HomeMy WebLinkAbout920899.tiff RESOLUTION
RE: APPROVE PURCHASE OF SERVICE AGREEMENT BETWEEN FAMILY EDUCATIONAL NETWORK
OF WELD COUNTY AND THE COLORADO DEPARTMENT OF HEALTH AND AUTHORIZE
CHAIRMAN 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 Purchase of Service Agreement
between the Family Educational Network of Weld County (FENWC) and the Colorado
Department of Health, Child and Adult Care Food Program, with the terms and
conditions being as stated in said agreement, and
WHEREAS, after review, the Board deems it advisable to approve said
agreement, 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 Purchase of Service Agreement between the Family
Educational Network of Weld County and the Colorado Department of Health, Child
and Adult Care Food Program be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is,
authorized to sign said agreement.
The above and foregoing Resolution was, on motion duly made and seconded,
adopted by the following vote on the 21st day of September, A.D. , 1992.
BOARD OF COUNTY COMMISSIONERS
ATTEST: � r� � WELD COUNTY, COLORADO
15n..Cfr
Weld County C erk to t Boardta:1:/L,_
e Kennedy, Chairman
BY: / -,c- -C.
Deputy Clerk to the Board �onstance L. Harbert, ro-Tem
APPROVED AS FORM: EXCUSED
C. W. Kir
ounty Attorney Gor n
W. H. ebster
920899
Telefax Numbers:
Main Building/Denver
(303) 3229076
4210 Ptarmigan Place/Denver
East 11th Avenue
(303) 320-1529 ROY ROMER
Denver, Colorado 80220-3716 Governor
Phone(303) 320-8333 First National Bank Building/Denver
(303) 355-6559
A4 Grand Junction Office JOEL KOHN
(303) 248-7198 Interim Executive Director
COLORADO
Pueblo Office
DEPARTMENT (719) 543-8441
OFAHEALTH
August 1992
Dear Child and Adult Care Food Program Authorized Representative:
Enclosed are your renewal materials for the Colorado Department of Health Child and Adult Care Food Program
(CDH-CACFP)for Fiscal Year 1993(October 1,1992 through September 30,1993).Please com plete the enclosed forms
and return them to our office ty Tuesday, September 8, 1992 in the envelope provided.
CIIECK off as forms are completed
ENCLOSED FORMS RETURN to our office.
2 CACFP 300 - Agreement 2
1-NCR CACFP 301 - Center Application (return white 1 (white copy only)
copy for each center, keep yellow copy)
2 CACFP 302 - Sponsor Application (not included if you 1 IN/A
are participating as a single center)
2 CACFP 100- Certificate and Statement of 1
Authority/Fourth Meal Document
2 CACFP 102 - Preaward Compliance Review/Center 1 L_J
Information (Additional)
1 Audit Questionnaire 1
1 Copy of two weeks' menus for each meal or snack claimed. In 1
addition, include infant menus for each age group (i.e., 0-3 mo., 4-7 mo.,
8 mo. up to 1 year) if you plan to claim infant meals (ages birth to 1 year).
1 Copy of your contract for meal service if your meals are prepared and 1
supplied by a vendor, local school district, or another child care center.
For-Profit Centers,please submit the following with the above application forms:
• If you are a For-Profit center, a copy of your current contract(s) with the Department
of Social Services for the care of Title XX children. (Please include all four pages.)
• If you are a For-Profit center, provide a roster of all children enrolled for the month
before you received this application for each center and identify those children for
whom Title XX payments were received.
Completion and approval of Form CACFP 300 Agreement will allow you to participate through September 30. 1994,
Your renewal, as always, is dependent upon whether the Federal government appropriates funds for the CACFP.
If you are a nonpricing center, you are no longer required to submit the Public Service Announcement Press Release.
Instead,the CDH-CACFP will send this release for you to your local news media announcing your intent to sponsor the
Child and Adult Care Food Program in your center(s). This will fulfill your Civil Rights obligation to advertise the
availability of the CACFP to all members of your community.
Again,ALL APPLICATION MATERIALS MUST BE COMPLETED AND RETURNED TO US BY TUESDAY,
SEPTEMBER 8, 1992 to the address listed below. Orieinal signatures of an official having authority to enter into
contracts on behalf of your organization are needed on your application materials. You may want to consider returning
all items by Certified Mail.
Child & Adult Care Food Program
Colorado Department of Health
4210 East 11th Avenue
Denver, CO 80220
If you choose not to participate.we would appreciate your letting us know. If you have any questions,call our office at
(303)331-8351.
Sincerely,
Kathryn A. Brunner, Administrator
Child & Adult Care Food Program
Enclosures
Special Notice
The Colorado Department of Health, Child and Adult Care Food Program
will be moving its offices in September 1992. The move will probably slow
down the renewal process. So, we kindly ask your cooperation to return all
material by the return date, Tuesday, September 8, 1992.
(CDII-CACFP 8/92)
9Z0::39
r
COLORADO DEPARTMENT OF HEALTH AGREEMENT NUMBER
CHILD & ADULT CARE FOOD PROGRAM 08-65103
APPLICATION FOR
SPONSOR OF CHILD CARE CENTERS
INSTRUCTIONS: Complete in duplicate. Submit original, continuation sheets if needed, and required attachments,
together with CACFP 301 (Application for Child Care Center), and attachments. Type or print
clearly.
1. NAME AND MAILING ADDRESS OF SPONSOR 6. IS THIS A PRIVATE ORGANIZATION?(Private means non-voremmentall
Weld County Division of Human Resources YES_ NO X
Family Educational Network of Weld County Give nem,and title of Owner of For Profit Title XX CanterOR Chair of the
1551 North 17th Avenue Organization Governing Board OR Chair of the Church Governing
P.O. Box 1805 Board:
Greeley, Colorado 80632 Chairman, Weld County
TELEPHONE NO:( 303 ) 355-0500 0eorne Kennedy Board oc rnmmiccinnprc
NAME TITLE
COUNTY: •
2. DO YOU PARTICIPATE IN THE HEAD START PROGRAM? 7. NUMBER OF CACFP-PARTICIPATING CENTERS UNDER YOUR
ADMINISTRATION
YES__1_ NO_ NONPROFIT CHILD CARE CENTERS
OUTSIDE-SCHOOL-HOURS CENTERS
3. DO YOU NOW PARTICIPATE IN OR HAVE YOU PARTICIPATED IN FOR PROFIT TITLE XX CENTERS
FEDERALLY-FUNDED PROGRAMS (including CACFP) IN THE PAST 3
YEARS? 12 HEAD START CENTERS
YES_- NO_ 14 MIGRANT MEAD START CENTERS
(II "yes."give name of program(s)and dates of participation.)
B. TOTAL NUMBER OF CHILDREN ENROLLED AT CACFP-PARTICIPATING
CENTERS UNDER YOUR ADMINISTRATION
CACFP 1985 to present
NONPROFIT CHILD
CARE CENTERS
A DO YOU PARTICIPATE IN THE COLORADO PRESCHOOL PROJECT? OUTSIDE-SCHOOL-HOURS
YES_S_ NO _ CENTERS
5. NAME AND TITLE OF ADMINISTRATOR FOR PROFIT TITLE XX
CENTERS
Walter J. Speckman Executive Director HEAD START CENTERS
Name Title 490
NAME AND TITLE OF CONTACT PERSON
MIGRANT HEAD START
Tere Keller-Amaya Director CENTERS 4.00
Name Title 9. DO YOU REQUEST ADVANCE PAYMENTS?
TELEPHONE NO:( 303 ) "OFF-f6n0 YES NO X
10. LIST ANY MONTHS WHEN YOU WILL NOT CLAIM MEALS FOR REIMBURSEMENT.
N/A
DESCRIBE YOUR PROCEDURE FOR COLLECTING,MAINTAINING AND REVIEWING THE FOLLOWING RECORDS FROM EACH CENTER:
1. Income Eligibility Forms(IEF) 4. Production Records
2. Record of Meals Served(ROMS) 5. Food Receipts and Invoices
3. Menus
Income eligibility forms are completed at the beginning of the school year. Teachers
complete Record of Meals Served and turn in to Family Services and the information is
compiled for the Meal Claim Forms. At the beginning of the school year menus are formulated
with the appropriate School Districts and approved by the Parent Folicv Council . Production
Records are done by the School District Cooks and reviewed by the Director.. Invoices are
approved by the Director and sent to the Fiscal Department for payment and recording
purposes. V
CACFP-302(5/90) a/ SS.Sli':�r 93
Page 1
DESCRIBE Si cannotaSsTEM FOR
DISBURSING
SIN C....droEMBr that UeRSEMENr by TeTOOYOUR CENTERS WITHIN. AYSOF RECEIPT FROM CDHCACFP.(Rein-
eed he sor.)
All centers are operated under the direction of the Head Start Program. Therefore,
the CCFP reimbursement is made to tho one nroCraw and does not need to he disbursed
to the othere facilities. All costs for each of the centers are paid under the
one Head Start Budget.
WILL YOU CONTRACT WITH A FOOD SERVICE MANAGEMENT COMPANY FOR MEALS(A'J YeS -XX : - NO—
It yes,please give company name.address.and name of contact person and delivery procedures.
Greeley/Evans School District 6 - Sue Roberts - Evans
Weld School District RE-3J - Shirley Foos , Hudson
Weld School District RE-5J - Milliken
. Food is prepared at a central location, delivered to the individual school cafeteria 's
ana delivered to the classroom. Proper storaae and food transnort containers are used.
St Vrain School District RE-1J - Cynthia Gruele - Frederick - Food is nrenared at the
High School and transported to the classroom, using proper storage and food transnort
containers .
DESCRIBE YOUR SCHEDULE FOR TRAINING ADMINISTRATIVE AND FOOD SERVICE PERSONNEL ON CACFP REQUIREMENTS(Give dates of training
session's) and topics to be covered.)
All staff involved in food service will be trained in October. When new information
is made available, training is provided to all necessary staff, reviews are conducted
monthly when all the documentation is collected for reporting ournoses .
