Loading...
HomeMy WebLinkAbout20022472.tiff RESOLUTION RE: APPROVE RENEWAL FORM 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 Renewal Form 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, commencing October 1, 2002, and ending September 30, 2003, with further terms and conditions being as stated in said renewal form, and WHEREAS, after review, the Board deems it advisable to approve said contract, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Renewal Form 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 is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said renewal form. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 9th day of September, A.D., 2002. BOARD OF COUNTY COMMISSIONERS n �,fA�` WELD COUNTY, COLORADO ATTEST: V l ey l �4 } " La�` EXCUSED sac.' GI Vaad, hair Weld County Clerk tot i' -1,,, / 4, David E. Lon:,, Pro-Tem BY: ‘-°•' �� �o Deputy Clerk to the Bo /71 /7� M. J. eile William H. Jerke of my Att n L $\.D. Robert D.tsden Date of signature: /7 \ 2002-2472 cc; c.7a-aU HR0073 Renewal Form CDPHE-CACFP October 1, 2002-September 30, 2003 Dear Center CACFP Representative: This form reflects the most current information the Colorado Department of Public Health and Environment,Child and Adult Care Food Program (CDPHE-CACFP)has on file concerning your center and its participation in the CACFP. Please review the form and verify the accuracy of the information. Make the necessary corrections(in red ink)to those items that are not correct and/or no longer applicable. Sign and return the form to the CDPHE-CACFP by Friday,September 6,2002. If you have any questions,please contact Sheila Sharpe or Shawna Morgan-Johnson at 303-692-2330. 1. CENTER/SPONSOR INFORMATION Name and Address: WELD COUNTY Agreement Number:65103-05 FAMILY EDUC NETWORK OF WELD CO PO BOX 1805 Federal Tax ID Number: 84-6000813 L GREELEY,CO 80632-1805 2. I have reviewed this form and certify that the information it contains's correct. Print Name:' Late Inn Uor , Signature:\lA 0 �TM' '7 " 6\-A A, 3. MAILING ADDRESS If you would like your reimbursement check mailed to an address different from the above,your W-9 form must reflect the correct address. Call the CACFP if you have any questions. 4. Number of Centers: 14 County: Weld Authorized Representative: 1. TERE KELLER-AMAYA 2. JULIE MALLORY Center Telephone: (970)353-3800 Alternate Telephone: Fax: (970)356-3975 5, Oct yr Nov Dec Jan Feb Mar�r}� Apr May Jun Jul Aug Sep Months Approved for CACFP Participation: :ego.] ul 41 rki e g joi tan 6. Commodities Cash-In-Lieu of Commodities: 7. Number of Shifts:2 8. License Capacity: 605 9. Does center care for infants? Bkfst AM Sn Lun PM Sn Sup Late Sn License Number: N/A Yes No License Expiration Date: 12/31/2002 Meals Approved : Allen , Timely Renewal: N Does Center claim infants on the CACFP? 10. Is this a pricing Hours: 6:30A-6:00P (up to first birthday) program? Yes No Days Open: MON-SAT Yes1"( No 11,Center contracts meal service?Yes > No 12.Contractor's Name: 5 SCHOOL DISTRICTS 93. Food Service Contract Expiration (please list additional contractors on the back) (please list additional dates on the back) Date: 5/23/2002 14. Meals are: Prepared at the center -! Prepared off site lej 15. Age Range of Participants: 0 to 5 16. FOR PROFIT CENTERS ONLY Step 1 -ShawnalSheila Step 2-Specialist Follow-up Information According to our records,your center has Packet Packet Incomplete Title XIX or XX contracts with these counties. Received:_ follow-up Please update as necessary. Initial Date County Expiration Date All Forms Received:_ Initial Date Forms Missing: Person Contacted: Card Sent: or Date Form Ltr Sent —Et Renewal complete: Date: _ Initial Card Sent(?)(see step 1):_already sent _send Y Y Y Y a) (n O) C N C N a)E a) E a E a).E CO W J~ CO W J~ U) -I W W J~ Z O i'iI Z O r. 2 O Z O 771 Q m N O to 4 a) N N N O h :BOLO co g aa) o a) i x aa) coO a) i aN O a) i M a0 O W , W cad,•- d N 0 Win j- c Cl) O W N=•EM N 0 Win Eco N 0 CO V 2 mU V 2 a)N~ 7 t r2 a)UF- R F E o p F E 0 0 p E 0 0 Rn P In .E 0 0 F- F— w C C N N N W c u9 o M a w c C a) N N a c C N N N 2 -o(nEO v` 2 �(nEO P m '60E0 v EkwEo _ v C' WdI- M (Lj O' WaF- M L KWEtF- M L d' W0_F- c L Oatf No Oaf No w Oaf° No w Oa6a N U W o) O W o) 0 W o) O W O) O o J ≤ 0 N -J C co a) J C 0 a) J ≤ co a) O C L co N N O ≤L co 0^ N O .E L co N N O ≤L N N m CO Sm cEO a, 2m = EO m Sm = EO 2 taco I— U JP O sm. O) U J~ ,M- O O, U J♦- O2 .m-. O, U m JH O^ O 00) N a co a w a C W a W . C W a a co u- UN O Uin O U_ in 0 Uin O JY JCN 5JY JY W U ii e2(4d m - �(q � m ix �(gd N ix a) H a, uWi 2.E Cu y ;E m w 2 E m w 2E `m Z L J ¢~ N J Q~ a -J Q~ a -J Q~ CL w w o w to w o d U O m NN Oi N No m N co m NQ E.D. H eE2 `YNE � m u) I; m YE9 m aCC n m~ o m~ o m~ o c ~ o U Y N z It 'm CC Q --I 0 re m) N W N a N N Q m o0o a co ti o0o 0 oo O a d op 'x Q - M z Cs c 3 M U M M ° (7 to J (y (1 M M Z Z O LO ao 0 `. o � " o ¢Lc) as ¢�¢ v, ). 