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Home My WebLink About20012785 MEMORANDUM TO: FILE April 7, 2004 'Ise FROM: Carol Harding, Clerk to the Board Office Manager,Coordin orb r COLORADO SUBJECT: Document Not Fully Executed 1 —— C The original of Document#2001-2785 (HR0072), which was approved by the Board of County Commissioners on October 3, 2001, and executed by the Board on October 16, 2001,was never received back in the Clerk to the Board's Office. All attempts to obtain copies of the document have been unsuccessful,therefore,this matter is being administratively closed and no further action will be taken by staff to obtain copies of the fully executed agreement. 2001-2785 HR0072 From: CAROL Harding To: Keller-Amaya, TERE Subject: 2001 CONTRACTS Tere, I am still trying to close out our records for 2001 and have failed to receive an executed copy of the Renewal Form for Child and Adult Care Food Program which was approved on October 3, 2001, and sent to the State by your office shortly thereafter. The last time I heard from you regarding the contract was on October 23, 2002, at which time you said you would forward it when received. Please give this high priority. WE MUST HAVE AN EXECUTED CONTRACT FOR OUR RECORDS. If you have questions, please call. Carol CC: Speckman, WALT; Warden, DON CAROL Harding - Re: Contracts 1 Not Yet Executed Page 1 From: TERE Keller-Amaya To: CAROL Harding Date: 10/23/02 12:55 PM M Subject: Re: Contracts Not Yet Executed Carol - We have not received the contract from the State. I will follow-up with them and see if we can possibly have them mail us a copy. I will keep you posted. Tere >>> CAROL Harding 10/23/02 12:43PM >>> Tere- On October 3, 2001, the Board of County Commissioners approved the Renewal Form for Child and Adult Care Food Program, which is among the Division of Human Resources, FENWC, Colorado Department of Public Health and Environment, and Child and Adult Care Food Program. Although signed by the Chair and Julie Mallory, a fully executed bopy has not been received from you after submittal to the State. Please forward copies to our office as soon as possible. It is imperative we have copies of the fully executed documents in order to close our records for the 2001 year. If for some reason you are unable to provide the copeis requested, please contact me directly at extension 4217. Thank you for your help. Carol CC: DON Warden; WALT Speckman Donna Bechler- signature on renewal form Paget,. From: Donna Bechler To: Keller-Amaya, TERE Date: 9/13/02 4:57PM Subject: signature on renewal form Tere, We have a renewal form for the Child and Adult Care Food Progam from October 2001, that we have not received back in our office with signatures. The resolution number is 2001-2785 and was a renewal form from October 1, 2001 to September 30, 2002. If you have a completed copy in your office, could you please send one to us so we can scan it into our system. Thank you, Donna Bechler Clerk to the Board O O 15k _� Q 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, 2001, and ending September 30, 2002, 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 3rd day of October, A.D., 2001, nunc pro tunc October 1, 2001. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: 1 i�"\\, I . / � �CUSED Weld County Clerk to the Bo! Geile, Chair ' O 4 ��USED BY: t-_in Vaad, Pro-Tem Deputy Clerk to the Board �i i ✓� Willis . Jerke APPROVED7AS : vi E. Long nfiAttgrn Robe D. Masden Date of signature: 76f 2001-2785 �C .' yv%5,) HR0072 MEMORANGJM TO: Weld County Board of County Commissioners 11 tcf— FROM: Walt Speckman, Exec. Director, Division of U.