p=3dcd. (SFSP Handbcok, Section 2)
[...--~Cal~teria-s~ie t--"l Children are Seated r':Ti Children Line Up
NaaiSa~ice I land are Given Meals IX~andPickUpMeels ['--~Other: '
B. If using ca[eteda-s['/e meal semice and if s~::nsor is a school food authod~,, w~l[ the site be implementing offer vs. serve?.. [] Yes [] No
10. List sro pers0nne[ who w~ll be involved to any extent in the meal service. (SFSP Handbook, Section 2):
TrrLEOFPOSIT~N NO. INPO$1TION SPECIFICFOODSER~CEPROGRAMDU~aS
Supepvl$or I To See That Each Chlld Gets a Meal
t
11. thdlcale what provisions will be made for meal service dudng periods of inclement weather. (SFSP Handbook, Section 2)
l-~]tndoor Meal r~lMeaT Service
Service L.J Will Be Cancelled []Other:
12. is this site implementing the apron b3 allow off-site consumption of food? ................ :. .................................... []Yes [] No
13. Ara meals delivered to the site? ...................................................................................... [~]Yes [] No
IF YES, COMPLETE iTEMS 14, 15, & i6. IF NO, FORM I$ COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14, thd]cate t~e-me aris o[ communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and
[-~.jSita Personnel Will Contact Administrative r--.q Site Personnel Will Communicate
Staff, Who Will Contact Vendor I IDirectly With Vendor
15. Will delive~J be wlthin one hour of the food service period? (SFSP Handbook, Section 2) ................................ l'~Yes
If no, desctibe arrangements within standards prescribed by local health authorities for delivery and holding of meals until [ime of service.
16. if there is an excess al'meals delivered, meals wl]] be (SFSP Handbook, Section 2
r-.-1stored in R.efrlgerator r~-~Thmwn Away nReturned to Vendor
r-"l
and Served the Next Day IXlat the ere L.J for Disposal I lather:
I CERT1FY that the information on this form is true and correct to the best of my knowledge. I cer~fy that this site has been visited
and that it has the capability and facilities for the meat service planned for the number of children anticipated. I know that
deliberate misrepresentation or wi~hoiding of information may result in prosecution under applicable state and federal statutes.
Or. Albert T. Thlgpen Interla Director of Parks & RecreatlonI
SUMMER FOOD SERVICE PROGP,.~M
SITE INFORMATION
PEASE ELEHEHTART SCHOOL
5924 ..IAO~ AV~MilF PORT ARTHUR TX 77642
From: June 10, 02through:Aug. 9, 02 eratingDays:
ATTACH A MAP WITH THE SiTE SER'vlCE AREA IDENTIFIED
Residential Camp '
1. Indic. ate Type of Site: L_.J (serving one fl: three meals)
Nonres~den~at Camp
I I (serving one t~ three meals)
2. List ALL counties served by this site: Jef ret'son
(409) 736-1142'
Sen'ing Pdmadiy Migrant ChikJren
one ~ three meals)
one or ~o me~s)
3. A; Is your site an open or restricted open site? ........................................................ [~Yes [] No
B, 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, Section 2) ............ .C.E ~SIIS TRACT 71 :~6.4~
D. if openlrest,ficted open sites, submit documentation suppling this percentage figure (such as census da[a; school data). For open/res~cted
open sites using school data, list the schools used to document site eligibi[i~,; attach formula used by school dist. to establish percentage ct free
& reduced )rice children.
E. Fcr enrolled sites, Forms 1531 will be used to document eligibili~. (National Youth Sports Program-refer to SFSP Handbook, SecQon 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced-price meals for the site? ..................................... 75 %
4. Did the site parc[pate in the previous years' SFSP? (SFSP Handbook, Section 2} ............................ }-~'~Yes [] No
If yes, give name of contracting organlza~ion: C I T¥ OF PORT ARTHUR
5. Monltodng Ptan (SFSP Handbook, Section 4)--- Enter date of monRodng review to be conducted within:
E. Meal Service Period Information SFSP Handbook, Section 2):
Breakfast
A.M. Supplement
P.M. Supplement
Supper
7. Do you plan to feed children under one (1) year old? ................................................................. [.Z_lYes LJ No
8. Method of Food Prepare(ion by Contracting Organization (SFSP Handbook, Sec[ion 2)
/
[] Food Au~hoS,~7 [] (axc)udes all-year co~tracts with on-sRo prep) [] Organization that is Sa~f-Prep j
g. A. thdica~e the s'/s:em [o be used tor ~e se~ing c~f meals and t~he supervision of ~tidren dudng ~a~ sa~ic~ ~d~. (SFSP Hand.ok, SecU~n 2)
~Caf~teda.s~e ~ Children are Seated ~ Children Line Up
~eal Se~[ce ~and are Given Meals ~ and Pick Up Meals ~ Other: '
8. if using ca[eteda-s~le mea~ semi~ and ~ s~nsor is a sch~[ food au~od~, ~11 the site ~ implementing o~r vs. se~e?.. ~ Yes ~ No
10. Us[ site pemonna~ who wilt ba invo[v~ [o any extent in the meal se~i~. (SFSP Handbook, Section 2):
SupePvisor I To See That Each Child
1 1. Indicate what provisions will be made for ma. al service dudng periods of inclement weather. (SFSP Handbook, Section 2)
~-~.]Iedoor Meal r---1 M eel Service
Service I IWii[ Be Cancelled [~Other:
12. Is this site implementing the option ~ allow off-sit e consurnption of food? ................ :- .................................... I'--~.Yes
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 t~e means et communicaUon with the vendor which will be used to adjust meal dellvedes. (SFSP Handbook, SecUons 2 and 6)
r.~lSita Personnel V/ti[ Contact Administrative r..-1Site Personnel Will Communicate
Staff, Y/h0 Will Contact Vendor I IOirectly With Vendor
15. Wi[I delivery be within one hour of the food service period? (SFSP Handbook, Section 2} ................................ r~Yes [] No
I[ no, dosc~be arrangements within standards prescribed by local health authorities for detivery and holding of meats un[ii [[me of service.
16. It there i~ an excess of meals delivered, meals will be (SFSP Handbook, Section 2)
~.~lStor ed in R~frigerator i~T.1Th rowe Away nReturned to Vendor
and Sen'ad the Next Day IX let t~e $~te IIfor Disposal UOther:
I CERTIFY that t~e information on this form is t~ue and correct to the best of my k~ow~edge. I certify that this site has been visited
and that it has the capability and faciIities for the meal service planned for the number of children anticipated. I know t~at
deNberata mlsrepresentat~on or wi~hotdin9 of information may result in prosecution under applicable state and federal statutes.