0 LO n. O a Y N ¢ O N co co o ¢ O N ¢ O N Q 4) m O J z a a . . z a a . . Z a a .. z a . . co Q U W C 0_ U W C d xk UW C a m n co d o o O ) OW o N CO N L U N N N L U N N N L U N N N L U Q C C CCL CD C C CCL a3 C C C p CO a CO m m N a C N a) a c a m N 2C m a N C U U U m 0 U U U N O U U U a) p U U U N O J J J H 0 J J J H 0 J J J ♦- U J J J H 0 0 N 0 0 00 w -o U a O m a 0 m 9 W 5Q W ' Q W fE ¢ W fEQ 0 C > c3 0 C > > C > > C > W mn W m , u_ 'm a° W 'A , O u o) 2 < 0 )p fa 0 , � ¢ O ,n � ¢ CC co o Fin w 00 O N F O N F° O I F O 7 F N >> N p uo 5 F (O op r- c c W0 W0 0 Z supo }} Z o }} Z a0 o >. Z 133 0 � U , , o c. 1- 000ti, F' UOO u I- 0Loo u Z J O U . Z 0 0 0 = Z D O 0 = Z 0 0 0 CO OOCO } w' O000 w DDO w Do w U} X W a U }X J o O } X J o O } X J E 0J0W Z. of —Imw t5 ❑ J0W c 0JOW .c am) WQOCC Z WQOC 2WQOW Z WZOC Z 2 WaC7 `w u_0_ w � WdC7 m fia0 a co co co U)) C N a N C N C N CO W (0 0 (0 W (/) 0 P E alb'E dE a E mR F- ~ till= (/) J N J CO J U) -JW O W W W 2 auto cn to " C to < WWO�In in " C to W N J_ a N O W N J- a N O W N J- 0)) N 0 W to d� O N O 2 Etnra t 2 warm- t 2 WU� a t 2 a)(Or t H ._ O FE o O FE o o F E o o -J rnY 7 E J o s F J cns in c J Ic ri 01 mica IP 2fiUEo -I' r0 Eo 2 2V(1) E9 p 2vUEo v W ._ W M c' WdF- M V IX Wai- M L IX L Kw`0_H cn t O as No Oaf NN U Oaf No U p ,�a No U In CO 0 W0) o Wa) o Wa) o J C 0 N J ≤ 0 0 -I .c 0 0 J C M 0 D C co a D C co a 7 C a 01 m E d. a 0 ≤L N ^ g G ≤L co N O S L co C N ≤ c N N C CO W owe) cc W mU W cc W a0 W cc W 010W W 2 CDcEo W xmcE6 ra) cEo x WcEo I- U ..-I03 R ' c) rn U .-.J1- o 0 0) O 3I- 2 0 rn Um-IH 2 0 rn N = .- 'N Q N = v 'N Q N = 'y Q (/) = a CI' n a c Co a W „ WW W Co U U N O O w O U_ a o U m c =Y 7CN ' =Y =Y O W U LU E 2 to E 2 UJ E '2 LU E ~ W N Q'- n N 2— o. M 2 - f° o 2.— co Z -c J ~ W _I J W < a J < 0 CL U a W 0 CD 0 W 0 CL W 0 EL W 0 co t0 Cu cco Cu cr) co NW O a W a a cooN Oi N Z coO eE � YEM d YE2 m O YE as m Q cur: r... COI_ r..... 047 r... 2 0 mro S O. co a 2 2 V w -J It O0 C 'w W I— Q W ` N S N = N = N n. co O J a O U o O W a p CC c co co U W CO U v-(�] c? q v- CO v- 0`) ZZ (,-- 00) C) Cu 'V M JVI Cn Ili C >- v- �() 0 •V 2 I— .- M W M Z o O Z .. O Q O J O W sa o a. r` Q Lo W 0) Y 0 0 0) W N-.0) 0 C co 0 O o`) C -O o> O .W. 01 .-1 I TA Z as Z as Z ao_ . . Z aa .. co Q • Uw a xkUw a ciw c a ° X c 0 O O o It 0 W 0 N N N L U N N N L U N N N L U N N N L U Q c c c o- CO c c c a �° c C c a @ C C C a Co W W W N c W W W c W W W a c W W W c 0 0 0 W 0 0 0 0 W 0 0 0 0 N 0 0 0 0 W o J J J H 0 J J J H 0 •J J J I- 0 J J J I— 0 O N O H 0 N O o v O 0 w 9 w .o m m c > o c p c c > u_ co r, LL m n u_ m n u_ 'mn 0 2 ¢ O ,o 2Q 0 ,n 2Q 0 up CC DD � ¢ O o O i o O 7 o O 7 o N I-, N F N I- N H r rCO r CD Mo 2 °o c z °o o } z a0 co z co g � U oo U � U Lc, 0 g zFU o0 HOL0O in zzo = zDoU = DoU = z U = CO DOW 'w DUco w DOM) w Dpm w t w1— > c Owr > c Ow '— > c Owr > C U > X J O U > X I O U > X J O U > J c EQJ0w .c 0 -0w _c 0 - 0w 'c QJOw o W w . a Z w <CO w Z CO w Z Wg00w Z W ¢O a > QOa O w ¢ O0 2 ¢ O � 0 > aaC7 `m u.0- `) > aa0 d � aa0 m Q N N N N Y S S S C CO 0) Co O) (o () O) d.E m_ d_ 0.E (q COCOJ -J -J -U) i W W W W 0 O C 71,1 z O 0 CD O — z O O) O O < 0) 0) O o Lo h 4 0) N )O O ? co l0 n i n w_ n 0) O N cc a N O� 0) Win - ,_ N O Win -. cOj N O Win nE0 N O W co - O .N O aowl- v t 2owH . t 2o(nry t 2our )), P E 0 0 p .E o 0 p ,E o 0 p j O O F F H F J O J O J O J O WmCW � N W =CWco.sc en N W .=CWN N WCCWM 2 CWaI- c) U CwdHM L CWaI- co t d' wal- N U 0 oa NO w O oa NO w O oa NO w O 05 a W o) 0 W O) O WO) O W O) O O J c O 0) J C O O) J C 0 0) J C O a) o') a m . a DE co a 7c CD O •CL N N (C6 OC. co N N O .cw N N O Cto (Ni C U) = mcEo r. ) W mS.00 j = ao) cEO "j i0c0o a z. I- U LLI m J H .M- d O) U m-II- 0) rn U m J H .5- a) rn 0 ,J F .M- a) o) CO J .- .ca- Q .- 'w Q U) 5 .- .N Q N = �- 'w Q co a n n n u) U U . ❑c o in ❑c U w ❑c U in Oc 3Y ≥ = = w ii = W IX U IX .7.--_..c0 d C �tA � a°i C �voC C2� a) Z L N Q~ a N Q~ a co MF n N MH a J N J `) J Q N J Q 0) U cm W co W O W O W co U' rn m rn m rn co rn co Z O N N N O N 0 N 0 N _y N a N a E co d Y _E a Ta a) Y E c) d Y E ma co co d m~ o m~ o 2 ca ID o 00H o a O C.) u) i P .N 1---- re ` N N N ¢ N >'• N Q Q O O + O Oaz, U O O W O O W n, N co co co d cc N Cr)S,J ^ 0") QQ C) k- v- 0") m U MM\ (' M 2 M fy W 0) ^ M\'L 1- co J N--- CO Cr (O•) •m Z `o W • • -. •Q I N Q <° � o ¢ `° 0 o a; (O o cc (.0 o U J m a a) d ? a s m a Z n a . . Z Q n .. w Q * Uw C d _ UW C d •• MX o a • 0) x o a O O O ikUW O N N N L U oU N N Ian L U N N N C U VUi 0 W L U Q C C C a C C C C a 'E C C C a C C C a RI O) O) 0) 0) C 0) 0) O) C C O) O) O) C N N N C C U U U O) O U U U 0) O 0000) O U U U N O J J J H 0 J J J H 0 J J J F 0 J J J F 0 0 0 O 0 O N 0 H o U 9 ❑ N 2 ❑ .