HomeMy WebLinkAbout20092366.tiffRESOLUTION
RE: APPROVE CERTIFICATE AND STATEMENT OF AUTHORITY AND TRUTH OF
APPLICATION FOR CHILD AND ADULT CARE FOOD PROGRAM AND AUTHORIZE
CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Certificate and Statement of Authority and
Truth of Application for the Child and Adult Care Food Program between the County of Weld, State
of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Human Services, Family Educational Network of Weld County, and the Colorado
Department of Public Health and Environment, with terms and conditions being as stated in said
Certificate, Statement of Authority, and Truth of Application, and
WHEREAS, after review, the Board deems it advisable to approve said Certificate,
Statement of Authority, and Truth of Application, copies of which are attached hereto and
incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Certificate, Statement of Authority, and Truth of Application for the Child
and Adult Care Food Program between the County of Weld, State of Colorado, by and through the
Board of County Commissioners of Weld County, on behalf of the Department of Human Services,
Family Educational Network of Weld County, and the Colorado Department of Public Health and
Environment be, and hereby are, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said Certificate, Statement of Authority and Truth of Application.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 2nd day of September, A.D., 2009.
ATTEST:
Weld County Clerk to th
BY
I
Deputy Clerk to the Board
APPROVEDT7S T%FOR(bh'
Date of signature: 94/07
David E. Long
g
BOARD OF COUNTY COMMISSIONERS
WELD COU OLORADO
William F. Garcia, Chair
Douglas'Rademaher, Pro-Tem
Sean Conway
,(A AID
ra Kirkmeyer
(C1/4' Cie)
CC' Ns Cv ostc
2009-2366
oqA4 /09
HR0080
MEMORANDUM
DATE: September 1, 2009
' TO: William F. Garcia, Chair, Board of County Commiissio ers
111� FROM: Judy A. Griego, Director, Human Se s D eartme
•11 111
COLORADO RE:
Child and Adult Care Food Program Certificate and
Statement of Authority & Truth of Application between the
Weld County Department of Human Services' Family
Educational Network and the Colorado Department of
Public Health & Environment
Enclosed for Board Approval is the Colorado Department of Public Health & Environment,
Child and Adult Care Food Program, Certificate and Statement of Authority & Truth of
Application. This was presented at the Board's August 31, 2009, Work Session.
This is the Child and Adult Care Food Program (CACFP) meal reimbursement contract for the
Department's Head Start Program.
If you have any questions, give me a call at extension 6510.
2009-2366
Certificate of Authority
Page 1 of 3
COLORADO DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT -
CHILD AND ADULT CARE FOOD PROGRAM
CERTIFICATE AND STATEMENT OF AUTHORITY & TRUTH OF APPLICATION
Whose address is:
Organization Type:
Date Form Printed:
WELD COUNTY
I egal Name of the Institution
Trade Name of the Institution/I)BA
1555 North 17th Ave
(Street Address)
Greeley
(City)
9703533800
(Telephone)
Public
CO 80632
(State)
9703046453
(Fax)
Institution Type:
Wednesday, August 26, 2009
(Lip Code)
Municipality
The Child and Adult Care Food Program (CACFP) rules and regulations 7 CFR 226.6(b)(15) requires
all institutions to certify that all information on the application is true and correct. The regulation also
requires the name, mailing address, and date of birth of the institution's responsible principals and
responsible individuals as defined in this document.
By entering into an agreement with the CACFP, the institution named above, all sites listed on
Attachment 13-1 of the CACFP agreement, and all individuals employed by the institution agree to abide
by all regulations governing the CACFP, the CACFP agreement, and all appropriate Federal and State
regulations and policies.
When there is a change of responsible principals or responsible individuals, it is the responsibility of the
institution to register the change by revising the institution's online application, using the CACFP Web -
based System, and submitting this form by mail with original signatures to the CDPHE-CACFP office
within 10 calendar days of the change. User IDs will only be issued for the CDPHE Web -based
Computer System to Principals or Individuals who have signed this document.