DHS
SUMMER FOOD SERVICE PROGP, A~M
SITE INFORMATION
SAN HOUSTON ELENENTAHY SCHOOL " *' (409) 985-552~-
3245 ~;6-1-h STREET PORT ARTHUR, TX 77642
,rom: June 10, OZthrough:Augo 9, 02 e~ingDay,: ~ 15 ~ 22 ~^~'
ATTACH A I'daP WiTH THE SITE SERVICE AREA IDENTIFIED
Residen'dal Camp ' r--i5~ Serving Primarily Migrant Chi~ren
1. indicate Type of Site: [] (serving one to three meals) I I(sarving one to three meals)
Nenresldent~al Camp r-:q Oth er S~
[] (ser4ng one to three meals) I X I[eerving one or two meals)
2. List ALL counties served by this site: Jef for Eon
3. A. Is your site an open or restricted open site? ........................................................ [~Yes [] No
B. Is your site enrolled? .......................................................................... r~¥es [] No
C. Site Eligibility: Enter the percentage of children eligible for flee andJor
reduced price meals for the site (SFSP Handbook, Section 2) ............ .C.E.N.S~I.~..T..R.A.C.T...~1..-..~1~.Oo4;4. .... '72 %
Low fo #oderate Incol®
D. If opeNres~ctad open sites, submit documentation suppo~ng this percentage figure (such as census data,' school data). For opea/res~'icted
open sites using school data. list the schools used to document site eligibilRy; st[ach formula used by school disL to establish percentage of ~Tee
& reduced pdce children.
E. For enrDlled sites, Forms 1531 witi be used to document eligibility. (National Youth Sports Program-refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced-price meals for the site? ..................................... 80 %
4. Did the site pa~cipate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ ~'~']Yes [] No
If yes, give name of contracting organization:. C ! T¥ OF PORT ARTHUR
5. Monitoring Plan (SFSP Handbook, Section 4)-- Enter d~e of monitodng review to be conducted within:
I
July I-~ I
6. Meal Service Pedod Information SFSP Handbook, Section 2):
'TO SE SERveD EEDINNING ENDING
Breakfast
A.M, Supplement
Lunch I~O 1t:15 12-: I 5
P.M. Supplement
Supper
7. Do you plan to feed children under one (1) year old? ................................................................. L----jYes [] No
8. Method of Food Preparation by ContracLing Organization (SFSP Handbook, S~ctian 2)
[] On Site [] Central Kitchen [] Food Authod~ [] {ezcludes ail.year contea~s with on-si~e pre~) [] Organization that is Se~-Prep
9. A. Indicate the sys:em to be used for the se~thg of meals and the supervision of childrsn du*dng meal service pedcd. (SFSP Handbook, Section 2)
j_-_--]Cafet~d~-s~le Children are Seated ~ Childrtn Line Up
Meal Servict [] and are Given Meals I~l and Pick Up Meals [] Other: '
B. If using ce~e[eda-sbj[e meal se~i~ and ~ sponsor is a school food au~od~, ~11 the site ~ implementing offer vs. se~e?.. ~ Yes ~ No
10. Ust site pe~onnel who ~11 be invoiv~ to any extent in the meal se~i~. (SFSP Handbook, Sec~on 2):
SupoPvlsor I To See That Each Child Gets a Meal
1 1. Indicate who[ provisions will be made for meal service during pedods of inclement weather. (SFSP Handbook, Section 2)
[~]lndoor Meal r-.1Meal Service
Service l IWiti ~e Cancelled []Other:
12. Is this site implementing the option to atlow oil-site consumption of food? ................ :. .................................... r-'Jyes J~]No
13. Are mea!s delivered to the site? ...................................................................................... J~JYes [] No
IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14. Indicate t~e means of oammunicatJon with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Secdons 2 and 6)
j--~ S]te Personnel Witi Contact Administrative r.-.i Sit e Personnel Will Communicate
Staff,:~bo Will Contact Vendor I IOirect~ With Vendor
15. W~II delivery be w~thin one hour of the food service perfod? (SFSP Handbook, Section 2) ................................ []Yes [] No
16. If there ks an excess of meals delivered, meats will be (SFSP Handbook, Section 2)
Flstored in Refrigerator FT-[Thrown Away ~---~Returned to Vendor
anti Served the Next Day IXlat the Site I flor Disposal J'--I Other:
I CERTIFY that the information on this form is t~-ue and correct to the best of my knowledge. ! certify that this site has been visited
and that it has the capabiIity and facilities for the rnea~ service planned for the number of children anticipatecJ. I know that
deliberate misrepresentation or'w~flqholding of information may result in prosecution under :~pplicable state and federal statutes.
Dr. A bert T. Thlgpen Director of Parks & Recreation
FOR
DHS
USE
ONLY
r'-lApprovad j~] Denieti, reason:
SUMMER FOOD 5.~RViCE PROGRAM
SITE INFORMATION
TNONAS EDISON NIDDLE SCHOOl.
~01 12"1'h STREET PORT ARTHUR
From: June 10, 02through:Aug, 9, 02
TX 77642
J (409) 98~-4~11
A'i'-I'AC H A MAP WITH THE SITE SERVICE AREA IDENTIFIED
Residential Camp ' ~ Site Serving Pdmadly Migrant Chlk~ren
1. Indicate Type of Site: [] (serving one to three meals) I I(~flg one to three meals)
j.~j Nanras~den§al Camp i.-~l 0ltl er alta
{serving one to three meals) J X IJaerving one or two meals)
2. List ALL counties served by this site: Jefferson
3. A. Is your site an open or restricted open site? ........................................................ ['~Yes [] No
B. Is your site enrolled? .......................................................................... []Yes [] No
C. Site Ellg~bitity: Enter the percentage of children eligible for flee and/or
reduced pdce meals for lY, e site (SFSP Handbook, Section 2) ............ .C.E. ISU.~' .T..R.A.C.T. ............... %
D. If opeNres~ficted open sites, submit documenta§on suppe~ng this pen:enrage figure (such as census data; schcol data), For openJrss~cted
open sltes using school data, list the schools used to document site eligibility; altech formula used by sobool dist. to establish percent, ge of tree
& reduced pdce children.