`O ❑ d U U 0 y O y 0 v, O a c o c a c o m c o U- N .o w ma LL and lL ma 0 co 2Q O Lc) � Q O in 2Q 0 inos on re C3 OE � a CC 0 7 b O o O 7b 0 o N N NN O M M M M co 5 co 5 Z 00 o Z 00 0 } zco 5 to 5 OD o > z a0 0 o U m U m v) ZDo0U 3 ZDoOU = ZDo0U = .....ZDo0U O OW c } v Ow co Do a 0 c a y} w w Ow '- } w Ow '- >- w C U} XJ o_ U } X _I o_ U} XJ O U } X ! o a) ❑ J m w '$ o J m w 'UJ r_ ❑ J Om w 45.c ❑ J O w c CD w QO Z <Ol Z W Z Jcl0W , 2 wa0 2 SLLo. C� � Li_ aO > C/� z Q n n C a) > a V c co 0) S / § W -J ® } a00 0) CO} k2 \ Nil $ �Eo a o =Eo ao kE tor 0 0 ill 0 0 # / , \ « # $! , > id 2.Aoo ,,,c a) 33�/ Q 1E § jI/ \ 2$ \ 2$ @ ( m W\gm ) q / WEn ® � Q / I- 5a]/ § w 3 En § , co = - g < 0 = - Q $ en� ( § \c , -0 § 5s , 0 Li w ) EEAm -A : - ) z f �/ @ �/ § a � k - a < ■ a ■ § 2 co co { ® 6 $ CA� O co § { _/ ( ] _/ o k IX \ \ � c \ 2 % k7 t- 2 \ § ) } ) ) % E § « w \ \ « w \ ) I a ) 0 co ® # ) A % a 2a0. .. •§ ® 0. 0. Q •S / k ) ( { k ) ( \ a « « Cu f ] \ ) a 0 ) ] ] a 0 E ■ 0 , W & § W § ) W 2 , t C > O ; $ 0 r ; ! ) / OE ) ) \O / ) { / ) { rii § no0 ZDoO g \ \ \ b \ \ \\ b \ E _ ) COW ) 5 §2 § / $ » E$ , / ±EE , \ 0 ! RENEWAL/NEW CENTER Child and Adult Care Food Program CERTIFICATE AND STATEMENT OF AUTHORITY This organization is a: For Profit Corporation ❑ Non-Profit Corporation igi Limited Liability Corporation U Sole Proprietorship U Public Entity U Partnership ❑ Church U I,(We),the undersigned,state that the child care center(s)listed on Attachment B of the Agreement(CACFP 300)or the Multiple-Site Summary Sheet is an integral part of, and therefore under the direct control of,the governing body of the l c>ck1 C0tx_n'- �,tr,<Thion n N cn—. -imS -VI(es Ern; lv rrluoa+io - a I (Name of the Organization,Business or Churcd) Tekt )r IL U- Lue1ct &xtn+i Whose address is: _ (Street Address) (City) (State) (Zip Code) (G,O ) (--3, --3- 3?roe e (Telephone) and that all funds relating to the Child and Adult Care Food Program(CACFP)will be subject to the control of the duly constituted governing body of the above-named organization,business,or church and that all funds received for the operation of the CACFP will be used exclusively for the purpose for which they were received. The individual(s)whose name(s)and signature(s)appears below is authorized to sign the Claim for Reimbursement and is fully empowered to enter into any agreement with the Colorado Department of Public Health and Environment,Child and Adult Care Food Program(CDPHE-CACFP);and may act for the above mentioned center, or sponsor of centers, in preparing and signing documents and reports pertaining to the management of the CACFP. When there is a change of Authorized Representative,it shall be the responsibility of the center or sponsor of centers to request from the CDPHE-CACFP office forms to register the change. The signature of the Authorized Representative on the Claim for Reimbursement must match one of the signatures on this form or the Claim for Reimbursement cannot be processed and your reimbursement will be delayed. AUTHORIZED REPRESENTATIVE(S) Ass signature � Signature y /eve_ kl(ye-- � trut4 c_ -,\U,-1, c Ma_1la r 0 Print Name Print Narne Director Health Specialist Title Title is/are the duly designated Authorized Representative(s)for the Center or Sponsor of Centers listed above. NOTE: It is to your benefit to have two people designated as Authorized Representatives. THIS BOX MUST BE SIGNED I(We)understand that the information on this form is being given in connection with the receipt of federal funds and that all of the pro 'vtcions of the Agreement(CACFP 300)apply. \ �� Weld County Board t�..1 �p David E. Long, Chair Pro-Tern of Commissioners Sign f the Chair of a ar f Directors,Pastor, Print Name Official Title Executive Director,o er 09/09/2002 Date JACACFILommon\FORMS`SJew Center Forms\CSACm03.doc 5/23/2002 Child&Adult Care Food Program RENEWAL/NEW CENTER SPONSOR OF CENTERS APPLICATION rq rar►r'a7' e lit :911,1;•_e_ •.irr•ifn.�1.