- O Human Resources DATE: October 1 , 2001 COLORADO SUBJECT: Contract Between the Weld County Division of Human Resources, Family Educational Network of Weld County, and the Colorado Department of Public Health and Environment, Child and Adult Care Food Program Presented before the Weld County Board of County Commissioners is a contractual agreement between the Weld County Division of Human Resources, Family Educational Network of Weld County (FENWC), and the Colorado Department of Public Health and Environment, Child and Adult Care Food Program for reimbursement to FENWC for meals served to children. If you have questions please contact Tere Keller-Amaya at extension 3342. 2001-2785 Renewal Form CDPHE-CACFP October 1, 2001 -September 30, 2002 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 September 4, 2001. If you have any questions, please contact Sheila Sharpe or Shawna Morgan 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 is correct. Print Name:-L.�.-1 t C'- 1 , �ifLik.o r-' __ Signature: \AS2i...0ikc-a0-41e 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: .i County. Weld Authorized Representative: 1. TERE KELLER-AMAYA 2. -eEVERbY-SithICHHEZ Center Telephone: (970)353-3800 Alternate Telephone: Fax: (970)356-3975 5. Oct Nov Dec Jan Feb Mar Apr May Jun Aug Sep y Months Approved for CACFP Participation: Vi ✓t ✓1 ✓' ✓t �t Jult ✓I 6' Commodities: ICash-In-Lieu of Commodities: :' 7. Number of Shifts:2 8. License Capacity: 605 g, Does center care for infants? Yes No Bkfst AM Sn Lun PM Sri Sup Late Sn License Number N/A ,7 �.� License Expiration Date: 12/31/2003 A `'Meals Approved: r i fr �� i Timely Renewal: N ....., .._..: Does Center claim infants on the CACFP? Hours: 6.30A-6,00P (up to first birthday) 10. Is this a pricing program? Yes ! No VI Days Open: MON-SAT Yes VI No I 11.Center contracts meal service? yes '/ No 12.Contractots Name: 4 SCHOOL DISTRICTS 13. Food Service Contract Expiration "—' (please list additional contractors on the back) (please list additional dates on the back) Date: 6/30/2000 14. Meals are:Prepared at the center '. Prepared off-site !v 15. Age Range of Participants: 0 to 5 16. FOR PROFIT CENTERS ONLY Step 1 -Shawna/Debbie 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 Initial Date Please update as necessary. Initial Date County Expiration Date All Forms Received:_ Forms Missing: Person Contacted: Card Sent:�— or Form.Ltr Sent. _ ate Renewal.complete: Date: Initial Card Sent.(?)(see step 1): already sent _send Ul'Lf c L/J7` ATTACHMENT B - PARTICIPATING CENTERS/SITES Listing of all centers/sites participating in the CACFP Agreement#: 65103-05 MEAL SERVICE SCHEDULE OR MEAL TIME RANGES (Must put Beginning & Ending Times) BILLIE MARTINEZ License# : 81834 BILLIE AM Snk Lunch PM Snk Supper Late Snk 341 14T 14T Y, COH AVE 80631 LicenseCap : 50 Times Times Times Times Times Times GRLicenseExp Date : 12/31/99 0730-0866 --430-1200 0230-0245 0430-0500 Telephone : (970)351-0312 `� Meals are Prepared:On-site 1 Off-site ti Send Nutrition Education Mtrl ToIN Main Office Contact Person:DOROTHY PEREZ Above Address Age Range of Children: 0 - 5 MEAL SERVICE SCHEDULE OR MEAL TIME RANGES (Must put Beginning & Ending Times) CENTENNIAL License# : 81833 Bkfst AM Snk Lunch PM Snk Supper Late Snk 1400 37 H ST 80620 LicenseCap : 50 Times Times Times Times Times Times EVANS, LicenseExp Date : 12/6/94 0730-0800 1130-4200 0230-9245 0430-0500 1` x1 Telephone : (970)339-3085 �' Meals are Prepared:On-site i Off-site Send Nutrition Education Mtrl To:n Main Office Contact Person:CLAUDIA TAPIA Above Address Age Range of Children: 0 - 5 MEAL SERVICE SCHEDULE OR MEAL TIME RANGES (Must put Beginning & Ending Times) DOS RIOS License# : 81829 Bkfst AM Snk Lunch PM Snk Supper Late Snk 2201 34TH ST LicenseCap : 50 Times Times Times Times Times Times EVANS, CO 80620 LicenseExp Date : 12/31/99 0730-6866 493&920O O230-0245 0430-0500 Telephone : (970)330-3220 7,43 ors 1, _. Meals are Prepared:On-site .1 Off-site itir Send