E. Fcr enr~'l~;d sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program-refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced-price meals for the slte? ..................................... 81%
4. Did the site par~cipate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ J'~JYes [] No
If yes, give name of contracting organization: C I T¥ OF PORT ARTHUR
5. Monitoring Plan (SFSP Handbook, Section 4).- Enter date o1' monitoring review to be conducted within:
6. Meal Service Period Information SFSP Handbook, Section 2):
TO ee SERVED aEGINNING ENDING
Breakfast
A.M. Supplement -
P.M, Supplement
Supper
7. Do you plan to feed children under one (1) year old? ................................................................. J~Yes L_.J No
8. Method of Food Preparation by Contracting Orgenizmion (SFSP Handbook, Section 2)
9. A. Indicate the sys!em to be used for the se~ing of meals and the supervision of children during meal service Faded. (SFSP Handbook, Section 2)
F~Cafete~a-s.~Ie r'-q Children ars Seated r%T'l Children Line Up
Meat$.rvlce I landareSivenMesls L~JandPJckUpMea[s E]Other: '
B. If using caister~a-sl'/le meal service and if sponsor is a school food authority, will'he site be implementing offer vs. serve?.. ['~ Yes [] No
10. List site personnel who will be involved to any extent in the meal service. {SFSP Handbook, Sec[ion 2):
TffLE OF POSlT~N HO. IN POSITION SPECIFIC FaO0 eaR.ca PROGRAM au~es
Supefvlsor I To See Tha+ Each Child gets a Meal
11. Indicate what provisions will be made for meal set, ce dudng pedods of inclement weather. (SFSP Handbook, Section 2)
E_~]1nd0or Meal ~lMeal Ser¥[ce
Service b. JWi[I Be Cancelled El Other:
t 2. Is this site implementing the opdon to allow off-site consumption of food? ................ :* .................................... [~.Yes [] No
13. Ars meals detiverod to the site? ...................................................................................... [] Yes [] No
IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT Bo'ri'OM.
14.. indicate t~e means of communicat~oo with the vendor which wi[[ be used to adiust meal deliveries. (SFSP Handbook, Sections 2 and 6)
F~i site Personnel Will Contact Administrative nS~e Personnel Will Communicate
Staff, Who Will Contact Van dar I I Dirscfly With Vend er
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ................................ []Yes [] No
If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until t~me of service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Sec[ion 2)
]Stored in P~efrfgerater i%-iThrown Away nReturnsd to Vendor
and Sorted the Next Day IXlat the Site I Ilar Disposal F'~ Other:
I CERTIFY that the information on this form ia t~ue and correct to the best of my k~ov4edge. I ce~fy that this site has been visited
and that it has the capability and facilities for the meat service planned for the number of children anticipated. I know that
deliberate misrepresentation or'w~thholdlng of information may result in prosecution under applicable state and federal statutes.
"'m';;;7;;e I
Dr. Albert T. Thlgpen Interle Director of Parks I Recreation
I
FOR []Approved []Denied, reason:
DHS
SUMMER FOOD SERVICE PROGRAM
SITE INFORMATION
FOR DHS USa ONLY
TRAVIS ELE#ENTARY SCHOOL s ; (409) 982-2898
1115 LAKEVIEN AVENUE PORT ARTHUR TX 77642
Fr~m: June 10, 02through:aug. 9, 02 ,~ingDays:- ~ l, ~ 22 ~A;*
A~ACH A MAP WITH THE SITE SER~CE AR~ IDEN~FIED
Reside~al Camp ' ~ S~ Se~ing P~man3~ Migent ChaSten
1. Indicts Ty~ of SRe: ~ {se~ingone~reem~ais) ~(~Mng one ~ three meals)
Nonre~denfial ~mp ~er S~
~ {se~ing one ~ ~[ee meals) ~{seMng one or ~o meals)
2. Lis: ALL ~unties se~e~ by ~is site: J ef fecson
3. A, Is your site an open or restricted open site? ........................................................ [~Yes [] No
B. Is your site enrolled? .......................................................................... F']Yes E~]No
c. Site Eligibility: Enter the percentage of children eligible for free and/or
reduced price meals for the site (SFSP Handbook, Section 2) ............ .C.E?..S.U,s..T.R..R,C.T..~.~. ......~.0.., .87.~ '90~ ~
D. If ope~rosbficted open sites, submit documentation supporting this percsn[age figure (such as census date, school data). For oper~restricted
open sites using school data, list the schools used to document site etigiblli~'; attach formula used by school dist. to establish percentage of free
& reduced price children.
E. For enrolled sites, Forms 1531 well be used to document eligibility. (National Youth Sports Program-refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document tho site:
F. What is the percentage of free and reduced-price meals for the sits? ..................................... 92 %
4. Did the site padJcipate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ ~lyes [] No
If yes, give name of contracting organization:
CITY OF PORT ARTHUR
5. Monitoring Plan (SFSP Handbook, Section 4)- Enter date of monitoring review to be conducted within:
~. F:rs tweek ::r or oraaon S. C. Addtbonal Reviews
aune 10714
6. Meal Service Period Information (SFSP Handbook, Section 2):
Breakfast
A.M. Supplement ~
Lunch 3J~ I I: 50 1,2: 50
P.M, Supplement
Supper
7. Do you plan to feed children under one (1) year o d? .................................. E~Yes [~]No
8. M~.thod of Food PreparaEcn by Contracting Organization (SFSP Handbook, Section 2)
j Sel[-P~c~.a:.3~on Vende~Jsing School Using Food 8erdce Uanagement Company Using PriYate Non-Pro~
g. A, IndT~[a lhe system [o be used far Ihe se~ing of meals and bhe SUpervision of chitdren during m~al se~ce ~ficd. (SFSP H~nd~eek, Section 2)
~Caf~[eda.s~le ~ Children are Seated ~ Children Line Up
Uea~ $e~ce ~and are GNen Meals ~ and Pick Up Meals ~ Other:~
B. If using cafeteria-si'lie meal service and if sp~naor is a school food au~ority, w~[I the site be implementing offer vs. serve?.. ~'-~ Yes [] No
10. List Site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Sec~on 2):
T~LEO;PO$1T~N I~O. mPOSlTION SPECIFiCFOOOSaR~CEPRO¢~MDU~ES
SuPaPvlsor I To See That Each Child Gets a Meal
1 1. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
[-~]lndeor Ileal r-,,-iM eel Service
Sen'ice I IWill Be Cancelted r--lOther:
12. I$ [hls sila implementlng the option :o allow off-site consumption of food? ................ .', .................................... r--lYes r~No
13. Are mealsdei;vered to [he site? ...................................................................................... ~]Yes r"'~No
IF YES. COMPLETE ITEMS 14, 15, & 18. IF NO, FORM IS COMPLETE F--XCEPT FOR CERTIFICATION AT Be'froM.
14. Indicate t~e-means et communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, SecEons 2 and 6)
[-X-~ Sit e Personnet WHI Cnn[a~ Adminisb'atlve ~ Site ParsonneI Will Communicate
Staff Who Will Conta ct Vendor I I 0irectJy Witti Vendor
15. W[[i de[ivory be wi:hin one hour of [he food service pedod? (S FSP Handbook. Section 2 ) ................................ [] Yes [] No
ff no, describe arrangemenls within standards prescribed by total health authorities for delivery and holding of meals un:il time el' service.