� Jaer:14 11 L� r'ti t"n 1. List the number of CACFP participating centers in each category under your administration: Nonprofit Child Care Centers 12 Head Start Centers Nonprofit Adult Day Care Centers Early Head Start Centers Outside School Hours Centers 9 Migrant Head Start Centers After School At-Risk Snack Programs For Profit Title XX Child Care Centers Emergency Shelters Serving Homeless Children _ For Profit Tile XIX Adult Day Care Centers 2. List the total number of participants enrolled at CACFP participating centers under your administration: Nonprofit Child Care Centers 629 Head Start Centers Nonprofit Adult Day Care Centers Early Head Start Centers Outside School Hours Centers Lgl7 Migrant Head Start Centers After School At-Risk Snack Programs For Profit Title XX Child Care Centers Emergency Shelters Serving Homeless Children For Profit Tile XIX Adult Day Care Centers 3. All centers must be visited at least three times a year with no more than six months between visits. One of the site visits must be conducted unannounced. A person from the sponsoring organization who is a recognized authority and has food program responsibility and knowledge of the CACFP should be assigned to do all site visits. The first site visit must occur during the first six week of operation. All non-school sponsored outside-school-hours centers must be monitored at least six times a year. If they are in session only nine months,they must be visited four times. Please describe how you will meet this requirement,including who will be responsible for the visits as well as an approximate schedule of when the visits will be made for fiscal year 2003. (Attach a separate page if necessary). You must use the CDPHE- CACFP Site Visit Form to conduct all required visits. A copy of this form is either enclosed in this packet,or will be enclosed in your approval packet. See Attached 4. Please describe your procedure for following up on problems discovered during monitoring visits. (Attach a separate page if necessary). See Attached J:\CACFPCommon\FORMS\Sponsor of Centers\APPLSOO03.doc 5. Sponsors are responsible for collection,maintenance,and review of the records for each center. Please describe the system you will use for collecting,maintaining,and reviewing the following records: (Attach separate page if necessary). A. Income Eligibility Forms(IEFs) See Attached fir all answers B. Records of Meals Served(ROMS) C. Menus D. Production Records E. Food Receipts and Invoices F. Claims for reimbursement 6. All center staff who will work with CACFP must receive initial training as well as annual training regarding the food program and nutrition. Please describe how you will train staff regarding the record keeping,administrative,and food service duties of the food program. Please include dates and topics to be covered. (Attach separate page,if necessary). See Attached 7. Before you bring on a new center,you will be required to conduct a pre-approval visit. You must use the CDPHE- CACFP site visit form(which is either enclosed in this packet or will be enclosed in your approval packet)to conduct this visit. A copy of the completed form must be submitted before you will be approved to claim meal reimbursement for a new center. Please describe how you will conduct your pre-approval visits including who will be responsible for conducting them. See Attached 8. List all sponsor personnel who will be involved in administering the CACFP using the chart below. Complete chart as specified,recording the duties of personnel listed in ADMINISTRATIVE DUTIES directly related to the CACFP. Administrative duties include managing finances and operation of CACFP. Do not include food preparation or serving duties. (Attach additional pages if necessary). SPONSOR STAFFING PATTERN FOR CACFP A.)Position B.)CACFP Duties C.) D.) E.)Annual Annual Percentage CACFP- Salary of Time Related Spent on Salary Only CACFP ,(Column C x; Duties` Column D) Administrator (or equivalent) Asst.Administrator (or equivalent) Clerical Support (or equivalent) Other(specify) Total CACFP-Related Labor 9. List all administrative budget expenses for CACFP related activities only using the chart below. Annual CACFP Administrative Budget(for CACFP related activities only)* CACFP-Related Labor(enter total from above). Do not include labor for food preparation or $ meal service. Office Supplies(including reproduction costs) $ Postage $ Transportation for Facility Monitoring(include mileage multiplied by$0.20) $ Telephone $ Office Rental/Mortgage Payment and Maintenance $ Utilities for Office Area $ Other(specify) $ Total CACFP Administrative Budget $ *No more than 15%of CACFP reimbursement may be used to cover administrative expenses. 