Nutrition Education Mtrl To:gtMain Office Contact PersO Above Address N ,, nt, _) Age Range of Children: 0 - 5 MEAL SERVICE SCHEDULE OR MEAL TIME RANGES EAST MEMORIAL License# : 81830 (Must put Beginning & Ending Times) E 20TH Bkfst AM Snk Lunch PM Snk Supper Late Snk 614 614 E20T, ST 80631 LicenseCap : 50 Times Times Times Times Times Times GRLicenseExp Date : 12/31/99 0730-_086Q -4486-1200 0230-0245 0430-0500 Telephone : (970)352-9478 s` it a' Meals are Prepared:On-site ,L;1 Off-site LL 1 Send Nutrition Education Mtrl To:RMain Office Above Address Contact Person: c ne r dt_r C�Lf4M- Age Range of Children: 0 - 5 f\ 1 N, ‘U t ATTACHMENT B - PARTICIPATING CENTERS/SITES Listing of all centers/sites participating in the CACFP Agreement#: 65103-05 MEAL SERVICE SCHEDULE OR MEAL TIME RANGES (Must put Beginning & Ending Times) FREDERICK License# : 66816 Bkfst AM Snk Lunch PM Snk Supper Late Snk 340 MAPLE LicenseCap : 54 Times Times Times Times Times Times FREDERICK, CO 80530 LicenseExp Date : 12/31/99 0730-0800 - ©0- 0230-0245 0430-0500 Telephone : (970)833-2230 `j�^' u/ t� �' Meals are Prepared:On-site Off-site Send Nutrition Education Mtrl To. Main Office Contact Person. - - 0 - 5 �] Above Address Prorize ri L et ce.Men Age Range of Children: ,_- MEAL SERVICE SCHEDULE-OR-MEAL TIME RANGES —` _....(Mast pt'fi Ueginning & Ending Times) FT MORGAN ---LLB License# : 03807 Bkfst- AM Snk Lunch PM Snk Supper Late Snk FT MORGAN, CO icenseCap 60 Times Times Times Times Times Times LicenseExp pats ;z-7-1-2131799 _ 0730-0800 1130-1200 0230-0245 0430-0500 F ..,etepFione : (970)867-7418 Meals are Prepare&On-site., Off-site Send Nutrition EducationYorl"`TMain Office Contact Person:DORA LOPEZ - 0 - 5 "� Q Above Address Age Range of Children:"- MEAL SERVICE SCHEDULE OR MEAL TIME RANGES GILCREST License# : 85080 (Must put Beginning & Ending Times) Bkfst AM Snk Lunch PM Snk Supper Late Snk 1175 BIRCH LicenseCap : 15 Times Times Times Times Times Times GILCREST, CO 80623 LicenseExp Date : 12/31/99 0730-08O -1130 1200 0230-0245 0430-0500 ',,3c. in') k -,S.:` Telephone : (970)737-6767 Meals are Prepared:On-site EA Off-site ,!,( Send Nutrition Education Mtrl To �1 Main Office Contact Person:KAYE WRIGHT 3 - 5 LJ Above Address Age Range of Children: MEAL SERVICE SCHEDULE OR MEAL TIME RANGES GRAND JUNCTION License# : 04252 (Must'put Beginning & Ending Times) GRAND JUNCTION, CO Bkfst AM Snk Lunch PM Snk Supper Late Snk LicenseCap : 42 Times Times Times Times Times Times LicenseExp Date : 0730-0800 1130-1200 0230-0245 0430-0500 Telephone : (970)434-7112 Meals are Prepared:On-site f j Off-site l'',J Send Nutrition Education Mtrl To: Main Office Contact Person:FLORENCE HARRINGTON 0 - 5 Above Address Age Range of Children: `�i ATTACHMENT B - PARTICIPATING CENTERS/SITES Listing of all centers/sites participating in the CACFP Agreement#: 65103-05 MEAL SERVICE SCHEDULE OR MEAL TIME RANGES HUDSON License* : 81828 (Must,put Beginning & Ending Times) 300 BEECH Bkfst AM Snk Lunch PM Snk Supper Late Snk HUDSON, CO 80642 LicenseCap : 50 Times Times Times Times Times Times LicenseExp Date : 12/31/99 0730-B8BD 1130-900 0230-0245 0430-0500 . �'T Telephone : (970)536-0440 are are Prepared:On-site Off-site Send Nutrition Education Mtrl To: Main Office Contact Person:GWEN CERRETTO 0 - 5 Above Address Age Range of Children: MEAL SERVICE SCHEDULE OR MEAL TIME RANGES (Must put Beginning & Ending Times) ISLAND GROVE VILLAGE License* : 85077 Bkfst AM Snk Lunch PM Snk Supper Late Snk 119 14TH AVE LicenseCap : 15 Times Times Times Times Times Times GREELEY, CO 80631 LicenseExp Date : 12/31/99 0730-0800 1130-4-28@- 0230-0245 -8490-0500 (p, \ k&:t> . -4.