DESCPREAP-
PRE OVUR AL FORM.PROCEDURE FOR CONDUCTING PRE-APPROVAL VISITS TO NEW CENTERS. IF AVAILABLE.ATTACH A COPY OF YOUR PREAP-
The pre-approval evaluation form will he used at each site.
PROVIDE A SCHEDULE FOR MONITORING FOOD SERVICE OPERATIONS AT YOUR CENTERS.Each child care center must be monitored at lent 3 times
each centre must be during the first six weeks
least d times each year,including once during CACFP operation.Then
s irsreviews
t m�h of CACFP operanot be more than tion.These rev months iews cannort Each t be more than three
u
months apart.
Monitoring of food service operations is done in November 1992,. February 1993, May 1993,
June 1992 and August 1993.
If problems are discovered during a monitoring review,whet corrective procedure will you follow?
An action plan will be written and follow-up in thirty (30) days.
Page 2 CACF ISM) 920299
SPONSOR STAFFING PATTERN FOR CACFP(List au sponsor personnel who will be involved in administering the CACFP in the chart below.Complete
chart as specifled recording duties of personnel listed in ADMINISTRATIVE DUTIES directly related to the CACFP.Administrative duties incite*managing
finances eno operation of CACFP.Attach additional sheets if necessary.)
v SALARY
PER HOUR NUMBER OF
INCLUDING DAYS PER
NUMBER OF FRINGE YEAR EACH SOURCE OF
NUMBER OF HOURS PER DAY BENEFITS EMPLOYEE FUNDS FOR ANNUAL
POSITION SPECIFIC CACFP PERSONNEL EACH EMPLOYEE (Indicate volunteers WILL SPEND SALARY CACFP-FUNDED
DUTIES IN THIS WILL SPEND ON and unpaid work ON CACFP (CACFP on SALARY
POSITION CACFP DUTIESwithEv'' DUTIES other) ONLY
A B
G (DXEXF)
ADMINISTRATOR State
(or equivalent) Reimbursements 1 varies 415.00+ 1? HH
ASSISTANT Coora1na for with
ADMINISTRATOR Schools Monitor 1 varies 83 II�i
(Or equivalent) $11.00+
CLERICAL Typing 2 varies
$ 7.00+ 25
(or equivalent) Correspondence, etc.
COOK
OTHER
(spicily)
ANNUAL CACFP ADMINISTRATIVE BUDGET TOTAL CACFP-FUNDED LABOR S
(ENTER CACFP PORTION ONLY)
CACFP-FUNDED LABOR
(Enter total from above) $
OFFICE SUPPLIES(Including reproduction costs)
POSTAGE
TRANSPORTATION FOR FACILITY MONITORING(include mileage multiplied by 200)
TELEPHONE
OFFICE RENTAUMORTGAGE PAYMENT AND MAINTENANCE
UTILITIES FOR OFFICE AREA
OTHER(Specify)
TOTAL CACFP ADMINISTRATIVE BUDGET $ 0
ANNUAL CACFP BUDGET FOR FOOD SERVICE OPERATIONS AT FACILITIES UNDER YOUR ADMINISTRATION
(ENTER CACFP PORTION ONLY)
FOOD PURCHASES s
FOOD SERVICE LABOR(Salaries of staff prepanng or serving meals) 120,000.00
FOOD SERVICE CONTRACTOR FEE
NONFOOD SUPPLIES(Napkins,straws dishwashing detergent.eta)
MAINTENANCE FOR FOOD PREPARATION,STORAGE AND SERVICE AREAS
RENT/MORTGAGE PAYMENT FOR FOOD PREPARATION,STORAGE AND SERVICE AREAS
UTILITIES
OTHER(Specify)
TOTAL FOOD SERVICE OPERATING BUDGET s 120,nflfl fill
LIST SOURCES OF CASH INCOME SPECIFICALLY FOR THE FOOD SERVICE OTHER THAN CACFP REIMBURSEMENT.
Head Start Grant, Migrant Head Start Grant & State Preschool Funds
•
I certify that the information on this application and the attached form CACFP-301 is true to the beat of my knowledge;that/will accept final administrative and
financial responsibility for total Child and Adult Care Food Program operations at all centers under my sponsorship;and that reimbursement will be claimed
only for meals served to enrolled panicipanit that the CACFP will be available to all eligible participants without regard to raps color,sett.national origin,age
or handicap at the approved food service facilities and that these facilities have the capability for the meal service planned for the number of participants
anticipated to be served or meals are provided bya food service management company in compliance with CACFP regulations-I understand that thisinforme-
tion is being given in connection with the receipt of Federal funds and that deliberate misrepresentation maysub/edt me to prosecution underappllcableState
and Federal criminal statutes.
//SIGNATURE OF ADMINISTRATOR OR AUTHORIZED REPRESENTATIVE DATE
v
CACFP 302(5/90) Page 3
act'.
CENTE. . INFORMATION (ADD. d'IONAL)
A. DONATED FOODS (COMMODITIES)
If you completed the Spring Survey we have checked off your choice below. If you began participation
on the CACFP atter the Spring Survey, we have checked off the cash-in-lieu choice for you.
The center or sponsor will receive:
❑ Regular donated commodities 65103-05
FAMILY EDUC NETWORK OF WELD
❑ Cash-in-lieu of commodities
--CASH-IN-LIEU OF COMMODITIES--
' ifiala
B• ❑ NOT APPLICABLE SINCE WE ARE NONPROFIT(Please Check Box). •
FOR PROFIT TITLE X X CENTER OR SPONSOR
We certify that at least 25 percent of the participants enrolled in one or more of our centers received
Title XX benefits in the calendar month prior to submitting this application to the Colorado Department
of Health, Child & Adult Care Food Program (CDH-CACFP).
We further certify that (check all boxes):
❑ We have submitted a copy of each of our contracts with the Title X X administering agency
(Department of Social Services) to the CDH-CACFP.
C We have submitted a roster of all enrolled participants,with Title X X beneficiaries identified,
from the month previous to this application/renewal.
❑ All centers listed on the Agreement CACFP 300 share the same legal identity as the sponsor.
Only centers that meet the "25 percent" requirement are listed.
❑ We will aol submit a Claim for Reimbursement for a center(s) which does not meet the "25
percent"requirement. In that event,we will inform the CDH-CACFP by the 10th day of the month
following the claim month.
C. NONDISCRIMINATION POLICY STATEMENT
(Nonpricing Centers)
We assure the Colorado Department of Health, Child and Adult Care Food Program that all
enrolled participants in the Child & 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, age, sex, or handicap, and there is no discrimination in the course of
the meal service.
Signature of PldministratororAuthorizeRepresentative Date
Administrator
Signature of Official of the Title Date
Colorado Department of Health,
Child & Adult Care Food Program
CACFP (4/92) - OVER - 920,133
CDH - CACFP
PREAWARD COMPLIANCE REVIEW
Educational Network of Weld County Agreement #
Center or Sponsor Name:Fami 1.Y
The Colorado Department of Health, Child & Adult Care Food Program, is required to conduct a preaward civil rights
compliance review of centers or sponsors applying for CACFP participation. Please complete the following information.
1. WRITE the racial/ethnic makeup of the population of the area to be served. Usually this information can be obtained
from the local school district, Chamber of Commerce, Census Bureau, or Public Library. Sponsor must combine this
information for all centers.
American Indian or Alaskan Native Hispanic (a person of Mexican, Puerto Rican,
Cuban, Central or South American, or other
Asian or Pacific Islander Spanish culture or origin, regardless of race)
Black (not of Hispanic origin) White (not of Hispanic origin)
2. *COUNT the actual number of children by racial/ethnic makeup in your center(s) and indicate those figures here.
Sponsor must combine for all centers.
- American Indian or Alaskan Native Hispanic (a person of Mexican, Puerto Rican,
Cuban, Central or South American, or other
- Asian or Pacific Islander Spanish culture or origin, regardless of race)
- Black (not of Hispanic origin) White (not of Hispanic origin)
3. The CDH-CACFP annually sends a press release for your center(s) to the local newspaper. What additional efforts
do you or will you use to assure that minority populations & grassroots organizations have an equal opportunity
to participate or are informed about changes in the Program?
Please check those 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)
X Paid advertisements in local newspapers
- Other. Please explain:
Do or will the items you checked above include the following nondiscrimination statement? Yes No
In the operation of the Child and Adult Care Food Program no child will be discriminated against because of race,
color, national origin, sex, age, or handicap. Any person who believes that he or she has been discriminated
against in any USDA-related activity should write immediately to the Secretary of Agriculture,
Washington, D.C. 20250.
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
*Visual identification may be used by centers or sponsors to determine the child's racial/ethnic category. A child may be included
in the group to which he or she appears to belong, identifies with, or is regarded in the community as belonging. Parents/Guar-
dians may be asked to identify the racial/ethnic group of their own child only aver it has been explained, and they as well as we un-
derstand that the collection of this information is strictly for statistical reporting requirements and has no effect on the
determination of their eligibility to receive benefits under the Program.As new children are enrolled,you will need to determine
their racial/ethnic background and keep this information in a confidential place.
CACFP 102 (4/92) - OVER -
920399
CDH-CACFP
CERTIFICATE AND STATEMENT OF AUTHORITY
CHECK CORRECT BOX: E NONPROFIT ORGANIZATION ❑CHURCH ❑FOR PROFIT ORGANIZATION!
I,(We),the undersigned,state that the child care center(s) listed on Schedule A of the Agreement(CACFP 111111
300)Is an integral part of and therefore under the direct control of and supervision of the governing body of
the
Weld County Division of Human Resources ' Family Educational fet'vork of Weld County
(Name at the Organization.Business or Church)
whose address is 1551 North 17th Avenue, P.O. Box 1805, Greeley, CO 89634
(Street or Route) (City) (Zip Code)
303 ) 356 _ 9600
(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 appears below is authorized to sign the Agreement and all other official documents in
connection with the CACFP.