10. List all food service operations expenses for CACFP related activities only using the chart below. Annual CACFP Budget for Food Service Operations at Facilities under Your Administration (for CACFP related activities only) Food Purchases $ Food Service Labor(salaries of cook and/or staff preparing or serving meals) $ Food Service Contractor Fee $ . ' 180,000 Non-food Supplies(napkins,straws,dishwashing detergent,etc.) $ Maintenance for Food Preparation,Storage,and Service Areas $ Rent/Mortgage Payment for Food Preparation,Storage,and Service Areas $ Utilities $ Other(specify) $ Total CACFP Food Service Operating Budget $ 180,000 11. List all sources of cash income specifically for the food service other than CACFP reimbursement. SOURCE INCOME AMOUNT Headstart/Migrant Headstart $ 270,000 Total Food Service Income(excluding CACFP Reimbursement) $ 270,000 I certify that the information on this application and any other application materials is true to the best of my knowledge; that will accept final and administrative and financial responsibility for all Child and Adult Care Food Program operations at all centers under my sponsorship. I further certify that reimbursement will be claimed only for meals served to enrolled participants;that the CACFP will be available to all eligible participants without regard to race,color, national origin,sex,age,or disability at the approved food service facilities. I also certify that these facilities have the capability for the meal service planned for the number of participants anticipated to be served,or the meals provided by a food service management company are in compliance with CACFP regulations:Additionally,I certify that neither the institution applying for CACFP participation,nor any of the sites for which the institution will be claiming CACFP meal reimbursement monies,have been disqualified from participation in any other publicly-funded program for violating that program's requirements. "Publicly-funded program"means any program or grant funded by federal,state,or local government I understand that this information is being given in connection with the receipt of Federal funds and that deliberate misrepresentation may subject me to prosecution under applicable State and Federal criminal statutes. St attire of Center Director or Autaorized Representative Date DEPARTMENT OF HUMAN SERVICES Family Educational Network of Weld County 1551 NORTH 17TH AVENUE IDGREELEY, Co 80632 C (970)353-3800 FAX(970)356-3975 COLORADO CACFP Renewal #3. The person responsible for conducting the site visits will be our part-time dietitian, Joyce Johnson. The monitoring visits will be done on a quarterly basis. #4. Follow up for problems discovered during the monitoring visits will be addressed as follows. The issue will be brought to the attention of the Health Specialist, who will address it with the appropriate people. The centers also have a nutrition concern form that can be completed any time there is a concern. #5. A. Income Eligibility Forms: Income eligibility forms are completed at the beginning of the school year. B. Records of Meals Served: Teaching staff complete the ROMS and turn them into the Health Specialist. The information is complied for the meal claim form. C. Menus: Menus are formulated with the appropriate school district and approved by Parent Policy Council. D. Production Records: Production records are completed by the school district cooks and reviewed by the Health Specialist. E. Food Receipts and Invoices: Invoices are approved by the Director and sent to the fiscal officer for payment and recording purposes. F. Claims for reimbursement: A report from the Health Specialist is given to the Director. The Director completes the form and sends it in for reimbursement. #6. Center staff receives training in November. New staff hired after November, receives training at new hire training and on the job training. #7. We currently have no plans to open another center. 2002-2003 WELD COUNTY HEADSTART FOODSERVICE MONITORING SCHEDULE September October November December Gilcrest 20 Milliken 4 Jefferson 8 Platteville 20 Madison 10 East Memorial 8 Billie Martinez 27 Centennial 16 Hudson 13 Island Grove 27 Dos Rios 16 Frederick 17 January February March Island Grove 9 Gilcrest 12 Frederick 13 Billie Martinez 9 Platteville 12 Jefferson 20 Dos Rios 15 Milliken 21 East Memorial 20 Centennial 15 Madison 27 Hudson 27 April May June Island Grove 4 Hudson 9 Billie Martinez 4 Jefferson 15 Dos Rios 18 East Memorial 15 Centennial 18 Frederick 22 Platteville 23 Madison 29 Gilcrest 23 Milliken 30 Monitoring Visits by: Joyce E. Johnson, MA Weld County Nutrition Consultant RENEWAL CIVIL RIGHTS COMPLIANCE RE\LEW Place center or sponsor of centers label in this area. The Colorado Department of Public Health&Environment,Child and Adult Care Food Program is required to conduct a pre-award civil rights compliance review of centers or sponsors of centers applying for CACFP participation. Please complete the following information: I. List the percentages for each racialethnic group in the community served by your center. Usually this information can be obtained from the local School District,Chamber of Commerce,Census Bureau,or Public Library. If you have more than one center,combine this information for all centers. % American Indian or Alaskan Native �x � % Hispanic(a person of Mexican,Puerto