-ii_ Telephone : (970)352-2627 Meals are Prepared On-site $ Off-site i Send Nutrition Education Mtrl To:N Main Office Contact Person,yr+.CNNY HOKE 0 - 5 Above Address {.fi,'innra Age Range of Children: MEAL SERVICE SCHEDULE OR MEAL TIME RANGES License* : 81831 (Must put Beginning & Ending Times) JEFFERSON Bkfst AM Snk Lunch PM Snk Supper Late Snk 1315 4TH AVE GREELEY, CO80631 LicenseCap : 30 Times Times Times Times Times Times LicenseExp Date : 12/31/99 0730-080e1 a�45 z s� 1130 9-PBB 0230-0245 0430-0500 L Telephone : (970)356-7408 Meals are Prepared:On-site Off-site :RI Send Nutrition Education Mtrl To: Main Office Contact Person:PAT(NCIA 5.9NDO�'R 0 - 5 Above Address Mp\i,, i t rl-i li IN Age Range of Children: MEAL SERVICE SCHEDULE OR MEAL TIME RANGES (Mues) MADISON License* : 81832 Bkfst AM Snkput'' Lunc�nning &PM Snk Ending Tim Supper Late Snk 24TH AVE & 6TH ST LicenseCap : 50 Times Times Times Times Times Times GREELEY, CO 80631 LicenseExp Date : 12/31/99 0730-8806 11304.20B- 0230-0245 0430-0500 Telephone . (970)353-2796 }'Csrir �x Meals are Prepared:On-site s Off-site -I'M{ Send Nutrition Education Mtrl To:N Main Office Contact Person.iEhRI=W-HAIVSEAI-- 0 - 5 Above Address nCOL t_<.): 1 P j Age Range of Children: C', 1 NJ IN ATTACHMENT B - PARTICIPATING CENTERSISITES Listing of all centers/sites participating in the CACFP Agreement#: 65103-05 MEAL SERVICE SCHEDULE OR MEAL TIME RANGES MILLIKEN License# : 85079 (Must put Beginning & Ending Times) BROAD Bkfst AM Snk Lunch PM Snk Supper Late Snk 300• MILLIKEN, CO 80543 LicenseCap : 30 Times Times Times Times Times Times LicenseExp Date : 0730-8886 1130-42BA' 0230-9245 0430-0500 Telephone : (970)587-2888 3c�, j ) Meals are Prepared:On-site a Off-site J Send Nutrition Education Mtrl To:El Main Office Contact Person:MABEL TAPIA g Range Address Age Ran e of Children: 3 - 5 MEAL SERVICE SCHEDULE OR MEAL TIME RANGES OLATHE License# : 03811 (Must,put Beginning & Ending Times) OLATHE, CO Bkfst AM Snk Lunch PM Snk Supper Late Snk LicenseCap : 35 Times Times Times Times Times Times LicenseExp Date : 12/31/99 0730-0800 1130-1200 0230-0245 0430-0500 Off-site Telephone : (970)323-5301 Meals are Prepared:On-site N'jj Send Nutrition Education Mtrl To:'Main Office Contact Person;fE6REARRIN6F-0N Above Address W. Age Range of Children: 0 - 5 ��1 1 nr� (YAP MEAL SERVICE SCHEDULE OR MEAL TIME RANGES (Must put Beginning & Ending Times) PLATTEVILLE ELEMENTARY License#: 87415 ; PLATTEVILLE, CO Bkfst AM Snk Lunch PM Snk Supper Late Snk LicenseCap : 24 Times Times Times Times Times Times LicenseExp Date : 12/31/99 0730-9898- -t?30=1200 0230-0245 0430-0500' �,. o Telephone . (970)785-2271 Meals are Prepared:On sit "i Off-site EA Send Nutrition Education Mtrl To.KMain Office Contact Person:KAYE WRIGHT 0 Above Address Age Range of Children: 3 - 5 ti �d i Child & Adult Care Food Program Certificate and Statement of Authority This organization is a: For Profit Corporation ❑ Non Profit Corporation ❑ Limited Liability Corporation ❑ Sole Proprietorship ❑ Public Entity ❑ Partnership ❑ Church ❑ 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 to TheJCcte.,-, htU s «,, (rri-LLrYa,-, Sort (' Wqr�pmifri poiicr l (Name of the Organization,Business or Church) / I Ie+t r d r p( (T Z" GOeici (ryA --' whose address is reP I p`f `1(.03 (Street or Route) (City) (Zip Code) 17u ) 353- aisIDC (Telephone Number) 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 and signature(s) appears below is authorized to sign the Claim for Reimbursement and is filly-empowered to enter into any agreement with the Colorado Department of Public Health& Environment CACFP and may act for the above-mentioned center or sponsor 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 to request from this office, Colorado Department of Public Health & Environment CACFP, forms to register the change. The signature of the Authorized Representative on the Claim for Reimbursement must match the signature on this form or the Claim