16. if [here is an excess of meals delivered, meals will be (SFSP Handbook, Section 2)
[-~ Stored in Refrigerator i.~.qThmwn Away r.--iReturned to Veod0r
and Ser,';ci the Next Day IX let the Site I Ifor Disposal l'--'1 nth er:
I CERTIFY that the information on this form is true and correct to the best of my knowledge. I certify that this site has been visited
and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that
deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes.
Dr. Albert T. Thlgpen Interim Director' of Parks & Recreation
DH$
SUMMER FOOD SERVICE PROGRAM
SITE INFORMATION
TYRRELL ELE#ENTARY SCHOOL
(409) 962-7:~73
4401 F£RNDALL: OHIVE PORT ARTHUR. TX 77642
Fram: June 10, O2 through: Aug. 9, 02 er~tingDays: ~ 15 22 ~A~.
ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED
1. Indicate Type of Site:
REsider~fiat Camp '
I (serving one to t~rse meals)
Nonres~den§al Camp
[] (serving one to three meals)
2. List ALL counties served by this site: Jeff e~'son
3, A. Is your site an open or restricted open site? ........................................................ [~]Yes [] No
B. is your s~te enrolled? .......................................................................... F"-~Yes [] No
C. Site Eligibility: Enter the percentage of children eligib[e for free and/or
reduced price meals for the site (SFSP Handbook, Section 2) ............ .CRN$.IJ.S' TRACT _ ! 02 63 %
' D. If opefVresb'icted open sites, submit documentation supporting this percentage flgure (such as census data; school data). For operEres~cted
open sites using school data, list the schools used to document site eligibilii,/; attach formula USEd by school dist. to establish percentage of free
& reduced price children.
E. Fcr enro'~led sites, Forms 1531 will be used to document eligibility. (National Youth Sports Program-refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced-price meals for the site? ..................................... 7;~ %
4.. Did the site participate in the previous years' SFSP? (SFSP Handbook. Section 2) ............................ r~tyes [] No
If yes, give name of contracting organization: C I TY OF PORT ARTHUR
5. Monltodng Plan (SFSP Handbook, Section 4)-- Enter date of moniloring review to be conducted within:
6. Meal Service Period Information (SFSP Handbook. Section 2):
NUMSER OF MEAL. SERVICE TIME,
TYPES OF MF~,L$ ELIGIBLE CH;LDRE~
TO BE SERVED BEGINNING I ENDING
Rreak~ast
A.M. Supplement --
Lunch j'~lO 11:4~ A.N. 12:4~ P.H.
P.M. Supplement
Supper
7. Do you plan to feed children under one (1) year old? ................................................................. E-] Yes [] No
8. Method of Fcod Preparation by Contracting Organization (SFSP Handbook, Section 2)
[] On $it~ {'~ Central Kitchen [] Food Author~' [](~cl,Jdes a[i-year contracts with on-sit~ prep) [] OrganL'adon that is Sgf-Pr.~p
9. A. lnd~ca~e the s~/~em ta be used [or the sewing o[ meals and the super,,'ision of c~ildren dudn9 re, eel service p.edod. (SPSP Handbook, Section 2)
l--.]Cafeteda-s~le r~l Children are Seated ~ Children Line Up
Meal So.ice L_J and are Given ~eals L-~-J and Pick Up Meals ~-'] Other: '
E. tf using cafe!eria-s~yle meal service and ff s~'.onsor is a school feed authodbj, ,Mil the site be implementing offer vs. serve?.. ~]Yes [] No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2):
T~LEOFPOSm~N NO, INPOaIT[ON SPeCIFICFOQOSER~CEPROGRAMDU~eS
SupePvlsor. ! To See That Each Child Oe+s a Meat
11. Indicate whal provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2)
~]lnd~or )4eal i.--iMeal Se~i~
So.ice ~Wi[[ Be Cancel:ed ~Other:
12. Is this site impTamen[ing the option to allow oE*site consump on af food? ...... ;- .................................... [~]~'es [] No
13. Are meals delivered to the si e'~ r~ [] No
........................................................................................ Yes
IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BO'i-rOM.
14. indicate t~e. means of cornmunica[ion with the vendor which will be used to adjust meal dellveties. (SFSP Handbook, Sections 2 and 6)
i~SEe Peraonset Wiit Contact AdmJnisb'atlve 1'--1SEa Personnel Will Communicate
Staff Who Will Contact Vendor I I Directly With Vend or
15. Will delivery be within one hour of the food service pedod? (SFSP Handbook, Section 2) ................................ []Yes [] No
It no, desctibe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service.
16. If there is an excess of meals de[~¥erecl, meals will be (SFSP Handbook, Sec[ion 2)
[--.~$tor~d in R~frigerator r-~-lThrown Away r--qReturned to Vendor
and Served the Next Day IXl at t~e Site I Ifor Disposal [] Other:
I CERTIFY that t~e information on this form is t~ue and correct to t~e best of my knowledge. I cer'dfy that t~is site has been visited
and that it has the capability and facilities for the r'r~al service planned for fl3e number of children anticipated. I know that
deliberate rn]srepresenLa§on or withholding of information ma), result in prosecution under applicable state and federal statutes.
$ignatum--O~cial of Contract, i~g Organization Date
Dr'. Albert To Thlgpen I Intm-le Director' of Par-ks & Recr-aa'l'Ion
~0~ [--] Appro¥~c~ [~Den~ed, reason:
PHS
SUMMER FOOD SERVICE PROGRAM
SITE INFORMATION
¥&SH I NGTON EL£H£#TARY
1200 TEXAS AVENUE PORT ARTHUR TX 77640
Prom: June 10, 02through:Au9.
ATTACH A MAP WITH THE SITE[ SERV1CE AREA IDENTIFIED
1. Indicate Type of Site:
(409) 983-2095'
Fi Residential Camp ' r~ $1t~ Se,wing Primadty Migrant Children
{serving one to three meals) Il(serving one to three meals)
Nonresidential Camp i.~l O~ er $~
[] (servingonetothreemeals) I X I(ser,~ng one or two meats)
2. List ALL cc, unties served by this site: Jefferson
3. A. Is your site an open or restricted open site? ........................................................ r~Yes [] No
B. Is your site enrolled? .......................................................................... E]Yes [] No
C. Site Eligibitibj: Enter the percentage Of children eligible for free and/or
reduced price meals for the site (SFSP Handbook, Section 2) ............ .C.E.N..~.U.S..T..R.A.C.T.. ~t ........ ~ 82 %
D. if operv'resbdcted open sites, submit documentation supporting this percentage figure (such as census data, school data). For open/res~c[ed
open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establgsh percentage o! ['fee
& reduced pdce children.