AUTHORIZED REPRESENTATIVE(S)
1. 2. ,"Tht :7r)(Y —.nV,hnl''�0 - "IL)^,(�
Signature Signature A
Tere Keller-Amaya Linda Talmadge-Luna
Print Name Print Name
Director of FENWC Office Manager of FENWC
Title Title
Is the duly designated Authorized Representative(s)for the Center/Sponsor listed above.It is to your
benefit to have two people designated as Authorized Representatives.
The Authorized Representative(s) is fullyrempowered to enter into any agreement with the Colorado Department
of Health 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 Health 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.
MAILING ADDRESS:
If you would like your reimbursement check sent to an address different from the above,please write it here:
Street Address
City State Zip Code
Business Phone
THIS BOX MUST BE SIGNED
l(we)understand that the information on this form is being given in connection with the receipt of Federal funds
and th all of the provisions of the Agreement(CACFP 300)apply. Chairman, Weld Coun tv
1y/ George Kennedy Board of County Commissioners
Signature of Chair of the Board of Directors. Print Name Offis Title
or Pastor,or Executive Director, / /�/J
or Owner 09/:2t9D, /"�' Date
(4/92) OVER 9ZO.,-.33
FOURTH MEAL DOCUMENT
Child care centers may claim 4 meals per child per day, if the child is in care eight (81 or more hours
each day. One of the 4 meals must be a snack.
In order to claim the 4th meal for an jndividual child, you must:
D Keep Records of Meals Served for the 4th meal.
❑ Keep menu and production records for the 4th meal.
❑ Keep time-in/time-out records for the child showing the child was in care 8 or more
hours OR, keep records showing the end of the first meal and the beginning of the last
meal were 8 hours apart.
❑ Apply for the 4th meal by completing the bottom of this form and returning it to our office.
As you can see, it may be an extra burden of paperwork for you to claim the 4th meal. And,
although the 4th meal certainly may be a supper, in most centers it will be a snack. Current reimburse-
ment for snacks is 46 1/2 cents for Free, 23 1/4 cents for Reduced, and 4 1/4 cents for Paid. Therefore,
the amount of reimbursement may not be enough to cover the cost of the extra labor involved.
Also, during our reviews, we have found that many centers do not have accurate time-in/time-out
records. Either the records are incomplete or they indicate that children in care less than 8 hours are
claimed for 4th meals. Because of this, we had to take back a significant amount of reimbursement
money causing hardship to the centers. Therefore, someone must be assigned to monitor these time-in/
time-out records. It may be easier to establish that the end of your first meal and the beginning of your
4th meal are 8 hours apart.
Y NO, a fourth meal will not be claimed.
❑ YES, a fourth meal will be claimed. (One of the 4 meals
must be a snack.)
Type of meal
Time of meal
Effective date
❑ We keep time-in/time-out records.
OR
❑ The end of the first meal and the beginning of the 4th meal are 8 hours apart.
When does first meal END? AM
When does 4th meal BEGIN? PM
(CDH.CACFP 6/92)
9;--;0239
AUDIT QUESTIONNAIRE
Id&Adult Care Food Program (CACFP)
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 office prepare this questionnaire.
Center/Sponsoring
Organization: Family Educational Network of Agreement Number: 08-651n3
'field County
Address: 1551 North 17th Avenue
P.O. Box 1805
Greeley„Colorado 80632
1. Do you contract with an accounting firm to conduct an audit of your
center/sponsoring organization? Yes x No
2. If your center/sponsor is part of another organization, does the
organization have an organization-wide audit? Yes x 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 x No
4. What is the legal name of the organization being audited?
Weld County Division of Human 'lesources
5. What federal funds does your organization receive other than CACFP?
(Examples: National School Lunch Program, Title XX)
Primary Sources:
Head Start $365,'3' 00
Migrant Head Start $7??,n37.nn
Job Training Partnership Act Fundc $ 1 ,446,406 on
Older American Act Funds $ 376.315 00
6. What is the total annual budget for the organization identified in Question#4?
(include all federal, state, and "other" funds) $5,155,166
7. When does your organization's fiscal year begin and end?
January 1 through December 31
8. Does your organization have fiscal year end schedules (financial
statements)? Yes x No
9. Does your organization have computerized records? Yes x No
Quesrionnairepreparedby: Marilyn Carlino pie. 9/11/0'
Title: Fiscal Officer, Weld County Human ResourcesPhoneNumber: ( 303 ) 353-2216, ext. 33/18
(Rev.7/92) p
920:99
•
COLORADO DEPARTMENT OF HEALTH Agreement Number �a-5513
CHILD 8 ADULT CARE FOOD PROGRAM
Family Educational 'rework of Weld County
AGREEMENT FOR CHILD CARE CENTER OR r+.er at Center ors.enser
SPONSOR OF CHILD CARE CENTERS
In order to carry out the purpose of Section 17 of the National School c. Collect family size and income information on the Income
Lunch Act, as amended, and the Regulations governing the Child 6 Eligibility Form(iEF)for children enrolled at all the centers listed
Adult Care Food Program(CACFP)issued thereunder(7 CFR Part 226) on Schedule A to determine which children are from families
the Colorado Department of Health(hereinafter referred to as the State meeting the income eligibility guidelines for free or reduced
Agency).and the Center or Sponsor,whose name and address appear meals.Children for whom family size and income information is
above,agree as follows: not available shall be reported under the paid(not eligible for
free or reduced meals)category only. An IEF Is valid for 12
THE STATE AGENCY AGREES THAT: months from the date the center or sponsor approves It.
Meals may be claimed for reimbursement beginning with
To the extent of funds available, it shall reimburse the institution for that date. it Is never retroactive from the approval date.
creditable meals served to eligible children at child care centers listed Meals claimed atter the expiration date an only be
on Schedule A attached hereto, during the effective period of this claimed In the paid category.
• Agreement.During any fiscal year,the amount of reimbursement paid to
the center or sponsor snail be based on actual count of meals served by d. Claim reimbursement only for meals served to eligible enro11s0
eligibility category. children in each income category within the limits of the license
or registration certificate.No more than 2 meals and 1 snack per
THE CENTER OR SPONSOR AGREES THAT: child shall be claimed.However,if a child is in care over 8 hours.
then an additional meal or snack may be claimed per child. In
this case.sign-irvsign-out sheets must show attendance of 8 or
1. It will comply with Title VI of the Civil Rights Act of 1964(P.L 88• more hours or 8 or more hours must elapse between the and of
352) and all requirements imposed by the regulations of the the first meal and the baninnirn of the fourth meal.
Department of Agriculture(7 CFR Part 15), Department of Justice
(28 CFR Parts 42 and 50),and FNS directives or regulations issued e. Submit Claims for Reimbursement In accordance with pursuant to that Act and the regulations to the effect that,no per- cedures established by the State Agency. Claims that pro-
pursuant son in the United States shall,on the ground of race,color,sex, received by the State Agency after noon on the 10th of the
national origin or ancestry,age,or handicap,be excluded from par- month shall be processed for payment the following month.Only
ticipation in,be denied the benefits of,or be otherwise subject to final claims received within 60 days following the close of the
discrimination under any program or activity for which the institu- claim month shall be eligible for reimbursement
tion receives Federal financial assistance from the State Agency
and hereby gives assurance that it will immediately take any f. Store, prepare,and serve food in conformance with all applio-
measures necessary t0 effectuate this Agreement.This assurance able State and local health laws and regulation&
is given in consideration of and for the purpose of obtaining any and
all Federal financial assistance,grants.and loans of Federal funds. g. Use cash-received-in-lieu-of commodities for the purchase of
reimbursable expenditures,grant or donations of Federal property. food.
By accepting this assurance,the institution agrees to compile data.
maintain record&and submit reports as required.to permit effec-
tive enforcement of Title VI and permit authorization personnel dur- h. Maintain full and accurate records of the Program, and
ing normal working hours to review such records, books, and retain such records for a period of three years and lour
accounts as needed to ascertain compliance with Title VI. If there months after the end of the fiscal year to which they
are any violations of this assurance,the Department of Agriculture, pertain.
Food and Nutrition Service.or the State Agency,shall have the right
to seek judicial enforcement of this assurance. This assurance is L Make all accounts and records pertaining to the Program avail-
binding on the center or sponsor,its successors,transferees,and able to the State Agency and to USDA for audit or review at a
assignees as long as it receives assistance or retains possession of reasonable time and place.
any assistance from the State Agency.
2. The governing body la responsible f• Provide adequate supervisory and operational personnel for
for the administration of the overall monitoring and management of each food service opera-
centers fisted on Schedule A of this Agreement,or it is an agency to tion, and to promptly take such actions that are necessary to
which the centers listed on Schedule A have delegated authority correct deficiencies found at the time of any onsite visit,review,
for the operation of the food service program. or audit
3. In order to qualify for reimbursement under this Agreement It shall k If a sponsor, monitor all centers at least 3 times each year.
conduct the Program In accordance with regulations governing the Including once during the lint 6 weeks of CACFP operation.
Child 8 Adult Care Food Program (7 CFR Part 226), appropriate These reviews cannot be more than 6 months apart.All outside-
OMB circulars, State regulations. State Agency policies, and school-hours centers must be monitored at least 6 times each
specifically,shall conform to the following requirements: year,including once during the first month of CACFP operation.
These reviews cannot be more than 3 months apart
a. Operate a nonprofit food service using all of the income solely
for the operation or improvement of such service. 4. It Is a public organization or a nonprofit organization which has tax
exempt status such as under section 501(a) of the Internal
b. Serve meals which meet the minimum nutritional requirements Revenue Code of 1954,or is moving toward compliance with the
specified in Schedule B of this Agreement requirements of the aforementioned section In accordance with
Section 228.10 of the Program regulations.