cannot be processed and your reimbursement will be delayed. AUTHORIZED REPRESENTATIVE(S) 1. ��t / 1 G, 2 Nig_Lo C2 CU��)) SinreSigna tire /2r� AZ,/ L Ji ►; ono It or 7i () Print Name Print Name 0-1✓ec,FI) ✓ Rea Nh c5 eCireil(Lt- Title Ti is the duly designated Authorized Representative(s)for the Center/Sponsor 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 Fede al funds and that all of the provisions of the Agreement (CACFP 300) apply. • k( Robert D. Masden Temporary Chair Signature of Chair of the Board of Directors, Print Name Official Title or Pastor,or Executive Director,or Owner October 3. 2001 Date (CDPHE-CACFP 306 6/99-d:\forms\cert-soa.PM5) Child&Adult Care Food Program RENEWAL CJvn. RIGHTS COMPLIANCE REVIEW 65103-05 05 WELD COUNTY FAMILY EDUC NETWORK OF WELD CO PO BOX 1805 GREELEY, CO 80632-1805 The Colorado Department of Public Health&Environment,Chda ana Amin L,d....,.,...._o_. 4uired 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 icl % Hispanic(a person of Mexican,Puerto Rican,Cuban, % Asian or Pacific Islander Central or South American,or other Spanish culture % Black(not of Hispanic origin) or origin,regardless of race) 1.3 % 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. c3 % American Indian or Alaskan Native (-1.53— % Hispanic(a person of Mexican,Puerto Rican,Cuban, Asian or Pacific Islander Central or South American,or other Spanish culture % Black(not of Hispanic origin) or origin,regardless of race) 73 % White(not of Hispanic origin) 3. Do you do any activities to assu1e,that minority populations and grassroots organizations have an equal opportunity to participate or are informed about changes in the Program? Yes ,N No If yes,please check all that apply: 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,gender, religion,age,disability,or political beliefs. (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 .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 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,gender,religion,age,disability,or political beliefs,and there is no discrimination in the course of the meals service. n N` ? arid/ Sign tore of Center ector or Auth ed Representative Date Signature of CDPHE-CACFP Program Director Date J:\CACFPCommon\RENEWALS\Civil Rights02.doc Child&Adult Care Food Program RENEWAL CIVIL RIGHTS COMPLIANCE REVIEW 65103-05 05 WELD COUNTY FAMILY EDUC NETWORK OF WELD CO PO BOX 1805 GREELEY,CO 80632-1805 The Colorado Department of Public Health&Enviro.........., 1 VMS 1.ugtaiu ld!oyuired 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 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 151 % Hispanic(a person of Mexican,Puerto Rican,Cuban, % Asian or Pacific Islander Central or South American,or other Spanish culture % Black(not of Hispanic origin) or origin,regardless of race) 1 3 % 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. 3 % American Indian or Alaskan Native <(rr % Hispanic(a person of Mexican,Puerto Rican,Cuban, Cf % Asian or Pacific Islander Central or South American,or other Spanish culture % Black(not of Hispanic origin) or origin,regardless of race) 73 % 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 X No If yes,please check all that apply: K 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 f.71 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,gender, religion,age,disability,or political beliefs. (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 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 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 charee regardless of race,color,national origin,gender,religion,age,disability,or political beliefs, and there is no discrimination in the course of the meals service. �� C OQ T/s t jai Si ture of Center Director or Authori Representative Date Signature of CDPHE-CACFP Program Director Date J'.