E. Fcr enr;i'~d sites, Forms 1531 will be used to document eligibility. (Na§0na[ Youth Sports Program--refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is [he percentage of free and reduced-price meals for the site? ..................................... 8~. %
4. Did the site participate in the previous years' SFSP? (SFSP Handbook, Section 2) ............................ E~Yes r-"~ No
If yes, give name of contracting organization: C I T¥ OF PORT ARTHUR
5. Monitorfng Plan (SFSP Handbook, Section 4)- Enter date of monitoring review to be conducted within:
,.%,=.;;,:;= e.;=%=;o,o,,,.. I
6. Meal Service Pedod Information SFSP Handbook, Section 2):
Breakfast
A.M. Supplement
Lunch
,.~0 12:00 P.N. l:O0 P.#.
P.M. Supplemenl
Supper
7. Do you plan to fend children under one (1) year oM? ................................................................. E~]Yes [] No
8. Me[hod of Food Preparation by Contracting Organization (SFSP Handbook, Section 2)
[] On Sit~. [] Central I<~tchen [] Food AuthoP,~ [] {~zcludes all-year contracts with on*site prep) [] Organization that is Self-Prep
9. A. Indicate the system to be used for me se_rT, ing of meals and I~e supervision of c..,hiIdren dudng n-eel service p-edod. (SFSP Handbook, Section 2)
E~]Cafeteda-style r~lChild res era Seated r%'1ChUdren Line Up
MealSe~ice I landsreGiYenMeala t. XJandPickUpMeale E~Other:.'
B. It using cafe[erie-ab/lo meat so.ice end if sponsor [sa school food authodb/, w~ll the site be implementing offer vs. serve?.. [-"-~Yes [] No
10. Mst site pemonne! who will be involved to any extent in the meal service. (SFSP Handbook, Section 2):
SupePvIsor t to See That Each Child gets a Heal
1 1. Indicate what provisions will be made for meal service during pedods of inclement weather. (SFSP Handbook, Section 2)
~llndoor Meal r~iMeal Servi~
12. Is this Site implore enUng the opUon ~ allow o~-s~e consumption of fo~? ................ ~- .................................... ~ Yes ~ No
13. Are mead delivered to Be site? ...................................................................................... ~Yea
IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FOPJVI IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM.
14. Indicate t~e means of communication with the vendor which will be used [o adjust meal deliveries. (SFSP Handbook, Secdons 2 and 6)
~lSite Personnel Will Contact Adminisb'stive r---1 Site Personnel Wile Communicate
Staff, Who Will Contact Vendor I I Directly With Vendor
15. WiII delivery be within one hour of Be food service period? (S FSP Handbook, Section 2) ................................ [] Yes [] No
It no, deecdbe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of service.
16. Ii there is an excess of meats delivered, meals will be (SPSP Handbook, Section 2)
[~Stored Tn R~frlgerater /.~lThmwn Away ~ Returned to Vender
and Sen'ed the Next Day IXlat the Site i Ifor Disposal I I Other:
I CERTIFY that He information on this form ia true and correct to the best of my knowledge. I cerdfy that this site has been visited
and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know that
deliberate misrepresentation or withholding of information may result in prosecution under appticable state and federal statutes.
Or. Albert T. Thlgpen Isferla Director of Parks & Recreation
FO~ J"--lApproved E~]Oenled, r~eson:
DHS
SUMMER FOOD SERVICE PROGRA~I
SITE INFORMATION
YHEATL£Y ELENENTARY SCHOOl.
(409) 985-9101
80G U. 53rd STRKI=T PORT ARTHUR TX 77640
From: June 10, OZ through:Au9. 9, 02 e~ingDays:
A~ACH A MAP WITH THE SiTE SER~CE AR~ IDEN~FIED
Reside~al Camp '
1. Indi~te Ty~ o~ Site: ~ {se~ing one ~ ~ree me,Is)
Nonre~den~al
~ (se~ing one ~ t~tee moab)
2. List ALL c~unties served by this site: Jefferson
Serving Pdmadl¥ Migrant ChiMren
(sar~ing one to three rneals}
[sen4ng one or ~o meals)
3. A. Is your site an open or restricted open site? ........................................................ [~]Yes [] No
B. 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, Section 2) ............ .C.E.I~.S.U.S..T.R..A.C.'[ ............... 96 %
D. If open/restdcted open sites, submit dooumen~don supporting this pemsntaga figure (such as census data, school data). For operVresLdcted
open sites using school data, list the schools used to document site eligibility; attach formula used by school dist. to establish percenbage of ~rae
& reduced pdce children.
E. Fcr enr~'~i'~d sites, Forms 1531 will be used to document aligibili[y. (National Youth Sports Program-refer to SFSP Handbook, Section 2.)
If the enrolled site used school data, list the school used to document the site:
F. What is the percentage of free and reduced-price meals for the site? ..................................... 9~ %
4. Did the site pa~cipate in the previous years' SFSP? (SPSP Handbook, Section 2) ............................ [~Yes []No
If yes, give name of contracting organization: C I T¥ OF PORT ARTHUR
5. Monitoring Plan (SFSP Handbook, Section 4)-- Enter date el' monitoring review to be conducled within:
6. Meal Service Period Information (SFSP Handbook, Section 2):
Breakfast
A.M. Supplement
P,M, Supplement
Supper
7. Do you plan to feed children under one (1) year old? ................................................................. [~Yes [] No
8. Method of Food Preparation by Contracting Organization (SFSP Handbook. Section 2)
[] On Sk~. [] Central KP, chen [] Food Aulhor~c/ [](excludes ail-year c0nttac~$ with on-site prep) [] Organ[zsfion that is Self-Prep
9, A. indicate [he eye',em lo be used for t~e ae~ing of meals and the super¥ision of children dudng meal service pehod. (SFSP Handbook, Section 2)
E~]Cafeteda-s,~]e f--.-1 Child ren are Seated ~ Children Line Up
Meal Service I I and are Given Meals ~ and Pick Up Id aais [] Other: _'
B. If using celeteria-s~'/le meaI service and if sponsor is a school food authority,, witt the site be implementing offer vs. sence?.. [] Yes [] No
10. List site pemonnel who will be involved to any extent in the meal service. (SFSP Handbook, Seclion 2):
T~LEOFPOSIT~N NO. INPOSITION SPECiFICFOODSER~CEPROGRAMDU~ES
Supepvlsor ! To See That Each Child ~efs a Meal
1 1. Indicate what pmvlsions wilt be made for me-al service during pedods of inclement weather. (SFSP Handbook, Section 2)
E~lndeor Meal ~Meal Service
Service gJWill Be Cancelled []Other:
12. Is this site implementing the option ~o allow off-sit e ccesumption of food? ................ .'* .................................... []Yes
13. A.,e meats delivered to bhe site? ...................................................................................... [] Yes []
IF YES, COMPLETE ITEMS 14, 15, & la. IF NO, FOPJ~ tS COMPLETE F_XCEPT FOR CERTIFICATION AT Bo'FrOM.