Rican,Cuban, / % Asian or Pacific Islander Central or South American,or other Spanish culture i % Black(not of Hispanic origin) or origin,regardless of race) `j a % White(not of Hispanic origin) 2. Count the actual number of children enrolled in your center for each group listed below. Write the number in the space provided. If you have more than one center,combine this information for all centers. o o American Indian or Alaskan Native `7 7`lc) Hispanic(a person of Mexican,Puerto Rican,Cuban, O'7, Asian or Pacific Islander Central or South American,or other Spanish culture S 2O Black(not of Hispanic origin) �7 or origin,regardless of race) _91 ,m White(not of Hispanic origin) 3. Do you do any activities to assure that minority populations and grassroots organizations have an equal opportunity to participate or are informed about changes in the Program? Yes J( No If yes,please check all that apply: Y Distribution of brochures of Program information at public locations X Public service announcements in local newspaper,on radio,or on television(circle media type used) Paid advertisements in local newspapers Other,please explain: The CACFP requires all advertising about the food program to contain a nondiscrimination statement. Do or will the items you checked above include the following nondiscrimination statement? Yes X No The U. S.Department of Agriculture(USDA)prohibits discrimination in its programs and activities on the basis of race,color,national origin,sex,age,or disability. (Not all prohibited bases apply to all programs.) Person with disabilities who require alternative means for communication of program information(Braille,large print,audiotape,etc.)should contact the USDA's TARGET Center at(202)720-2600(voice and TDD). To file a complaint of discrimination,write USDA,Director,Office of Civil Rights,Room 326-W,Whitten Building, 1400 Independence Avenue,SW, Washington,D.C.20250-9410 or call(202)270-5964(voice and TDD). USDA is an equal opportunityprovider and employer. 4. Is membership in a specific organization required before children can be enrolled?Yes No X If yes,please explain: 5. Have you ever been found to be in noncompliance of the Civil Rights laws by any federal agency?Yes No X If yes,please explain: We assure the Colorado Department of Public Health and Environment,Child and Adult Care Food Program that all enrolled participants in the Child and Adult Care Food Program at the center(s)described on the application forms are served the same meals at no separate charge regardless of race,color,national origin,sex,age, or disability,and there is no discrimination in the course of the meal service. u_Q1Loe�� �'3/O`�? Si ture of Center Director or Authorized resen[ative Date Signature of State Program Director CDPHE-CACFP Date J:\CACFPCommon\FORMS\Renewal Fonns\RcnCivil Rights03.doc RENEWAL CIVIL RIGHTS COMPLIANCE REVIEW Place center or sponsor of centers label in this area. The Colorado Department of Public Health&Environment,Child and Adult Care Food Program is required to conduct a pre-award civil rights compliance review of centers or sponsors of centers applying for CACFP participation. Please complete the following information: 1. List the percentages for each racial/ethnic group in the community served by your center. Usually this information can be obtained from the local School District,Chamber of Commerce,Census Bureau,or Public Library. If you have more than one center,combine this information for all centers. % American Indian or Alaskan Native % Hispanic(a person of Mexican,Puerto Rican,Cuban, % Asian or Pacific Islander Central or South American, % Black(not of Hispanic origin) or origin,regardless of race) r other Spanish culture % White(not of Hispanic origin) 2. Count the actual number of children enrolled in your center for each group listed below. Write the number in the space provided. If you have more than one center,combine this information for all centers. 0 American Indian or Alaskan Native —11 7p Hispanic(a person of Mexican,Puerto Rican,Cuban, 0,0 Asian or Pacific Islander Central or South American, Spanish C /n Black(not of Hispanic origin) or other S anish culture P or origin,regardless of race) ,(29/,r) White(not of Hispanic origin) 3. Do you do any activities to assure thatthat minority populations and grassroots organizations have an equal opportunity to participate or are informed about changes in the Program? Yes f` No If yes,please check all that 1 apply: 4_Distribution of brochures of Program information at public locations Public service announcements in local newspaper,on radio,or on television(circle media type used) Paid advertisements in local newspapers Other,please explain: The CACFP requires all