\CACFPCommon\RENEWALS\Civil Rights02.doc r Child&Adult Care Food Program 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/Sponsorin // r / J/ 5etuide5 Organization: POIa COan7/y di(//5/Dll Dfi /y�1/Y/tn/ Agreement Number: (n5 /O:4-OC Address: Mindy LCru('a/i,, C/ /t47Z//l/l' 100V guar/y /'5 LX /Pr E,pee/et, (a P‘,3,,1 1. Do you contract*with an accounting firm to conduct an audit of your center/sponsoring organization? Yes ✓ No 2. If your center/sponsor is part of another organization,does the organization have an organization-wide audit? Yes No "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. / 3. Is a review of the CACFP included in that organization-wide audit? Yes V No 4. What is the name of the organization being audited? Kgpi/hit6pl//e,men F 5. What federal funds does your organization receive other than CACFP? (Examples: National School Lunch Program, Title XX) Dollar amount List: received per year: kV/A- $ 31,,D, COO a/3A- $ hilf 61/4s- flea(' ila.el- $ 02,310 , V17bra"ems fir $ 5S01000 6. What is the total annual budget for the organization identified in Question#4? (include all federal, state, and"other" funds) $ ii 1, G 6 g <f 'A (poe I 7. When does your organizations's fiscal year begin and end? I / I through I A131 8. Does your organization have fiscal year end schedules(financial statements)? Yes I/ No 9. Does you organization have computerized records? Yes No * Aalordit contracts,mast incladerhe paragraph on the reverse side of this form, • Questionnaire prepared by: Au/,Q/Lye ////,leG/A/O Date: (r//510/ Title: L--11:544 / ()free , /(, p!i 5- Phone Number:(910 ) 353 3f00 (/ ail 3-370 (CDPHE.CACFP 6/99 c:\Fomis\AuditQue.PM5) OVER CcJ 71 Child & Adult Care Food Program ° RENEWAL/NEW CENTER SPONSOR OF CENTERS APPLICATION 65103-05 05 WELD COUNTY FAMILY EDUC NETWORK OF WELD CO PO BOX 1805 GREELEY,CO 80632-1805 1. List the number of CACFP participating centers in each category under your administration: Nonprofit Child Care Centers jr) 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 6.2-29 Head Start Centers Nonprofit Adult Day Care Centers Early Head Start Centers Outside School Hours Centers oZo 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 visit being more than six months apart. A person from the sponsoring organization who is a recognized authority and has food program responsibility and knowledge on 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 2002. (Attach a separate page). You must use the CDPHE-CACFP Site Visit Form to conduct all required visits. A copy of this form will be enclosed in your approval packet this fall. 4. Please describe your procedure for following up on problems discovered during monitoring visits. (Attach a separate page). 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)JftBrLQ CI .�; bi1"4F.erns a-re- Cormple-Fed Ck* +he bed;nn''iro or*%- &k•.00I year. B. Recor s of Meals erved(ROMSyTea_oiher S Co - y le.+-e The Rcnn c.r d Inke 'l-he R e.o-NM QEe;o- S— s-41c In -n-og--; ;e Ccrneiledit- �1 C. MCRurn i"vrvv,a r ,�r� �* wow b inn; a�- .p achcol v V�y 2fincts are F� uIa�-ed wN� �Q ri c\`k O1 d;s'1�-ie≥ts v- ruse en+ Polio 'a.�; �c; I. D. Production Records - Pre done k *W...e Africk.doorev; ec.Jed by E. Food Receipts and Invoices Sf'VOi Cos are a yermied by Me tb;reckw c4- ccrk`0 e. F\ era...\ OFF;C-er For 9O-mn- en+ 4 reeor<4 n5 Pu,-rel:23Ses- F. Claims for reimbursement l:\CACFPCommon\NEWCTR.FRM\APPLSOC02.doc )) qq 6. Sponsors of centers must distribute CACFP reimbursement funds to centers within five(5)day of receipt from the CDPHE-CACFP. Please describe how you will accomplish this. (Attach separate page,if necessary). "9\el n' \ t .r ernerhs are made dm-,2,:24-1t4 $c t,Oatl . tnd i Vidua-e Cert}ert do r\04- reeeav2 &reek- reimbu.rseirer -. 