Serve the same meal at no separate charge from tuition to *OF
enrolled children who are in attendance at meal time(non- U a For Profit Title XX center-it certifies that it receives funds under
pricing institution)and so designate on Application Form Title XX of the Social Security Act for at least 25 percent of each
and Nondiscrimination Policy Statement and abide by the centers enrolled children during the month preceding application
terms of the Nondiscrimination Policy Statement and Pro-
gram Verification Rules (Regulations 22623 M. toorrenewalofthePeeoingandshallcontinuetocertifysuchfnlor-
oration in each suecesoing month.The institution shall not claim
-OF reimbursement for meals served in any For Profit center for any
Have an identifiable separate charge from tuition for meals month during which the center receives Title XX funds forties then
served to enrolled children (pricing institution) and so 25 percent of its enrolled children.
designate on Application Form and Nondiscrimination
Policy Statement and abide by the terms of the Nondis- 5. All child care centers listed on Schedule A have a valid license or
crimination Policy Statement and Program Verification registration certificate for providing child care.
Rules(Regulations 226.23 h.2).
CACFP 300(412) PAGE ONE 0,,,
6. It provides organized child care in nonresidential situations. The Agreement may be terminated upon ten(10)days written notice on
the part of either party hereto,and the State Agency may terminate this
Agreement immediately after receipt of evidence that the terms and
7. It accepts final financial and administrative responsibility for total conditions of this Agreement and of the regulations governing the Pro-
CACFP operations for each child care center under its juris- gram have not been fully complied with by the center or sponsor.Any
diction. termination of this Agreement by the State Agency shall be in accord
with applicable laws and regulations(Federal Regulations 226.6 10c).
8. It will annually make available to the local media serving the area No termination or expiration of this Agreement,however.shall affect the
from which the center or sponsor draws its attendance, a public obligation of the center or sponsor to maintain and retain records and to
release announcing the availability of meals to all eligible enrolled make such records available for audit.A center or sponsor may appeal a
children without regard to race, color, sex, national origin, age, termination according to procedures outlined in 7 CFR Part 226.
or handicap.
The terms of this Agreement shall not be modified or changed in any
9. It understands and agrees that any materials developed with Pro- way other than by the consent in writing of both parties hereto.
gram funds by the center or sponsor may be freely reproduced,pro-
duced.or otherwise used by the USDA Food and Nutrition Service, RECORDKEEPING REQUIREMENTS
the Colorado Department of Health,or by other institutions under
the Child 8 Adult Care Food Program. The center or sponsor must keep full and accurate records pertaining to
its food service as a basis for the Claim for Reimbursement and for audit
THE STATE AGENCY AND CENTER OR SPONSOR MUTUALLY and review purposes.The records to be kept include the following:
AGREE THAT: i. Menus and food production records indicating quantities of foods
1. Schedule A listing centers approved for participation and meals to prepared.number of persona prepared for,and serving sizes.The
be claimed for reimbursement, shall be a part of this Agreemert. food production record must include the number of adults
Centers or meals may be added to or deleted from Schedule A served.
as the need arises. All such changes must be confirmed in writing and sent to the State Agency. All such references to Daily record of meals served to children broken down by name by
Schedule A shall be deemed to include such Schedule as sup- • )e of meal (breakfast, lunch, supper, or snack) and by income
plemented and amended. _ category-tree, reduced,or paid (Record of Meals Served form).
2. The State Agency shall notify the center or sponsor of any change 3. Approved Income Eligibility Forms for enrolled children categorized
in the minimum meal requirements or in the applicable rates of as free or reduced.
reimbursement as soon as possible after notification from USDA
4. Documentation of income to the food service operation from funds
3. The center or sponsor may contract with a local school food to subsidize food service program,from State Agency CACFP reim-
authority or with a food service management company for the prep- bursement,from payments for adult meals and from all other sour-
aration and delivery of meals or meal components. The center or cos, including loans and donations to the food service program
sponsor shall remain responsible for fulfillment of the terms of the
Agreement.The center or sponsor must submit a copy of this con-
5. Invoices or receipts from food service operation uurchases indud-
Iract to the State Agency. ing bills from food service management companies.payroll records
including fringe benefits,equipment costs,maintenance and repair
4. For the purposes of this Agreement the following terms shall fees,office costs,utilities costs and other administrative costa
mean, respectively:
This documentation shall ensure that all reimbursement funds are
DEFINITIONS- used:(1)solely for the conduct of the food service,or(2)to improve
such food service operations principally for the benefit of the
"Children"means(a)persons up to their 13th birthday and under, enrolled
IN TO THE lOPERATION DOCUMENTATIONO TE CALF ALL CO BTS E PERTAIN-
IN-
(b)children of migrant workers 15 years of age and under,and(c)
PEC
mentally or physically handicapped persons, as defined by the ALLY ITEMIZED. DOCUMENTATION MUST CLEARLY SHOW
State Agency.enrolled in an institution or child care facility serving THAT THE P INCOME AND
FOOD
SERVICE
INONPROFIT BASED ON AV.
a majority of persons 18 years of age and under.
"Enrolled child"means a child whose parent or guardian has sub- 6. License, registration,or certification documentation
mined to the center or sponsor a signed document which indicates
that the child is enrolled for child care. 7. Documentation of visits to child care centers to monitor c'
• pumice.This requirement pertains only to sponsors who admin 15
"Milk" means pasteurized fluid types of unflavored or flavored more than one child care center in accordance with Fed-
whole milk.lowfat milk skim milk.or cultured buttermilk which meet Regulation 226.16(d)-
State and local standards for such milk except that,in the meal pat-
tern for infanta(0 to 1 year of age)."milk"means unflavored types of 8. Documentation of enrollment
whole fluid milk or an equivalent quantity of reconstituted
evaporated milk which meets ouch standards.All milk should con- 9. Documentation of attendance (rollbooks or sign in/sign out
tain vitamins A and D at levels specified by the Food and Drug onsets)
Administration and be consistent with State and local standards for
such milk. 10. Documentation of Civil Rights racial/ethnic data
"Verification" means a review of the information reported by the 11 Documentation of staff training pertaining to CACFP
center or sponsor to the State Agency regarding the eligiblity of
enrolled children for free or reduced meals.
12 Daily records of times children are in the center(S)(Also known
. This Agreement shall be effective with respect to meals served as sign-in/sign/out records).
during the period commencing the 1st day of October 1992 and 13. Special Diet Statement or Special Diet Statement for Handicapped
ending September 30, 1994 unless terminated earlier as herein Child documenting Statement
variances Spefiam the CACFP meal patterns.
as
provided.The State Agency may renew this Agreement, by notice
in writing given to the center or sponsor, for such period as funds 14. Food service management company contract or other food
are available for carrying out the Program. The State Agency service contracts.
Agreement to reimburse the center or sponsor is conditioned upon
the continued availability of funds appropriated for the Child 6 Adult 15. All Department of Social Services contract(s)- For Profit Title X
Care Food Program in a sufficient amount, and no legal liability on centers only.
+a part of the Government for the payment of any money shall arise
unless and until such appropriation shall have been provided. 16. Record of payment and billing forms from Department of Social
Services - For Profit Title XX centers only
17. Record of deposi JACFP reimbursement 9;.L.6,533
PAGE TWO
SCHEDULE A
Does your organization have more than one licensed center? YES X NO
Fill In the name,address and other information of your centers participating in the Child&Adult Care Food Program.
(Attach additional sheets If necessary.)
TYPE OF
CENTER LICENSE
NAME&ADDRESS c-toad Can MEALS TO BE CLAIMED
OF CENTER H-HwdSr CAPACITY LICENSE
O Cuids&died LICENSE WRITTEN EXPIRATION
Han NUMBER ON LICENSE DATE
P-For Pion BREAKFAST AM MACK LUNCH PM SNACK SUPPER
25-I nfa it/Todd er TIMES OF MEALS
Hudson Elementary H 30-Pre-school 11c15
300 Beach €3:30 n 3i
Hudson, CO 80642 12: 15
NUMBER OF CHILDREN
60 60 60
TIMES OF MEALS
Frederick H ac 11:15
340
Pk 8 30 t 3:00
Frederick, CO 80530 12: 15
NUMBER OF CHILDREN
60 60 50
TIMES OF MEALS
Milliken H N/A
8:30 11:15
Rt 3:00
300 Broad 12:I5
Milliken, CO 80530 NUMBER OF CHILDREN
60 60 60
TIMES OF MEALS
Island Grove • H ry/q 'E1:311 11:15
.' 3.40 •
119 14th Avenue i?s5
Greeley, CO 80631 NUMBER OF CHILDREN
60 60 Fn
TIMES
Kersey Elementary H N/A 8:30 11:15 11: 5 MEALS
510 Clark I 3.00.
Kersey, CO 80644 1?:15
NUMBER OF CHILDREN
60 60 50
This Schedule is part of CACFP 300 92:0 :39
Due to an error, item #1 on page one is incomplete. It should read
as follows:
1. It will comply with Title VI of the Civil Rights Act of 1964
(P.L. 88-352) and all requirements imposed by the Regulations
of the Department of Agriculture (7 CFR Part 15) , Department
of Justice (28 CFR Parts 42 & 50) , and FNS directives or
regulations issued pursuant to that Act and the Regulations,
to the effect that, no person in the United States shall, on
the grounds of age, sex, handicap, color, race, or national
origin, be excluded from participation in, or be denied the
benefits of, or be otherwise subject to discrimination under
any program or activity for which the applicant received
Federal financial assistance from the Department; and HEREBY
GIVES ASSURANCE THAT it will immediately take any measures
necessary to effectuate this agreement.
THIS ASSURANCE IS given in consideration of and for the
purpose of obtaining any and all Federal financial assistance,
grants and loans of Federal funds, reimbursable expenditures,
grant or donation of Federal property and interest in
property, the detain 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, or 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 applicant by the Department. This
includes any Federal agreement, arrangement, or other contract
which as one of its purposes the provision of assistance such
as food, food stamps, cash assistance for the purchase o
food,and any other financial assistance extended in reliance
on the representations and agreements made in this assurance.