14. [ndlcate t~e means of communica[ion with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections 2 and 6)
r~Site Personnel Will Contact AdmiMaL, atJve r.-i Site Personnel Will Communicate
Staff Wh0 Will Contact Vendor I IOirectly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2) ................................ ~]Yes [] No
[~ no, descn~e arrangements within standards prescribed by local he aith autheddes for delivery and holding of meals until time of se~ice.
18. If there is an excess of meals delivered, meals will ~ (SFSP Handb<x3k, SecUon 2
[---{Storecl in P~efrlgerator r~lThmwn Away r--qReturned to Vendor
and Sec'ed the Hezt Day [~lat the Site bJfor Disposal []Other:
I CERTIFY that the information on this form ls true end correct to t~,e best of my knowledge. I certify that this site has been visited
and that it has the capability and facilities for the meal service planned for tile number of children anticipated. ! know that
deliberate m~srepresentafion or withholding of infon'~ation may result in prosecution under applicable state and federal statutes.
Dr. Alber'l' T. Thlgpen
IT;;terlm Director of Parks & RecreationI
['"]Approved E~]Denied, reason:
DHS
SPECIAL NUTRiTiON PROGRAMS Marc~ 2(;01
SINGLE AUDIT IDENTIFICATION DATA
For Program Year 2002__
(SNP Use Only)
CITY OF PORT ARTHUR PARKS AND RECREATIO# DR. ALBERT T. TBIGPE#
444 47h STREET PORT ARTHUR TX 77641
Telep/',3~e No. ;Texas ID No. (Payee D No ) Con~'act NO.
( 409 ) 983-8210 1-74-600188~-0 75-
09/:~0/~002 E~] For Prsfit E_~] Non-,Profit ~ Oov~mmen~
Check the appropriate box(es) to Indicate the type(a) of program(s) In which you currently participate or for which you are applying:
COMMOOITY A$~STANCE PROGRAMS PROGRAM NOS. CASH RE]MSURSEMENT PROGRAMS PROGRAM NOS.
[] A - National School Lunch [] AD - Adult Day Cars TX-
[] B - Charitable Institutions [] BL- National School Lunch/Breakfast TX-
[] C - Ama Agency on Aging [] CC - CACFP Center TX-
[] G - Summer Camps [] DH - ~3ACFP Da~' Home TX-
[] H - Summer Food Service [] SF - Summer Food T'X-
[] J - Jails [] SM - Special. Milk TX.
[] CS - Commodity Supplemental Food Prog. []CS - Commodity Supplemen~ Food Prog. TX.
Give the source and amount of any federal funds that your agency expends other than from those programs listed above:
SOURCE AMOUNT
--] SINGLE AUOrr EXEMPT1ON-I cart~¥ that I am not required to submif an audit under the Single Audit ACt for the following reason(s):
I[] I am a for-profit org. anization. [] I expend less t~an $300,000 annually in total federal funding.
SINGLE AUDIT ASSURANCE-I understand that if I meet the requirements of the Si*ngle Audit Act, I wilt agree to submit an audit
as a condition of eligibility to participate in the Special Nutrition Programs and that failure to do so as required could result in
adverse action including the withholding of my claim for reimbursement payments and tremination of my contract. I also
understand that if I am a private non-profit organization subject to the requirements of the Single Audit Act and have a financial
audit performed annually, I must also obtain a single audit on an annual basis.
Name ~lease type or pdnt) J TiUe
T*x.. Depa.~, SFSP COMMODITY PROGRAM
SPECIAL NUTRITION PROGRAM
CERTIFICATE OF AUTHORITY
This is to certif7 that the following person(s):
Name of Authorized Representative (p/ease type orpdnQ
Stephen B. Fltzglbbons
Title
X
Signature-Authorized Representative
Name of Author',ed Representative (please type orprinO
Dr. Albert T. Thlgpen
Title
leterim Director of Parks
X
Signature-Authorized Representative
Is (am) designated as an Authorized Representative of
Name of Contrac~ng Organ~ation
City of Port Arthur
Address (Street. CW, State. ZIP)
444 4th Street Port Arthur, TX 77641 (P.O. Box 1089 Port Arthur, TX 77640
The representetNe(s) designated above, and myself, acknowledge that each is individually authorized on behalf of
the contracting organization to make v~itten agreements with the Texas Department of Human Services to operate a
food program, to sign document~ or reports about the agreement, and to present claims for reimbursement, when
appropriate, to the department.
By signing this document, we certiF/ individually and collectively that to the best of our knowledge and belie[, all
documen~ submitted physically or elecb'onicafly on behalf of the above named Contracting Organization pursuant to
our parficipaUon in any and all programs administered by Special Nutrition Programs, TDHS. are/will be true and
con'ect in all respect:s, that they am/will be completed according to the temps and conditions of existing agreements
including amendmente, that records aretwiti be available to support any and all claims, and that we will not submit
claims (excluding amended/adjusted claims) for goods or services for which we have already received payment. We
recognize that we are fully responsible for any excess amounts which may result from errors made in relation to the
compleUon and submission of claims. We are also aware that deliberate misrepresentation or withholding of
)eton'nation may result In prosecution under applicable state and federal statutes.
Name of Offidal of Contrac~ng Agenc3t (p/ease ~pe orprint) Tflle
Steph~n Fltzglbbons City #eql6er
X
Signature-Official of Contracting Agency
DELETED AUTHORIZED REPRESENTATIVES: A contracting organizaUon may not have more than three (3)
Author[zed Representatives, including the Official of tile Contacting Agency.-If you are replacing or deleting an
Authorized RepresentatNe, list the name(s) of the Individual(s) to be removed as Authorized Representative(s) below:
NameofDele~edRepresentaf. ive ] NameofDeletedRepresentative NameofDeletedRepresentative
FO~ OHS USE ONLY
[Co~tracl No.
75-
're× s SFSP COMMODITY PRO GRAM Form
t Human Serv~ce~ May 2Q00
SPECIAL NUTRITION PROGRAM
CERTIFICATE OF AUTHORITY
This ts to certify that the following pemon(s):
Name of Authorized Representative (please type or print)
Thaddeus Sanders
Title
Leisure Services Hansger
X
Signature-Authorized Representative
NameefAuthodzedRepresentative(p/easetypeorprint) J Title
X
Signature-Authorized Representative
is (are) desl~mated as an Authorized Representative of
Name of Contracting Organization ]
City of Port Arthur
Address (Street, City, State, ZiP)
444 4th Street Port Arthur, TX 77641 (P.O. Box 1089 Port Arthur TX 77640
The representative(s) designated above, and myself, acknowledge that each is individually authorized on behalf of
the contracting organization to make written agreements with the Texas Depar'cnent of Human Services to operate a
food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when
apprepnate, to the deparl~ent.