RESPONSIBLE PRINCIPAL
S
The CACFP defines a responsible principal(s) as the person(s) who are financially and
administratively responsible for the administration and operation of the institution. Specific to the Child
and Adult Care Food Program, these individuals assume responsibility for the following:
• The institution accepts final administrative and financial responsibility for all child and adult
centers and family day care home providers supervised by the institution.
• The institution must operate a nonprofit food service using all of the income received from the
CACFP solely for the operation or improvement of such service.
• A failure to properly administer the CACFP could result in termination of the CACFP agreement
and the placement of the above named institution and any responsible principals and
responsible individuals on the National Disqualified List.
• Placement on the National Disqualified List means the institution, and all of its responsible
principals and responsible individuals are prohibited from future participation in the CACFP.
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8/26/2009
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Certificate of Authority Page 2 of 3
We, as responsible principals, authorize the responsible individual(s), whose name(s) and signature(s)
appear in this document, to perform key functions of the CACFP. Additionally we, as responsible
principals, acknowledge legal and financial responsibility for all actions taken by the individuals
conducting CACFP operations for the institution.
As a Responsible Principal, I certify the following:
• All information on the institution's application is true and correct.
• The above named institution has not been disqualified from participation in any other publicly
funded program in the past seven years.
• I have not been a principal in an institution participating in a publicly funded program that has
been ruled ineligible as a result of violating that program's requirements during the past seven
years.
• I have not been convicted of a business -related offense during the past seven years.
• I am not on the Child and Adult Care Food Program (CACFP) National Disqualified List.
By signing below, I acknowledge that I have read and agree to all information contained in the
CACFP agreement and understand that submission of false information and certifications will lead
to placement on the National Disqualified List and may subject me to any other applicable civil or
criminal penalties.
Responsible Principal's Title: Director
Name: Judy A. Griego Date of Birth: 5/10/1951
Address other than 315 N. 11th Avenue
institution's address: Greeley , CO 80631
Phone number other than institu i n's phone number: 9703811512
Signature: _
Date Signed:
Vic
By signing below, I acknowledge that I have read and agree to all information contained in the
CACFP agreement and understand that submission of false information and certifications will lead
to placement on the National Disqualified List and may subject me to any other applicable civil or
criminal penalties.
Responsible Principal's Title: Weld County Commissioner
Name: William F. Garcia Date of Birth: 6/30/1972
Address other than 915 10th Street PO Box 758
institution's address: Greeley , Co 80632
Phone number other tl�/ins^titution's phone number: 9703367204
Signature: �/ t t/v ( Date Signed: SEP 0 2 7009
By signing below, I acknowledge that I have read and agree to all information contained in the
CACFP agreement and understand that submission of false information and certifications will lead
to placement on the National Disqualified List and may subject me to any other applicable civil or
criminal penalties.
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8/26/2009
Certificate of Authority
Page 3 of 3
Responsible Principal's Tide: Director
Name: Janet Flaugher
Address other than
institution's address:
5005 Pawnee Drive
Greeley , CO 80631
Date of Birth: 2/13/1946
Phone number other than institution's phone number: 3037101542
GU(c{\ L -t_(
Date Signed: "1 alp/ o 9
RESPONSIBLE INDIVIDUALS Responsible individuals are the persons authorized by the
responsible principals as individuals with responsibility/authority for key functions of the CACFP, such
as those in a management position, an individual preparing and submitting the claim for reimbursement,
the cook, etc.
RESPONSIBLE INDIVIDUAL # l
Responsible Individual's Title: Health Specialist
Name: Amber Arens
204 South 8th Street
Address:
LaSalle, CO 80645
Phone number: 9703533800
Signature: ( ) 4/IDL i '< a Lc 11,
Date of Birth: 10/17/1981
Date Signed: t`'it2'��j
RESPONSIBLE INDIVIDUAL # 2
Responsible Individual's Title: FCP Specialist
Name: Leticia Galindo
Address:
PO Box 12
Gill, CO 80624
Phone number: 9703533800
Signature. ' )(I1 (I c ' JC).' k'1 , v-��
Date of Birth: 4/8/1960
Date Signed: c :-)c W (tfi
1i
http://co.cnpxpress.com/Applications/Certificate.aspx 8/26/2009
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