7. All center staff that will work with CACFP must receive initial training as well as annual training regarding the food program and nutrition. Please describe how you will be training staff regarding the recordkeeping requirements, administrative, and food service duties of the food program. Please include dates and topics to be covered. (Attach separate page, if necessary). Cart reoc;ve_- 0.;r`I r R i n fiovem>,er* CoVer *%s e a-*brer- art! -4op;Cs 8. Before you bring on a new center,your sponsorship will be required to conduct a pre-approval visit. Please describe the procedure you will use. (Attach separate page, if necessary). Please attach a copy of your pre-approval evaluation form as well. Lee W;11b2opeh;r ctx 4\erCCn%ery.hpweoer 'cam44C., 4zrru?, we Q.1/4e not csa-'-re when-. we wI i i b.e do; fm`44.4:45 . - 9. Will any of the centers in your sponsorship contract with a food service management company or a caterer for meals? Yes No )(, If yes, please list for each center the food service management company,their address, contact name, and type of delivery procedure that will be used to supply meals for the center. (Attach separate page, if necessary). Food Service Management Company: Food Service Management Company: Address: Address: Contact: Contact: 10. 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. (Attach additional pages if necessary). SPONSOR STAFFING PATTERN FOR CACFP A.)Position B.)CACFP Duties C.)Annual Salary D.)Percentage of E.)Annual CACFP- Time Spent on Funded Salary Only CACFP Duties (Column C x Column D) Administrator (or equivalent) Asst. Administrator (or equivalent) Clerical Support (or equivalent) Cook Other(specify) Total CACFP-Funded Labor �cci�a7,r-� • 11. List all administrative budget expenses for CACFP related activities only using the. ..rt below. Annual CACFP Administrative Budget(for CACFP related activities only) CACFP-Funded Labor(enter total from above) $ 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 $ 12. 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 staff preparing or serving meals) $ Food Service Contractor Fee $ I wO OO u 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 S Utilities S Other(specify) $ Total CACFP Food Service Operating Budget $ coo 13. List all sources of cash income specifically for the food service other than CACFP reimbursement. SOURCE 1 INCO1l4YE AMOUNT , 1-4ena ru4 I in (f ,r,* l`irir\ SIYL�'-�' $ iY7C7CX�C� �S $ $ Total Food Service Income(excluding CACFP Reimbursement) $ 7C/apJ I certify that the information on this application and any other application materials is true to the best of my knowledge; that I will accept final and administrative and financial responsibility for all Child and Adult Care Food Program operations at all centers under my sponsorship. 1 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: Additionally,I 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. 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. Si ature of Center Director or Auth zed Representative Date -ROC/-5,7717-.-: a DEPARTMENT OF HUMAN SERVICES Family Educational Network of Weld County 1551 NORTH 17TH AVENUE IlDPO BOX 1805 GREELEY, CO 80632 O (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. 2001-2002 WELD COUNTY HEADSTART FOODSERVICE MONITORING SCHEDULE September October November December Gilcrest 20 Milliken 1 Jefferson 1 Platteville 20 Madison 10 East Memorial l Billie Martinez 27 Centennial 17 Hudson 2 Island Grove 27 Dos Rios 17 Frederick 18 January February March Island Grove 10 Gilcrest 12 Frederick 14 Billie Martinez 10 Platteville 12 Jefferson 20 Dos Rios 16 Milliken 15 East Memorial 20 Centennial 16 Madison 27 Hudson 27 April May June Island Grove 4 Hudson 3 Billie Martinez 4 Jefferson 8 Dos Rios 18 East Memorial 8 Centennial 18 Frederick 9 Platteville 26 Madison 