By signing this document, we ce~fy individually and collectively that to the best of our knowledge and belief, all
dDcumente submitted physically or electronically on behalf of the above named Contracting Organization pursuant to
our participation in any and all programs administered by Special Nutrition Programs, TDHS, am/will be true and
correct in ali respects, that they areh,vfll be completed according to the terms and conditions of existing agreements
Including amendments, that records are/will be available to support any and all claims, and that we will not submit
claims (excluding amended/adjusted claims) for goods or services for which we have already received payment. We
recognLze that we are fully responsible for any excess amounts which may result from errors made in relation to the
completion and submission of claims. We are also aware that deliberate misrepresentation or withholding of
Information may result in prosectYdon under appticable state and federal statutes.
Name of Official of ConLracting Agency (p/ea.~e Q4oe orl~fnt) ] Tdle
Stephen Fltzglbbons ~ City Hanager
X
Signature-Official of Contracting Agency
DELETED AUTHORIZED REPRESENTATIVES: A contracting organization may not have more than three (3)
Authorized Reprosentsfives, Including the Official of the Conbacfing Agency. If'you are replacing or deleting an
Authorized Representative, list the name(s) of the Individual(s) to be removed as Authorized Representative(s) below:
Name of Deleted Representative Name of Deleted Representative Name of Deleted Representative
FOR DHS USE ONLY
Co,b-ac1 No.
75
R e',.ai~ed 5y
IDate Received
(C-ASD)
TEXAS DEPARTMENT OF HUMAN SERVICES (DHS)
CLIENT SERVICES HUB SUBCONTRACTING PLAN
APPLICANT STATUS DETERMINATION
DHS Contract Identifier: (To be entered by A.qency prior to distribution)
Description Goods/Services Purchased: (To be entered by Aclency prior to distribution)
PREAMBLE: The Texas Department of Human Services and other Health and Human Services agencies are committed
to promoting full and equal business opportunities for all businesses in state contracting. To better promote these
opportunities, it is imperative that we collect information on prime contractors and their subcontractors to determine if an
entity meets the General Services Commission (GSC) Historically Underutilized Business (HUB) cert~cation criteria.
PURPOSE: The purpose of the Applicant Status Determination form (C-ASD) and the Subcontractor Status
Determination form (C-SSD) is to collect HUB-related information about a prime contractor and its subcontractors.
PROCEDURE: Please complete this form with information about the prime contractor. Complete Form C-SSD
(additional copies may be attached if necessary) with information about subcontractors. Return the signed and completed
forms to DHS (Address and Contact Person). After DHS reviews the information, a representative may contact you to
share additional information about HUB certification and reporting. Information on the State of Texas HUB program can
be found on the GSC website at http://www.gsc.state.tx.us or by contacting Hope Degollado, DHS HUB Coordinator, at
(512) 438-5429 or by email at hope.deqoilado~,,dhs.state.tx.us.
1.v' Print Legal Name of Prime Contractor:
2?Print the 14-digit Vendor Identification Number assigned by th~ State of ~'s--(~'(~r~troller (or enter the
Federal Tax ID # (9-digits): 1-74-600! 88~-0
3.~'~ls the owner or company a for-profit entity? If no, skip to number 9. Yes [] No []
4. Is Prime Contractor a GSC certified HUB? (see HUB definition on form C-SSD). Yes [] No []
If yes, p¥~ase provide your GSC Certification No, and continue with number 9.
5. Is the Prime Contractor certified as a minority/women-owned business from an I Yes [] I No [] I
agency other than the GSC?
If yes, please provide the name of the certifying agency.
6. Please indicate which group best describes the individuals who own at least 51% of the assets and interest
and/or classes of stock and equitable securities. These individuals must demonstrate an active
participation in the control, operation and management of firm's daily business affairs.
Asian Pacific Americans (AS)
Black Americans (BL)
Hispanic Americans (HI)
Native Americans (NA)
American Women (WO)
None of the above
7. Is your primary place of business in Texas? Yes [] No []
8. Has the Prime Contractor maintained or exceeded gross receipts o_r total Yes [] No []
employment levels four consecutive years in any of the following categories of
the U.S. Small Business Administration's size standards?
· Financial and Accounting - $17,000,000 ,, Wholesale Commodities - 100 Full Time Employees
~. Medical and Other Services - $5,000,000 · Manufactured Commodities ~ 500 Full Time Employees
9.V~lf Prime Contractor will NOT subcontract any portion of the contract/agreement, please check this box. []
Complete Form C-SSD if any contract/agreement activities will be subcontracted.
To the best of my knowledge, I certify the above information to be true and complete.
Signature of Contractor's Authorized Representative Date
Zo
CERTIFICATION
REGARDING DEBARMENT, SUSPENSION, INEUGIBILiTY
AND ¥OLUNTARY EXCLUSION FOR COVERED CONTRACTS
Federal Executive Order 12549 raquiras the Texas Department of Human Services (DHS) to scraen each covered potential contractor to
determine whether each has a fight to obtain a contract in accordance with federal regulations on debarment, suspension, ineligibility, and
volunta~ exclusion. Each covered contractor must also screen each of its covered subcontractors.
In this certifcation "contractor" refers to both centmctcr and subcon~'actor, "con,act" refers to both contract and subcontract.
By signing and submitting this certificatlo~n the potential contractor accepts the following ten'ns:
1. The cedi~1catien herein below is a material repmsentatian of fact upan which reliance was placed whan this centract was anterad inte. EE it
is later determined that the potential conlractor knowingly rendered an erroneous certirmatJon, in addition to otha' remedies available to
the federal government, the Department of Health and Human Services, United States Deparituent of A~cultum or other federal
depariment or agency, or the Texas Department of Human Se~ices may pursue available remedies, including suspension and/or
dabs'merit,
2. The potential contractor shall ~ovide immediate written notice to the person to which this ~tion is submitted If at any time the
potential contractor leams that the cer~catk)n Was erroneous whes submitted or has become erronecus by reason of changed
circumstances.
3. The words "covered contract," "deban'ed," 'suspeorled," 'inel~'ble," 'pa,'tJcipant," person, "principal," "proposal," and "voluntarily
excluded," as used in this certirmation have meanings based upan materials in the Dermitioes and Coverage sections of federal rules
implamsnting Executive Order 12549. Usage is as defined In the attachmanL
4. The potential contractor agrees by submitting this c~llan that, should the I:m3posed covered conb'act beantered into, it shall not
knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voludian'ly excluded from
pafiidpation in this covered ~ansaction, unless authorized by the Department of Health and HLm'.en Services, United States Department
of Agriculture or other federal department or agency, and/or the Texas Department of Human Se~,ices, as applicable.