BY ACCEPTING THIS ASSURANCE, the center or sponsor agrees to
compile data, maintain records and submit reports as required,
to permit effective enforcement of Title VI and permit
authorized CDH personnel during normal working hours to review
such records, books and accounts as needed to ascertain
compliance with Title VI. If there are any violations of this
assurance, the Department of Health, Nutrition Services, shall
have the right tc seek judicial enforcement of this assurance.
This assurance is binding on the center or sponsor, its
successors, transferees,and assignees as long as it receives
assistance or retains possession of any assistance from the
State Agency.
90133
SCHEDULE A .
Does your organization have more than one licensed center? YES—I-- NO
Fill in the name,address and other information of your centers participating in the Child&Adult Care Food Program.
(Attach additional sheets if necessary.)
TYPE OF
CENTER LICENSE
NAME&ADDRESS C-OS� CAPACITY LICENSE MEALS TO BE CLAIMED
OF CENTER 0.OMOB&tut LICENSE WRITTEN STIRAT1DN
Rtan NUMBER O4LICENSE DATE
P•Fu PioIS BRfSN AN SNACK LURCH Pa MOC SUPPER
TIM OF MEALS
8:=30-: 11:15
Gilcrest Elementary H N/A & 3:00-
1175 Birch
Gilcrest, CO 80623 19; 15
NUMBER OF CHILDREN
60 60 60
TIMES Of MEALS
Billie Martinez Elementary H 5-Infant $.:30 : 11: 15
341 14th Avenue Toddler c 3:nO
Greeley, Co 30631 0-Pre-school 17: 15
NUMBER OF CHILDREN
60 50 Fn
TIMES OF MEALS
Madison Elementary H ! O 8:30 11:15
,. 24th Avenue & 6th Street °' 3:O0-
Greeley, CO 80631 17. 15
NUMBER OF CHILDREN
60 60 60
TIMES OF MEALS
East Memorial •Elementary H EB:1 11
614 East 20th Street 3.:7014-
Greeley, CO 80631 NUMBER OF CHILDREN
60 Fn Fn
TIMES OF MEALS
Jefferson Elementary H "" 3>3 . 11:1.5
1315 4th Avenue
Greeley, CO 80631 NUMBER IOFCHILDREN
60 60 50
This Schedule is vart of CACFP 300 9AAJ,,:b
Due to an error, item #1 on page one is incomplete. It should read
as follows:
1. It will comply with Title VI of the Civil Rights Act of 1964
(P.L. 88-352) and all requirements imposed by the Regulations
of the Department of Agriculture (7 CFR Part 15) , Department
of Justice (28 CFR Parts 42 8 50) , and FNS directives or
regulations issued pursuant to that Act and the Regulations,
to the effect that, no person in the United States shall, on
the grounds of age, sex, handicap, color, race, or national
origin, be excluded from participation in, or be denied the
benefits of, or be otherwise subject to discrimination under
any program or activity for which the applicant received
Federal financial assistance from the Department; and HEREBY
GIVES ASSURANCE THAT it will immediately take any measures
necessary to effectuate this agreement.
THIS ASSURANCE IS given in consideration of and for the
purpose of obtaining any and all Federal financial assistance,
grants and loans of Federal funds, reimbursable expenditures,
grant or donation of Federal property and interest in
property, the detain 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, or 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 applicant by the Department. This
includes any Federal agreement, arrangement, or other contract
which as one of its purposes the provision of assistance such
as food, food stamps, cash assistance for the purchase o=
food,and any other financial assistance extended in reliance
on the representations and agreements made in this assurance.
BY ACCEPTING THIS ASSURANCE, the center or sponsor agrees to
compile data, maintain records and submit reports as required,
to permit effective enforcement of Title VI and permit
authorized CDH personnel during normal working hours to review
such records, books and accounts as needed to ascertain
compliance with Title VI. If there are any violations of this
assurance, the Department of Health, Nutrition Services, shall
have the right to seek judicial enforcement of this assurance.
This assurance is binding on the center or sponsor, its
successors, transferees,and assignees as long as it receives
assistance or retains possession of any assistance from the
State Agency.
Sa3233
SCHEDULE A .
Does your organization have more than one licensed center? YES X NO
Fill In the name,address and other information of your centers participating in the Child &Adult Care Food Program.
(Attach additionalaheets If necessary.)
TYPE OF
CENTER LICENSE
NAME a ADDRESS C-Chtt Cue MEALS TO BE CLAIMED
OF CENTER H-Had Sart CAPACITY UCENSE
0-aaaea SCmt UCENSE WRrrtEN D(PIMTIIXL
Noun NUMBER CNLICENSE DATE R Far PionEREAIOAST AM STACK LUNCH Pa SNACKSUPPER
TIMES OF MEALS
Centennial Elementary H 25-Infa t g}�O tl'r15'
1400 37th Toddler & 3:00
Evans , CO 80620 30-Pre- chool
NUMBER OF CHILDREN
60 60 6'0
TIMES OF MEALS
8:00 11: 15
Dos Rios Elementary H 25 Migr nt c 3:10
2201 34th Street Program Only 12:15,
Evans , CO 80620 NUMBER OF CHILDREN
60 59 60
Ft. Morgan (Migrant Only) H TIMES OF MEALS
Site To Be Determined in
. May 1993 (Infants Only)
NUMBER OF CHILDREN
TIMES OF MEALS
Brighton (Migrant Only) H
Site To Be Determined in
May 1993
NUMBER OF CHILDREN
TIMES OF MEALS
****NOTE: The times for 7-30 1') 45 244-5;
the Migrant Programs are
different from the times
indicated on this contract. NUMBER OF CHILDREN
The times will be
This Schedule is nart of CACFP 300 42O 'n1A
Due to an error, item #1 on page one is incomplete. It should read
as follows:
1. It will comply with Title VI of the Civil Rights Act of 1964
(P.L. 88-352) and all requirements imposed by the Regulations
of the Department of Agriculture (7 CFR Part 15) , Department
of Justice (28 CFR Parts 42 i 50) , and FNS directives or
regulations issued pursuant to that Act and the Regulations,
to the effect that, no person in the United States shall, on
the grounds of age, sex, handicap, color, race, or national
origin, be excluded from participation in, or be denied the
benefits of, or be otherwise subject to discrimination under
any program or activity for which the applicant received
Federal financial assistance from the Department; and HEREBY
GIVES ASSURANCE THAT it will immediately take any measures
necessary to effectuate this agreement.
THIS ASSURANCE IS given in consideration of and for the
purpose of obtaining any and all Federal financial assistance,
grants and loans of Federal funds,- reimbursable expenditures,
grant or donation of Federal property and interest in
property, the detain 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, or 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 applicant by the Department. This
includes any Federal agreement, arrangement, or other contract
which as one of its purposes the provision of assistance such
as food, food stamps, cash assistance for the purchase o:
food,and any other financial assistance extended in reliance
on the representations and agreements made in this assurance.
BY ACCEPTING THIS ASSURANCE, the center or sponsor agrees to
compile data, maintain records and submit reports as required,
to permit effective enforcement of Title VI and permit
authorized CDH personnel during normal working hours to review
such records, books and accounts as needed to ascertain
compliance with Title VI. If there are any violations of this
assurance, the Department of Health, Nutrition Services, shall
have the right to seek judicial enforcement of this assurance.
This assurance is binding on the center or sponsor, its
successors, transferees,and assignees as long as it receives
assistance or retains possession of any assistance from the
State Agency.
o093
SCHEDULE B
Requirements for Meals — Child it Adult Care Food Program
Each institution participating in the Program shall serve one or more of (21 Lunch or supper-1/2 cup of milk;1 ounce(edible portion as
the following types of meals,as provided in its approved application:(1) served)of lean meet.poultry,or fish,or 1 ounce of cheese,or
Breakfast. (2) Lunch, (3) Supper, (4) Snacks served between such 1 egg,or 1/4 cup of cooked dry beans or peas:or 2 table-
other meats. spoons of peanut butter; 1/4 cup of vegetables or fruits or
both consisting of two or more kinds: 1/2 slice of bread or
1. Except as otherwise provided in this section,and;n any appendix to bread alternate, or 1/4 cup of cooked enriched or whole-
this part, each meal shall contain, as a minimum, the food corn- grain rice,macaroni,noodles,or other pasta products.
parents as follows:
a. A breakfast shall contain: (3) Snack—select two of the following four components-1/2
cup of milk; 1/2 ounce of meat or meat alternate (which
(1) A serving of fluid milk as a beverage,or on cereal,or used in includes 2 ounces or 1/4 cup of yogurt):1/2 cup of juice,or
part for each purpose. equivalent quantity of fruit,or vegetables:1/2 slice of bread
or bread alternate, or 1/4 cup (volume) or 1/3 ounces
(2) A serving of vegetable(s)or fruit or full-strength vegetable or (weight),whichever is less,of cereal,or 1/4 cup of cooked
fruit juice, or an equivalent quantity of any combination of enriched or whole-grain rice, macaroni, noodles or Other
Pasta products.
these foods.