22 Gilcrest 26 Milliken 24 Monitoring Visits by: Joyce E. Johnson, MA Weld County Nutrition Consultant Ce/ Jn' A 6-10 Mint illiligallikrikiliriallgagtilikita 2001 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAYr District 6 Closed/ - FENWC Head Start PANCAKE ON STICK CINNAMON ROLL,,; PRETZEL W/ TOAST, PEANUT will provide Meals W/ SYRUP, FRESH FRESH FRUIT,` ' CHEESE SAUCE, BUTTER JUICE, BREAKFAST this day FRUIT,WHOLE MILK WHOLE MILK` KIWI WHOLE MILK WHOLE MILK District 6 Closed/ , I a' M. SNACK FENWC Head Start WHEAT CRACKERS, JUICE SODA MUFFIN,PINEAPP LE CRACKERS, JUICE will provide Meals JUICE CRACKERS , JUICE this,Aay 44-44-44 , - S Dist ct.6 osed „„y„ FENWC Head*Start SAUSAGE &CHEESE BBQ RIB ON BUN, CHEESE BURGER FRUIT, MEAT, will provide Meals ON A BUN, POTATO GREEN BEANS, ON BUN, OVEN BREAD AND LUNCH this day TOTS, PINEAPPLE PEARS Sir GRAPES, • it , FRUIT, CHEESE TRAY, TIDBITS,JUICE, ICE CREAM CO. r,u WHOLE WHOLE MILK WHOLE MILK k x SANDWICH,WHOLE a MILK I MILK District 6 Closed/ _ F" "" P.M SNACK FENWC Head Start VANILLA WAFER CHEESE STICKS, ` ORANGE WED'at CRACKERS, JUICE will provide Meals MILK PINEAPPLE JUICE WHOL5$4,_K Q4-, this day ,y, �� 75 R2 'rt gvs k f 41^-,1 District 6 Closed/ } DINNER FENWC Head Start CHICKEN NUGGETS, SCRAMBLED EGGS, � ,C W r r CHEESE, MEAT, `; will provide Meals DICED POTATO, HASH BROWN1, k≥n, CH CRACKERS,FRUIT, this day APPLESAUCE FLOUR TORTILLA z 1 A n® WHOLE MILK MUFFIN, WHOLE MILK APPLE SAUCE, - e =LL.;' S WHOLE MILK WATERMELON, l ,ti WHOLE MILK August 20-24 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY I CEREAL, PINEAPPLE PANCAKE ON STICK CINNAMON ROLL, PRETZEL W/ MANAGER'S CHOICE WHOLE MILK W/ SYRUP, FRESH FRESH FRUIT,_ CHEESE SAUCE, BREAKFAST FRUIT, WHOLE MILK WHOLE MILK KIWI, WHOLE MILK g A.M SNACK FRESH FRUIT, WHEAT CRACKERS, JUICE;,SODA' MUFFIN,PINEAPPLE MANAGER'S CHOICE WHOLE MILK JUICE CRACKERS , JUKE. 'u _; CHICKEN NUGGETS, PEPPERONI PIZZA, SOFT'TACO, HOT DOG ON A BUN, FRENCH FRIES, CORN, FRESH LETTUCE AND POTATO ROUNDS, LUNCH APPLESAUCE APPLES,WHOLE TOMATO, CORN APPLESAUCE WHOLE MILK MILK MUFFIN, PEARS, WHOLE MILK WHOLE MILK I P.M. SNACK RITZ CRACKERS, VANILLA WAFER CHEESE STICKS, OR A GE WEDGES MANAGER'S CHOICE APPLE JUICE MILK PINEAPPLE JUICE Li I -, ROAST BEEF, FLOUR TORTILLA SCRAMBLED EGGS, MACAR0II'W/ - SAUSAGE AND DINNER ROIL W CHEESE DICED HASH BROWN, CHEESE UCE„ 5 CHEESE ON BUN, DINNER MASHED POTATOES, FLOUR TORTILLA, r i ; GREEN BEANS, POTATOES WI : r P€ACHES, MUFFIN, APPLE SAUCE,! BR© L* APPLES, WHOLE GRAVY, ORANGE 4 WHOLE MILK WHOLE MILK TWA m . MILK WEDGES i 1 CI WEEK OF AUGUST 13-17-DISTRICT 6 CLOS£D....FENWC HEAD 011 i - ' °PROVIDE MEALS A 27-31 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY CEREAL,FRUIT OATMEAL,FRESH CEREAL FRESH FRENCH TOAST, BAGEL W/ CREAM JUICE,WHOLE MILK FRUIT, WHOLE MILK FRUIT,'WHOLE MILK CHERRY SAUCE CHEESE JUICE OR i BREAKFAST WHOLE MILK FRUIT, WHOLE MILK AM SNACK ANIMAL CRACKERS, FRUIT LOOPS, CHEESE STICK WILD RITZ CRACKERS, PEACHES,WHOLE JUICE GRAPE JUICE BERRY JUICE PINEAPPLE JUICE MILK GRILLED HAM AN1D'" CHILI W/ FRITOS, FRENCH TOAST W/ CHICKEN STRIPS, NACHOS W/ CHEESE SANDWICH, ._ BABY CARROTS, SYRUP,YOGURT, MASHED CHEESE SAUCE LUNCH }FR NC,I F ,„.,42, FRUIT JUICE WHOLE POTATO TRIANGLE POTATOES, REFRIED BEANS, PEACHES,WHOLE!•..• MILK FRUIT JUICE WHOLE BISCUITS, GRAVY, WATERMELON, MILK MILK WHOLE MILK WHOLE MILK GRAHAM WHEAT CRACKERS, .�rn PM SNACK SODA CRACKERS, CRACKERS,WHOLE ORANGE PINEAPPLE WHOLE RAISIN BREAD, APPLE JUICE MILK JUICE LMILK s APPLE JUICE .. :;;,,L,-„,::::,;:.,„:„7,c4.2d SCRAMBLED ; , HAMBURGERS, CHEESE FLOUR CHILI'F 1NS,, 3 ..t7";.%;;., HASH BROWN, BAKED BEANS, TORTILLA,JUICE, WEDGES O , TNAGER'S CHOICE DINNER APPLE WEDGES, ,FLOUR TORTILLA, WHOLE MILK WHOLE MILTS - R ACHES,WHOLE o `� "� ` 5t µ 51 *I 22,7 MILK - a Hello