advertising about the food program to contain a nondiscrimination statement. Do or will the items you checked above include the following nondiscrimination statement? Yes )( No The U.S.Department of Agriculture(USDA)prohibits discrimination in its programs and activities on the basis of race,color,national origin,sex,age,or disability. (Not all prohibited bases apply to all programs.) Person with disabilities who require alternative means for communication of program information(Braille,large print,audiotape,etc.)should contact the USDA's TARGET Center at(202)720-2600(voice and TDD). To file a complaint of discrimination,write USDA,Director,Office of Civil Rights,Room 326-W,Whitten Building, 1400 Independence Avenue,SW, Washington,D.C.20250-9410 or call(202)270-5964(voice and TDD). USDA is an equal opportunity provider and employer. 4. Is membership in a specific organization required before children can be enrolled?Yes No 1{ If yes,please explain: 5. Have you ever been found to be in noncompliance of the Civil Rights laws by any federal agency?Yes No K If yes,please explain: We assure the Colorado Department of Public Health and Environment,Child and Adult Care Food Program that all enrolled participants in the Child and Adult Care Food Program at the center(s)described on the application forms are served the same meals at no separate charge regardless of race,color,national origin,sex,age, or disability,and there is no discrimination in the course of the meal service. VC61411010 QC of Center Director or Authorized resentative Date Signature of State Program Director CDPHE-CACFP Date J:\CACFPCommon\FORMS\Rcnewal Fonns'RenCivil Rights03.doc Child and Adult Care Food Program RENEWAL/NEW CENTER AUDIT QUESTIONNAIRE Organizations receiving federal funds are required to be audited. The information requested on this form will help us satisfy those requirements. It may be helpful to have someone in your accounting or business office,or someone on your board who is familiar with auditing procedures,prepare this questionnaire. Please return this form even if you do not receive federal funds. Center or Sponsoring Q /� Agreement Organization: WL1a �ti/nl y Oi !, JBA.i 0/Monn.V S/U/Ce5 Number: Address: IM 41 (/L/MI/d,a/ /(/6/1Wk n1/U///&toil O ) &)A /505- ivF«// y , (6' 3Z) -.5a I. Do you contract" with an accounting firm to conduct an audit of your center/sponsor IZ1Yes ❑ No of centers? If your center/sponsor of centers is part of another organization,does the organization have 0'Yes ❑ No an organization-wide audit? The term"organization-wide audit"means an audit of all funds received by an organization,including federal,state,local,and private funds. The audit must include a random sampling of all federal funds received by the organization,and it must be conducted by an independent auditor. 2. Is a review of the CACFP included in that organization-wide audit? 1J Yes U No 3. What is the legal name of the organization being audited? We 14 (7t1/47// LI Yes ❑ No 4. What federal funds does your organization receive other that CACFP? (Examples: National School Lunch Program,Child Care Assistance Payments[Title XX],etc.) List: Dollar Amount received per year: NPR/� 90, s a�57;73337 #11/1 Sf&.ef-_ 07,P00, S/e $ /0 /4- x,3',7 I /,3 Gf/</i rr(r $ SG / 4/l// Pegs � 6. What is the total annual budget for the organization identified in Question#4? (Include all federal,state,and"other"funds). $ /(0 ,l 7y 50 7. When does your organization's fiscal year begin and end? From (Jc/Al To et e- 8. Does your organization have fiscal year end schedules(financial statements)? 'Yes LI No 9. Does your organization have computerized records? 0"Yes ❑ No *All audit contract must include the paragraph on the reverse side of this:form. Questionnaire prepared by: /I//1/// /1 /i/r///i i� Date: b/Z9/, Titre: —4(11/ al(tt /'4D//5 Phone Number: 35.3 - 38CC) ee'/3.33"0 OVER' - 1:\CACFPCommoo\FORMS\Reoewal Forms\AUDQUES03.doc 5/13/2002 Certification Regarding Debarment, etc. This certification is given by the Contractor in compliance with regulations implementing Executive Order 12549, Debarment and Suspension, 7CFR Part 3017.510. The Contractor hereby certifies, by execution of the contract,that neither it or its /' cipals is presently debarred, suspended, proposed for debarment, declared ineligib o untarily excluded from participation by any federal department of agency. J:\CACFPCommon\FORMS\Renewal Forms\AUDQUES03.doc 5/13/2002 4:4 { e. La x w o m x E 2 S ▪ as o b 4O W ti Y 5' 2 � r vi m o 10 • .• o Siu. O c vs e v — _ 4O •• m co x N y g E flI :1 Oill Yca• uo aI:" = U . i11llI ; Ro 7x. o AsC hd c$ 8 a ❑ m 3 a°'. 3a � 7 w o U s PaU . a O. 2 Fo F V) U ^ EaL xo m 0 3 AP4 00W U 6 W •'C u d v U .