(3) A serving of whole-grain or enriched bread:or an equivalent b. Age 3 up to 6:
serving of cornbread-biscuits,rolls,muffins,etc,made with (1) Breakfast-3/4 cup of milk, 1/2 cup of juice or fruit or
whole-grain or enriched meal or flour;or a serving of whole- vegetables;1/2 slice of bread or bread alternate,or 1/3 cup
grain or enriched or fortified cereal;or a serving of cooked (volume)or 1/2 ounce(weight),whichever is less of cereal or
whole-grain or enriched pasta or noodle products such as an equivalent quantity of both bread and cereal.
macaroni,or cereal grains such as rice-bulgur,or corn grits;
or an equivalent quantity of any combination of any of (2) Lunch or supper-3/4 cup of milk,1 1/2 ounces(edible par-
these foods. tion as served)of lean meat,poultry,or fish,or 1 1/2 ounces
of cheese,or 1 egg,or 3/8 cup of cooked dry beans or peas.
b. Both lunch and supper shall contain: or 3 tablespoons of peanut butter, 1/2 cup of vegetables or
(1) A serving of fluid milk as a beverage. fruits or both consisting of two or more kinds. 1/2 slice of
bread or bread alternate,or 1/4 cup of cooked enriched or
(2) A serving of lean meat,poultry or fish;orcheese;or an egg;or whole-grain rice, macaroni, noodles or other pasta
cooked dry beans or peas; or nuts or nut butters; or an Product&
equivalent quantity of any combination of these foods.These
foods must be served in a main dish,or in a main dish and one (3) Snack—select two of the following components-1/2 cup of
other menu item,to meet this requirement.Cooked dry beans milk; 1/2 ounce of meat or meat alternate(which includes 2
or dry peas may be used as the meat alternate or as part of the ounces or 1/4 cup of yogurt); 1/2 cup of juice or an
vegetable/fruit component.but not as both food components equivalent quantity of fruit or vegetables;1/2 slice of bread
in the same meal- or bread alternate;or 1/3 cup(volume)or 1/2 ounce(weight).
whichever is less,of cereal,or 1/4 cup of cooked enriched or
(3) A serving of two or more vegetables or fruits.or a combination whole-grain rice,macaroni,noodles,or other pasta products
of both.Full-strength vegetable or fruit juice may be counted
to meet not more than one-half of this requirement a Age 6 through 12
(1) cup of milk; 1/2 cup of juice or fruit or
(4) A serving of whole-grain or enriched bread;or an equivalent vegetables;
etables; l slice of bread or bread alternate,or 3/4 cup
serving of cornbread. biscuits, rolls, muffins, etc.. made of (volume)or 1 ounce(weight),whichever is less,of cereal or
whole-grain or enriched meal or flour:or a serving of cooked equivalent quantity of both bread and cereal.
whole-grain or enriched pasta or noodle products such as
macaroni.or cereal grains such as rice.bulgur,or corn grits:or (2) Lunch or supper-1 cup of milk;2 ounces(edible portion as
an equivalent quantity of any combination of these foods. served)of lean meat,poultry,or fish,or 2 ounces of cheese
or 1 egg,or 1/2 cup of cooked dry beans or peat or 4 table-
c. Snack shall be served between other meal types and contain two spoons of peanut butter;3/4 cup of vegetables or fruits or
of the following four components: both consisting of two or more kinds; 1 slice of bread or
(1) A serving of fluid milk as a beverage,or on cereal,or used in bread alternate, or 1/2 cup of cooked enriched or whole-
pan for each purpose. grain rice,macaroni,noodles or other pasta products.
(2) A serving of meat or meat alternate. (3) Snack—select two of the following four components-1 cup
of milk; 1 ounce of meat or meat alternate(which Includes 4
ounces or 1/2 cup of yogurt);3/4 juice or equivalent quantity
(3) A serving of vegetable(s)orfrui11e1 or full-strength vegetable
or fruit juice,or an equivalent quantity of any combination of 3/frcuo(v(volume)
or vegetables; (weight),bread or breatler ss,or
3er cup ty1/2 cu)or 1 ounce e or whichever is less,of
these foods.Juice may not be served when milk is served as cereal or 1/2 cup of cooked, enriched or whole-grain rice,
the only other component. macaroni,noodles or other pasta products.
(4) A serving of whole-grain or enriched bread:or an equivalent d. Age 12 and over,Adult-sized portions based on the greater food
serving of cornbread,biscuits,rolls,muffins,etc.made with needs of older boys and girls.
whole-grain or enriched meal or flour;or a serving of whole-
grain or enriched or fortified cereal;or a serving of cooked Infant mealpawhole-graintterns:
or enriched pasta or noodle products such as
macaroni,or cereal grains such as rice,bulgur,or corn grits; (1) 0 through 3 months;
or an equivalent quantity of any combination of these
foods. (a) Breakfast-4.6 fluid ounces of Iron-fortified infant
formula
2. Except es otherwise provided in this section the minimum amounts
of component foods to serve at meals as set forth in subparagraphs (b) Lunch or supper-4-6 fluid ounces of Iron-fortified
(b)(1), (2), and (3) of this section are as follows: infant formula
a Age 1 UP to 3; (c) Snack-44 fluid ounces of iron-fortified infant formula.
(1) Breakfast-1/2 cup of milk, 1/4 cup of juice or fruit or
vegetables,1/2 slice of bread or bread alternate,or 1/4 cup (2) 4 through 7 months;
(volume)or 1/3 ounce(weight),whichever is lest of cereal or (a) Breakfast-4.8 fluid ounces of iron-fortified infant lor-
an equivalent quantity of both bread and cereal. mule,0-3 tablespoons of iron-fortified dry infant cereal
PAGE FOUR (optional).
(b) Lunch or supper-4-8 fluid ounces of iron-fortified infant a Breakfast:
formula; 0.3 tablespoons of iron-fortified dry infant
cereal(optional);0-3 tablespoons of fruit or vegetable of (1) Include as often as practical an egg.or a 1-ounce serving
appropriate consistency or a combination of both (edible portion as served)of meat,poultry or fish;or 1 ounce
(optional). of cheese; or 2 tablespoons of peanut butter or an
equivalent quantity of any combination of these foods.
- (e) Snack-4.8 fluid ounces of iron-fortified infant formula (2) Additional foods may be served as desired.
(3) 8 months up to the first birthday,
b. Lunch or supper. Additional foods may be served as desired.
(a) Breakfast-6-8 fluid ounces of iron-fortified infant fomula
or 6-8 fluid ounces of whole milk;2.4 tablespoons of iron- e. Snack Include as often as practical a serving of meat or alter-
fortified dry infant cereal; 1.4 tablespoons of fruit or nate such as peanut butter or cheese or other foods needed to
vegetable of appropriate consistency or a combination of satisfy appetites.
both.
5. If emergency conditions prevent an institution normally having a
(b) Lunch or supper-6.8 fluid ounces of iron-fortified infant supply of milk from temporarily obtaining delivery thereof,the State
formula or 6-8 fluid ounces whole milk;2-4 tablespoons agency.may approve the service of breakfasts,lunches,or suppers
of iron-fortified dry infant cereal and/or 1.4 tablespoons without milk during the emergency period.
of meat, fish, poultry, egg yolk or cooked dry beans or
peas.or 1/2.2 ounces(weight)of cheese or 1.4 ounces 6. Substitutions may be made in food listed in paragraphs(b),(1),(2).
(weight or volume)of cottage cheese or cheese food or and(3)of this section if individual participating children are unable,
cheese spread of appropriate consistency: and 1.4 because of medical or other special dietary needs, to consume
tablespoons of fruit or vegetable of appropriate consis- such foods.Such substitutions shall be made only when supported
tency or a combination of both. by a statement from a recognized medical authonty which includes
recommended alternate foods.
(e) Snack-2.4 fluid ounces of iron-fortified infant formula
whole fluid milk or full-strength fruit juice,0.1/2 slice of
crusty enriched or wholegrain bread (optional). or 0-2 STATE AGENCY AND CENTER OR SPONSOR FURTHER
cracker-type products(optional)made from whole grain AGREE THAT:
or ennehed meal or flour and which are suitable for an
infant for use as a finger food. The center or sponsor shall accept full responsibility for providing
proper accountability,storage.and use of USDA commodity foods and
Breast milk,provided by the infant's mother.may be served in place of in so doing,shall promptly provide a written response to claims that mis-
infant formula from birth through 11 months of age. However, meals handlings, diversions, and/or losses resulting from improper use or
containing only breast milk do not qualify for reimbursement. Meals storage have occurred
containing breast milk served to infants 4 months of age or older may be
claimed for reimbursement when the other required meal component or components are supplied by the child care facility. The center or sponsor shall use USDA commodity foods received under
this Agreement solely for the benefit of those persons served or assist-
ed by the center or sponsor and shall not c nerwise dispose of USDA
3. For the purpose of this section. a cup means a standard mea- commodity foods without prior written ape pval of the State Agency.
surfing cup.
4. To improve the nutrition of participating children additional foods
may be served with each meal as follows:
SIGNATURE ON BEHALF OF CENTER OR SPONSOR
I certify that the information on this form is true and correct to the best of my knowledge.I understand that this information is being given in con-
nection with the receipt of Federal funds,and that deliberate misrepresentation may subject me to prosecution under applicable State and
Federal �minat sta a
/--� = '1 t :I- -C : I ?7L' " 10-=
Signature , _ //
Tere Keller-Amaya Director of FENWC —
Pnnt Name Title Date
.Please complete, sign, and return both agreements to the Colorado Department of Health Child et Adult Care Food Program.
SIGNATURES ON BEHALF OF COLORADO DEPARTMENT OF HEALTH
CHILD & ADULT CARE FOOD PROGRAM
For the Executive Director.Colorado Department of Health Date
Administrator.CACFP
Title Data
•
TO BE FILLED OUT BY COLORADO DEPARTMENT OF HEALTH, Center or Sponsor will receive for its child care centers. Head
CHILD 8 ADULT CARE FOOD PROGRAM: Start Centers,outside school hours centers, or For Profit Title
XX Centers:
ERegular Donated Commodities
OR
s Cash-in-lieu of Commodities(with bonus commodities)
•
PAGE FIVE 92Q:39
COLORADO DEPARTMENT OF HEALTH Agreement Number 13-65103
CHILD 8 ADULT CARE FOOD PROGRAM
Family 'ducational "letwork of Weld County
AGREEMENT FOR CHILD CARE CENTER OR Nees al comer o.sponsor
SPONSOR OF CHILD CARE CENTERS
In order to Carty out the purpose of Section 17 of the National School c. Collect family size and income information on the Income
Lunch Act, as amended. and the Regulations governing the Child 8 Eligibility Form ilEF)for children enrolled at all the centers listed
Adult Care Food Program(CACFPI issued thereunder(7 CFR Part 226) on Schedule A to determine which children are from families
the Co'or ado Department of Health(hereinafter referred to as the State meeting the income eligibility guidelines for free or reduced
Agency).and the Center or Sponsor,whose name and address appear meals.Children for whom family size and income information is
above, agree as follows: not available shall be reported under the paid(not eligible for
free or reduced meals)category only. An IEF Is valid for 12
THE STATE AGENCY AGREES THAT: months from the date the center or sponsor approves It.