Do you have or do you anticipate having subcontractom under this proposed cantract? ........................ [~/Yea [] No
5. The potential contractor further agrees by submitting this certification that it will inctude this certification titled "Certification Regarding
Deban'~nt, Suspension, Ineligibtiity, and Voluntary Exclusion for Covered Contracts" without medifcation, in all covered
subcontracts"; and in sdiicttailons for all covered subcontracts.
6. A contractor may rely upon a certification of a potential subcontractor that it is not debarred, suspended, ineligible, or voluntaniy
excluded from the covered cuntract, unless it I~ows that the certh3caiton is erroneous. A contractor must, at a minimum, obtain
certifications from its covered subcontractors upon each subcontmct's initiation and upon each renewal.
7. Nothing contained in all the foregoing shall be constnJed to require establishment of a system of records in order to render in good
faith the cerlifica§on 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 conlractor in a covered contract knowingly enters into a
covered subcontract with a person who is suspended, debarred, ineligible, or voinntafily excluded Eom participation in this
transactien, in addition to other remedies available to the federal govemmant, Department of Health and Human S~'vices, United
States Department of Agriculture, or other federal department er agency, as applicable, and/or the Texas. Department of Human
Services may pursue available remedies, including suspension and/or debarmenL
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INEUGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED
CONTRACTS
Indicate In the appropriate box which statement applies to the covered potential contractor:
[] The potential contractor certifies, by submission of this certification, that neither it nor its principals is presently
debarred, suspended, proposed for debarment, declared Ineligible, or voluntarily, excluded from participation In this
contract by any federal dapm"[mest m' agency or by the State of Texas.
[] The potential contractor is unable to certify to one or more of the terms In this certification. In this Instance, the potential
contractor must attach an explanation for each of the above terms to which he is unable to make certification. Affach the
explanation(s) to this certification.
Name of Contractor IVendor ID No. or Social Security No. IDHS Contract No. (if applicatlle)
Signalu~eo[?,ubhod. zedRepresentetive INTERIN DIRECTOR OF PARKS & RECREATION
of Hu~.~ Se~c~s CERTIFICATION REGARDING FEDERAL LOBBYING
(CedificatJon for Con~c~, Gmn~. Loans, and Co~emfive Agreeing}
PR~MBLE
Federal ~gis~n, S~t~n 319 ~ Pub[~ ~w 101-121 ~n~ly pmhibi~ end.s ~m u~ng f~ml~ appro~a~ ~nds to lobby ~e ex~ve or leg~ia~ve
brushes of ~ fed~ai ~vem~nL S~n 319 s~l~ ~ms ~um ~ ~ ~ng a~ A ~mi g~ment ~e ~e,"New Resigns
on Lobbing," ~ish~ in ~e F~eml Register, Febm~ 26,19~, ~u~es ~ ~d dictum in s~fic i~es a~ defin~ te~s:
Co~ Awards and Su~wa~s-Con~c~, gmn~, and ~m~ve agreem~ o~r ~e $1 ~,~ ~mshdd n~ (1) ~ons, and (2) ~scl~ums,
if required. (See ~flon te~ number 2 ~ming d~d~.)
Lobbyin~To ~bby means "to i~e~ or at. rapt to ~ue~ an offer or emp~ ~ any ag~ (f~ml), a m~r of ~ngm~, an offi~ or employee
of Congre~, or an empio~ of a mem~r of C~gre~ in ~n~ ~ any of ~e folding ~ f~erai ac~o~:
· ~e ~ard~g of any f~al ~n~c~
· ~e ~i~ ofanyf~eml granL
· ~e maki~ ofanyf~ll~n,
· ~e extension, ~nfin~on, r~e~l, amendmen~ or m~i~ ~ any fedem~ ~n~, grant, ban or ~pemfive agreemenL"
LIm~ Use ~ ~pmp~t~ Fu~s N~ Pmhl~te&The pmhib~ ~ us~g appmp~ted ~nds d~s not ap~y to ac~vifies by one's o~ employes wi~
r~t to:
· liaison ac~ti~ ~ federal ag~c~s a~ C~gmss not ~ mla~ ~ a ~ f~eral ac~on;
· provid~g any ~nfo~aflon s~lly mquest~ by a f~ml ag~ or Co~re~;
· dls~ssion an~ dem~a~n of pr~cb or s~ ~ no[ r~at~ to a s~c ~lid~fi~ for a ~e~ ac~n; or
. pmfe~nal and t~n~l s~s in preying, su~i~ ~ n~a~ ~y ~d, pm~ ~ a~n for a f~eml ~n~, gran[ I~n or c~ra~ve
ag~m~t ~ for m~g I~al ~uimme~ ~1 ~ ~ of any f~ ~ grant, I~ or ~m~ve a~m~L ~he ~i~on also ~s
not apply ~ such se~s prodded ~ nonemplo~s ~ ~e ~me
Pr~sslonal ~d T~nl~[ S~lces-Pmfe~onal and [~ni~l se~s shall ~ ad~ and anal~is ~y app~ing'any
p~fe~ional or ~ni~l ex~e. Note ~at ~e ~f~s~ and [~ni~i se~ exemp~ is s~f~y limi~ to ~e meH~ of ~e matter.
~her Nlowable A~ie~The ~ohi~fion on use of f~r~ly a~mp~t~ ~s d~ ~t ap~y ~ infighting a~es
not in ~nn~fion wi~ a s~c~c ~ver~ federal a~on. These a~i~ include ~ r~ated ~ I~bla~on and mgula~ons for a program vem~ a sp~fic
Funds ~r Than F~e~ ~ro~a~n~Them is no fede~ resection on ~e u~ of n~f~eral funds to I~by ~e federal
~bili~ of ~er StYe and Fede~l R~m~n~Nei~er ~e go~mm~[-~de ~ n~ ~e I~ affect either (1) ~e
appli~biii~ of ~st p~nciples in OMB dr~lam A~7 and A-I~, ~ (2} Hdem to ~e T~s S~te Approp~afions A~ ~ di~llow u~ of s~ ~s for
~ * TERMS OF CE~IFICATION
or ~p~ee o~ any ag~w, a ~r ~ ~g~s, an o~ ~ ~ of ~. ~ ~ em~ of a me~ of Congre~ ~ ~nnec~n wi~ the awa~g
S~a~ard Fo~-~L.)
Do you ha~ or do you anticipate ~vl~ co.md su~ards un~r ~ls ~on? .................................... [ ~ lYes I INo
OF
PORT
IClTT ARTHUR PARK & REC.
PARKS & RECREATION S~na~R~r~ent~ Date