�. cn U N .12 m F U N v .. Y 3 a c o c U v U t , . �.� N w E3 pill G r.�. i tied ;kwt ,b y t O x hq t 'tH NO 8. ..,y4 v�yDII, 2 E k5_ W P9 d fljfl FO o ti :' .T.T �?. ,, „ O. a Cj e. mg ! s aq3 l� m o'ta� C� 3 ` .a .:. a f ., y�{ l▪ ey a s F° , �r ry� C3 T1 r M .. %7 ci (y ,� �.' t ;.Jr r LL O o0 � CJ IX r x a'iJ '. 4 14,...d '. 8 a M"r 40 ., , 8 .. CO .. m ❑ ❑ a. 9 �' �C p o 0.1 m c carri .ed '� !A W a1 a . coa r= v O 0. L a3 U Will y0. b o 4.7 'O O S l lin a m ea7 ^' aC v : °I 3 Uvm a. �ICQm .d �l°'„ n gam 4ri o v d o v cn °' o o 3 ,, n T d O 3 U U A 0 3 F 15. E"' co o a x F x U as N o U aj/ en_U ti i 'U �. �" N U N h ± uf 4 4 cc F 0 la 2 y = m Pi I v v Y O a eHu ,� ., (L) ....1 .c a°' i .. W m h E 0s °1 b ISO " ba 0 I R a 7 F I W m h .� a - � O o m �C mo 3a ¢ � . dm �' 'W 0m oU c P7 rn v� 1 P7 > "� '°Ji. ..7 �', E P1 3 .7 '�' B $ U °' LW U c v °' o U W U 3 U o v v b C m 3 Z •ro 3 U U /.. ., a H c x c u cxi U w 3 a c U L. T.) :c ..�{"e - .N. LL P U N Cq U 2 cc 0 re 0 'O y ` V Y `' WPM it, - * ry F0 f s jf �.. .. c _Y a .. 3 O X 27 Z 1IP slot b,ron,'t A �, F:., © v " . 0 o " o - 0 3 3i ` 4.S . S ! a o u _ - a g ,x eU �eY 'o a m � eU aY y "Ti-,,, m c U co e m z g e m e 3 E,E, 0 0 = c7,e e a c .. + L 0A 4 Vl CO L .7 id !n L L .7 O C V] § S M W W m P7 .� �N .o-- o 0.l o 3 o f U O i d a* r pOp N O y�y fn (� ttl H ❑ O P -1 N ,t , , A bf , ' 3 V c es rn V �' `� c sat ....elan a'.,. (' 'td ',, ";.P41 IV U o C1 t3 G a :"-ti''' `M'� w+YW i Y .� G N _h m ri' Pk 4`1t•+ 0,is ',, n�4a" V o U U �. m W N .a " l$ y } k '' ,k `� Y x C '03O Oyc-� a On Ca O O .4 _C O N CI W " d O O C x;42 2 0. y .3 � a 't ed Z+ N CO t a .. �+ Q WCi .CUy6 east: A ....ii co 0P. � F � IA a0i .6v0 m ^ u Y u d t, Y X I.d 4 ,1I.... F ct v � Ta` aoa3® `� a;- e7 °' `ad `3n `e 2 `aI � aoo � roi° z � w 4 a e c 2 —y •'.1 5 ee v� ,tpi e�E. ) .:.1 4 o rd U 11-';: r m•o C2 U, ' �'� at y.�1 a°-. h c e 3 — U . 0 v C� d i- It . . .` 011 o° 2 � n 'x A t4 c4 to F' O pp���`uA�ac .iy o� :o s'� c �` 4, u -1, m« p ti d ` ..�,� Cp C b c° U P. ce'. it Y .o. It. :c 3 oiclie asF , {P L �Y+ twvc`wanx. N m"g' t`"�„{M,,� s 1 a� .`°1 E—, p. MCI 0 3 r ,, 5. s y� �+ - n, `^ A,.. o a� Y N .G y p N O In N m m •- I J O -• 0 ❑ V d .. vY 0.' DI. U xOa .S_Q fnr'a 'OO ff 4i11ii cl,�W oo `ovcog = , `a3 'OII' r ' "' H. ,g in o ilt �` 1fF y alli V cl �., a V Q.? 0 x .p, �S 0 3 � 1 v C m CO m _ E" N Cr r7 .0 iF gl 75 Y N dieve1 k _ 3 q hk a a s o Y 3 ,,, W a s x Y sIV m u u FO -o u• W m "., ,pi a ¢ e °7 a .x c ca, wont ate' 1 '9 0 ad a 0 4 _. C O G% 1 �GF 0 y�.7 y m c' t 0 .7 c m 0 L pq..7 's'y `/� m E. in + f-0 o .a c,� 07 � a. 0.1 c U U _ 4F N O C N .. t y •O N O Z C .0 i d C 0 N U Vi C�J u -- .�] m w . vi D w oZ. V . o s tl e , V 3 0E 'o. mot_ occ - m - r J e7 To co en a7 ) N 41co 0) �°- r "� °.2 � a o 0 °1 a2 is O v w0 a V d C. r•— m . ~ u L I 0- I N V •— m 3 a) U: 3 .. O £ t 7 v 3 d •Of - 3 c I; 0) a) . R can `m c a) °d, co I CO c w e W co I W 0 V in d N ILA 3 a 0 V " a E ! I— o. Z r CL U ao In g o, Y o - d — ^r p of J C _ CD N rn = 1° t 1 N O a, d as in m' ¢_ v a0) r o .0- 3 O n 3 a a' - •c Z. o 0 z a r •3- = a a m -- 3 m 2 aci 0 aci ai a`� t.) a 0 ai w . o y . aw1 z a, p 1 0 = U a. �?, m U V $ 0- k 0 N 'c U CO a t=i: ci m a Z V Nc oo p 0 aNs —N N CI 0 a7 = •�'p N y N a.^t y L O 7 N on •N --� c 'au) a V p '� O m mc, a y n .g- I U 3 m = d vv o o ¢ oU a G R R d N c EN a m in 3 a0. E to y v Z E x a m c°s N •0 o o n _ _ C - m r J CI m as ye a ^� 0 R ,� a r W U)• 0 a_ 0 rn c7 is _c 0 c •= CJ cu y d i0 a c = 7 an y L d d d y V £ - as w 4- m co 3 0 N a a E § O`- v a Z •m 3 N T- E o a _O o 'C p a Qn E ul U ... .. a) • cm a% c a) - c0 a U U a) N Y to l0 J N 0 0 a' a) , 2 '- a z N 1d 0 a) P = Ca cam°- c m a rn o "ti- 0 o v a o � m m o a •£ • O a = m an •c a o a =_ E 2 o L � � � E - m m a in E L 2 Cl)U 0 g a c c c � CO O. a x a LO V m a c " " -o 00 d U G 0 = = = 2 > > 3 EE 3 a Z a Q CO (A U) < 0 y $y s,at m . IXs yd",w+' �,x%" 'eW&n A 4,,4^ --wh`�y, e PP f a. Imu V sue D ma a rif MEMORANDUM (it DATE: September 9, 2002 CTO: Weld County Board of County Commissioners C FROM: Wafter J. Speckman, Exec, Director, Division COLORADO of Human Services SUBJECT: Agreement Between the State of Colorado Department of Public Health & Environment Child Adult Care Food Program and the Family Educational Network of Weld County Presented before the Weld County Board of County Commissioners for approval is the annual agreement between the State of Colorado, Department of Public Health and Environment Child Adult Care Food Program and the Family Educational Network of Weld County for reimbursement of meals served to children in the Head Start and Migrant and Seasonal Head Start Programs. For further information please contact Tere Keller-Amaya at extension 3342. 2002-2472 Hello