Meals may be claimed for reimbursement beginning with
To the extent of funds available- it shall reimburse the institution for that date. It Is never retroactive from the approval date.
creditable meals served to eligible children at child care centers listed Meals claimed after the expiration data can only be
on Schedule A attached hereto, during the effective period of this claimed In the paid category.
• Agreement.During any fiscal year,the amount of reimbursement paid to
the center or sponsor shall be based on actual count of meats served by d. Claim reimbursement only for meals served to eligible enrolled
eligibility category. children in each income category within the limits of the license
or registration certificate.No more than 2 meals and 1 snack par
child shall be claimed.However.if a child is in care over 8 hours.
THE CENTER OR SPONSOR AGREES THAT: then an additional meal or snack may be claimed per child. In
this case, sign-in/sign-out sheets must show attendance of 8 or
1. It will comply with Title VI of the Civil Rights Act of 1964(P.L 88- more hours or 8 or more hours must elapse between the sag of
352) and all requirements imposed by the regulations of the the first meal and the beginninn of the fourth meal.
Department of Agriculture 17 CFR Part 15), Department of Justice
(28 CFR Parts 42 and 50),and FNS directives or regulations issued e, Submit Claims for Reimbursement In accordance with pro-
pursuant to that Act and the regulations,to the effect that,no per- cedures established by the State Agency. Claims that are
son in the United States shall, on the ground of race, color, sex, received by the State Agency after noon on the 10th of the
national origin or ancestry,age,or handicap,be excluded from par- month shall be processed for payment the following month.Ony
tic:cation in, be denied the benefits of,or be otherwise subject to final claims received within 60 days following the close of the
discrimination under any program or activity for which the institu- Claim month shall be eligible for reimbursement
lion receives Federal financial assistance from the State Agency
and hereby gives assurance that it will immediately take any f. Store. prepare,and serve food in conformance with all applic-
measures necessary to effectuate this Agreement.This assurance able State and local health laws and regulation&
is given in consideration of and for the purpose of obtaining any and
all Federal financial assistance,grants.and loans of Federal funds. g. Use cash-received-in-lieu-of commodities for the purchase of
reimbursable expenditures.grant or donations of Federal property. food.
By accepting this assurance,the institution agrees to compile data.
maintain record& and submit reports as required, to permit effec-
tive enforcement of Title VI and permit authorization personnel dur- h. Maintain full and accurate records of the Program, and
ing normal working hours to review such records, books, and retain such records for a period of three years and four
accounts as needed to ascertain compliance with Title VI. If there months after the end of the fiscal year to which they
are any violations of this assurance.the Department of Agriculture, pertain.
Food and Nutrition Service,or the State Agency,shall have the right
to seek judicial enforcement of this assurance. This assurance is i. Make all accounts and records pertaining to the Program avail-
binding on the center or sponsor,its successors.transferees.and able to the State Agency and to USDA for audit or review at a
assignees as long as it receives assistance or retains possession of reasonable time and place.
any assistance from the State Agency.
J. Provide adequate supervisory and operational personnel for
2. The governing body is responsible for the administration of the overall monitoring and management of each food service opera-
centers listed onSchedule Aofthis Agreement,or it is an agency to tion. and to promptly take such actions that are necessary to
which the centers listed on Schedule A have delegated authority correct deficiencies found at the time of any onsite visit renew,
for the operation of the food service program. or audit
3. In order to qualify for reimbursement under this Agreement It shall k. If a sponsor, monitor all centers at least 3 times each year,
conduct the Program in accordance with regulations governing the Including once during the first 6 weeks of CACFP operation.
Child & Adult Care Food Program (7 CFR Part 226), appropriate These reviews cannot be more than 6 months apart.All outside-
OMB circulars, State regulations. State Agency policies, and school-hours centers must be monitored at least 6 times each
specifically, shall conform to the following requirements: year.including once during the first month of CACFP operation.
These reviews cannot be more than 3 months apart
a. Operate a nonprofit food service using all of the income solely
for the operation or improvement of such service. 4. It Is a public organization or a nonprofit organization which has tax
exempt status such as under section 501(a) of the Internal
b. Serve meals which meet the minimum nutritional requirements Revenue Code of 1954,or is moving toward compliance with the
specified in Schedule B of this Agreement requirements of the aforementioned section In accordance with
Section 22618 of the Program regulations.
Serve the same meal at no separate charge from tuition to son
enrolled children who are in attendance at meal time(non• tf a For Proflt Title XX center,it certifies that it receives funds under
pricing institution)and so designate on Application Form Title XX of the Social Security Act for at least 25 percent of each
and Nondiscrimination Policy Statement and abide by the centers enrolled children during the month preceding application
terms of the Nondiscrimination Policy Statement and Pro- to or renewal of the Program and shall continue to certifysuch infor-
gram Verification Rules (Regulations 226.23 ni)s oration in each succeeding month.The institution shall not claim
or reimbursement for meals served in any For Profit center for any
Have an identifiable separate charge from tuition for meals month during which the center receives Title XX funds for less than
served to enrolled children (pricing institution) and so 25 percent of its enrolled children
designate on Application Form and Nondiscrimination
Policy Statement and abide by the terms of the Nondis- 5 All child care centers listed on Schedule A have a valid license or
crimination Policy Statement and Program Verification registration certificate for providing child care.
Rules (Regulations 226.23 h.2).
•
CACFP 300 (4/92) PAGE ONE 9201;39
6. It provides organized child care in nonresidential situations. The Agreement may be terminated upon ten 1101 days written notice cr
the part of either party hereto,and the State Agency may terminate tints
Agreement Immediately after receipt of evidence that the terms ac'
7. It accepts final financial and administrative responsibility for total conditions of this Agreement and of the regulations governing the Pro
CACFP operations for each child care center under its juris• grain have not been fully complied w h by the by the center
r shall be sponsor.
Any
y
diction. termination of this Agreement by the
Swith applicable laws and regulations(Federal Regulations 226.8 10C)-
B.
tion or expiration of It annually
cent available to er or sponsor he drawsl media its attendance, a pub the lic obigaa No tionaof the centtero sponsorogmaintanand retain shall affect the
records and t0
children without r regard totrace,color,of aalssext national o all l origilled make n, age, terminatiohn according ecords loDle for audit.A center procedures outlined in 70FRrPart 228.elan
or handicap. The terms of this Agreement shall not be modified or changed in any
9. It understands and agrees that any materials devdloped with Pro- way Other than by the consent in writing of both parties hereto.
gram funds by the center or sponsor may be freely reproduced,pro-
duced.or otherwise used by the USDA Food and Nutrition Service,
the Colorado Department of Health,or by other institutions under • RECORDKEEPING REQUIREMENTS
the Child 8 Adult Care Food Program. The center or sponsor must keep full and accurate records pertaining to
its food service as a basis for the Claim for Reimbursement and for audit
THE STATE AGENCY AND CENTER OR SPONSOR MUTUALLY and review purposes.The records to be kept include the following:
AGREE THAT: t. Menus and food production records indicating quantities of foods
1. Schedule A.,listing centers approved for participation and meals to
prepared. number of persons prepared for,and serving sizes.The
be claimed for reimbursement, shall De a part of this Agreement. food production record must include the number of adults Ce leted from Schedule A as the need arises. All e suchsuched to or changessm must served.
be confirmed n
writing and sent to the State Agency. All such references to 2. Daily record of meals served to children broken do and wn by name comby
Schedule A shall be deemed to include such Schedule as sup- type of meal lbr reduced,lunch,
or paid supper,
or snack)Maals Served form).
plementsd and amended. category -
2. The State Agency shall notify the center or sponsor of any change 3. Approved Income Eligibility Forms for enrolled children categorize('in the minimum meal requirements or in the applicable rates of as tree or reduced.
reimbursement as soon as possible after notification from USDA.
4. Documentation of income to the foods Svice 0oe.'ati0n from e Agency CACFP funds
3. The center or sponsor may contract with a local school food to subsidize food service program,
authority r li a food service meal company for teeer prep- bursement.from payments for adult meals and from all other sour-
ces,and delivery of meals or meal components.The center or
including loans and donations to the food service program
sponsor shall remain responsible for fulfillment of the terms of the
Agreement.The center or sponsor must submit a copy of this con-
5. Invoices or receipts from food service operation purchases inClud-
tract to the State Agency. ing bills from food service management companies,payroll records
- including fringe
4. For the purposes Of this Agreement the following terms shall
fees,officebenefits.
costs.utilities administrative coats and other ad nistrative costs.
mean, respectively'.
This documentation shall ensure that all reimbursement funds are
DEFINITIONS used:(1)solely for the conduct of the food service,or(2)to improve
_ such food service operations principally for the benefit of the
"Children" means la)persons up to their 13th birthday and under, INGIled children.TO THE OPERAT ON OF THE CACFP MUST BH S ECIFIC-
m Children o p ysicall handrs- pp years
persfns. and einunder,and lc)
mentally or physically handicapped persons. as defined by the ALLY ITEMIZED. DOCUMENTATION MUST CLEARLY SHOW
State Agency,enrolled in an institution or child care facility serving H E FOODOME AND SERVICE
CE IS NONPROFIT BASED ON ALL
a majority of persons 18 years of age and under. CACFP
"Enrolled child"means a child whose parent or guardian has sub- 6. License,registration,or certification documentation
mined to the center or sponsor a signed document which indicates 7. Documentation of visits to child care centers to monitor C'
that the child is enrolled for child care. Thisp of visits pertains care whoa admit, i
whole
pasteurized fluid types of ubuavrmil wo fflh ored meet
more than one child care center in accordance with Fec-
whole milk lowfat milk skim milk or cultured buttermilk which meet Regulation 226.161tl1.
State and local standards for such milk except that,in the meal pat-
tern for infants 10 to 1 year of age)."milk"means unflavored types of
whole fluid milk or an equivalent quantity of reconstituted
evaporated milk which meets such standards.All milk should con- 9. Documentation of attendance (rollbooks or sign in/sign out
tam vitamins A and D at levels specified by the Food and Drug sneets)
Administration and be consistent with State and local standards for 10. Documentation of Civil Rights racial/ethnic data
such milk
"Verification" means a review of the information reported by the 11 Documentation of staff training pertaining to CACFP
enrolled children rfot�free or the aretluceCmeals.te Agey regarding the eligiblity of
12 Daily records of times children are in the center(s) (Also known
. This Agreement shall be effective with respect to meals served
as sign4rvsignroul records).
during the period commencing the 1st day of October 1992 and
ending September 30, 1994 unless terminated earlier as herein 13. Special Diet Statement or Special Diet Statement for Handicapped
or Sps from the CACFP meal patterns.
provided.The State Agency may renew this Agreement, by notice Child documenting
in writing given to the center or sponsor, for such period as funds are available for carrying out14. Food service management company contract or other food
the Program. The State Agency 14.
contracts.
Agreement to reimburse the center or sponsor is conditioned upon For Profit Title XX
the continued availability of funds appropriated for the Child 8 Adult 15. All Department of Social Services contract(s)-
Care Food Program in •sufficient am0unt, and no legal liability on centers only.
,+e part of the Government for me payment of any money shall-arise
unless and until such appropriation shall nave been provided. 16. Record of payment and billing forms from Department of Social
Services - For Profit Title XX centers only
17. Record of oepos. ,.ACFP reimbursement
PAGE TWO
Ct<TM n-n nn
SCHEDULE A
Does your organization have more than one licensed center? YES X NO
Fill in the name,address and other Information of your centers participating in the Child &Adult Care Food Program.
(Attach additional sheets it necessary.)
TYPE OF
CENTER LICENSE
NAME&ADDRESS GaddCan MEALS TO BE CLAIMED
OF CENTER r4 tS Son CAPACITY LICENSE
6Cusis Sdm LICENSE WMTMN EXPIRATION
Nm s NUMBER CN LICENSE DATE
R For Profit BREM LISri AM SMACK LUNCH MI SMACK SUPPER
TIMES OF MEALS
Hudson Elementary H 25 11:15
300 Beach 8:30 n 3:00
Hudson, CO 80642 12:15
NUMBER OF CHILDREN
5:'7 50 60
TIMES Of MEALS
Frederick H 8.30: 11: 15
340 Maple st 3:00
Frederick, CO 80530 12. 15
NUMBER OF CHILDREN
5n Fn 50
TIMES OF MEALS
8:30 11: 15
Milliken H >?, 3:00
300 Broad 17. 15
Milliken, CO 80530 NUMBER OF CHILDREN
60 60 60
TIMES Of MEALS
Island Grove H B 3n 11:15
119 14th Avenue
Greeley, CO 80631 1?:i'5
NUMBER OF CHILDREN
60 50 Fn
TIMES OF MEALS
Kersey Elementary H
11:25
510 Clark
3 _
Kersey, CO 30644 1?:15
NUMBER OF CHILDREN
60 60 5n
This Schedule is part of CACFP 300 alCet,...: �J
Due to an error, item #1 on page one is incomplete. It should read
as follows:
1. It will comply with Title VI of the Civil Rights Act of 1964
(P.L. 88-352) and all requirements imposed by the Regulations
of the Department of Agriculture (7 CFR Part 15) , Department
of Justice (28 CFR Parts 42 & 50) , and FNS directives or
regulations issued pursuant to that Act and the Regulations,
to the effect that, no person in the United States shall, on
the grounds of age, sex, handicap, color, race, or national
origin, be excluded from participation in, or be denied the
benefits of, or be otherwise subject to discrimination under
any program or activity for which the applicant received
Federal financial assistance from the Department; and HEREBY
GIVES ASSURANCE THAT it will immediately take any measures
necessary to effectuate this agreement.
THIS ASSURANCE IS given in consideration of and for the
purpose of obtaining any and all Federal financial assistance,
grants and loans of Federal funds, reimbursable expenditures,
grant or donation of Federal property and interest in
property, the detain 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, or 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 applicant by the Department. This
includes any Federal agreement, arrangement, or other contract
which as one of its purposes the provision of assistance such
as food, food stamps , cash assistance for the purchase o
food, and any other financial assistance extended in reliance
on the representations and agreements made in this assurance.
BY ACCEPTING THIS ASSURANCE, the center or sponsor agrees to
compile data, maintain records and submit reports as required,
to permit effective enforcement of Title VI and permit
authorized CDH personnel during normal working hours to review
such records, books and accounts as needed to ascertain
compliance with Title VI. If there are any violations of this
assurance, the Department of Health, Nutrition Services, shall
have the right tc seek judicial enforcement of this assurance.
This assurance is binding on the center or sponsor, its
successors, transferees,and assignees as long as it receives
assistance or retains possession of any assistance from the
State Agency.
SCHEDULE A .
I� Does yourorganiaSon have more than one licensed center? YES v NO
FM In the name,address and other information of your centers participating in the Child &Adult Care Food Program.
(Attach sddtionat sheets if necessary.)
TYPEOF
CENTEFI UCENSE
NAME a ADDRESS GCmdCa. MEALS TO BE CLAIMED
OF CENTER CAPACITY UCENSE
Go sdJm1 LICENSE WRMEN E1(PIRATICM
HOLES NUMBER ONUCQSE GATE
P-For Pee BREAKFAST AM SUCK I,— I wBwct ISM
TIMES OF MEALS
8:30- 11:15
Gilcrest Elementary H & 3:00
1175 Birch 17, IS
Gilcrest, CO 80623 NUMBER OF CHILDREN
60 60 ' 5n
TIMES • MEA
Billie Martinez Elementary H :30 11: 15
341 14th Avenue 1 %15 3:n0
Greeley, Co 30631
NUMBER OF CHILDREN
60 Cr) Fn
TIMES OF MEALS
Madison Elementary H 8:30 1:15
24th Avenue & 6th Street % 3:1n
Greeley, CO 80631 12• i �
NUMBER OF CHILDREN
60 50 60
TIMES OF MEALS
East Memorial •Elementary H 11:15
614 East 20th Street -3;11,1-
Greeley, CO 80631 NUMBER OF CHILDREN
6n An An
TIMES OF MEALS
18:-31-1 11" 5
Jefferson Elementary H
1315 4th AvenueGreeley, CO 80631 NUMBER OF CHILDREN
60 50 50
•..___�_��_,_:_���rerVDam 9i0:1519 199
Due to an error, item 41 on page one is incomplete. It should read
As-follows:
1. It will comply with Title VI of the Civil Rights Act of 1964
(P.L. 88-352) and all requirements imposed by the Regulations
of the Department of Agriculture (7 CFR Part 15) , Department
of Justice (28 CFR Parts 42 & 50) , and FNS directives or
regulations issued pursuant to that Act and the Regulations,
to the effect that, no person in the United States shall, on
the grounds of age, sex, handicap, color, race, or national
origin, be excluded from participation in, or be denied the
benefits of, or be otherwise subject to discrimination under
any program or activity for which the applicant received
Federal financial assistance from the Department; and HEREBY
GIVES ASSURANCE THAT it will immediately take any measures
necessary to effectuate this agreement.
THIS ASSURANCE IS given in consideration of and for the
purpose of obtaining any and all Federal financial assistance,
grants and loans of Federal funds, reimbursable expenditures,
grant or donation of Federal property and interest in
property, the detain 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, or 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 applicant by the Department. This
includes any Federal agreement, arrangement, or other contract
which as one of its purposes the provision of assistance such
as food, food stamps, cash assistance for the purchase o
food, and any other financial assistance extended in reliance
on the representations and agreements made in this assurance.
BY ACCEPTING THIS ASSURANCE, the center or sponsor agrees to
compile data, maintain records and submit reports as required,
to permit effective enforcement of Title VI and permit
authorized CDH personnel during normal working hours to review
such records, books and accounts as needed to ascertain
compliance with Title VI. If there are any violations of this
assurance, the Department of Health, Nutrition Services, shall
have the right to seek judicial enforcement of this assurance.
. This assurance is binding on the center or sponsor, its
successors, transferees,and assignees as long as it receives
assistance or retains possession of any assistance from the
- ' State Agency.
920,:!33
SCHEDULE A ,
Does your organization have more than one licensed center? YES ' NO
Fill In the name,address and other information of your centers participating in the Child &Adult Cars Food Program.
(Attach a ddluonat sheetta.K necessary.)
TYPEOF
CENTER LICENSE
NAME a ADDRESS cdieCai. LICENSE MEALS TO BE CLAIMED
OF CENTER OQaie.Srloat LICENSE WmTT81 EIQIRATICN
Man NUMBER CNUCERBE DATE BREAKFAST' e..AY "' u . PIMA= SUPPER
R For PMa
TIMES OF MEALS
Centennial Elementary H
8:00 1.15
1400 37th ' 2' 3:On.
Evans , CO 30620 q0. 1:
NUMBER OF CHILDREN
50 6n 6l
TIMES • MEA
8:00 111: 15
Dos Rios Elementary H Ik 3:n?
2201 34th Street 12: 15
Evans , CO 80620 NUMBER OF CHILDREN
60 - 6n Fn
TIMES OF MEALS
Ft. Morgan (Migrant Only) H
Site To Be Determined in
May 1993 ( Infants Only)
NUMBER OF CHILDREN
TIMES OF MEALS
Brighton (Migrant Only) H
Site To Be Determined in
May 1993
NUMBER OF CHILDREN
TIMES OF MEALS
****NOTE: The times for 7::3t: 10:45
the Migrant Programs are
different from the times NUMBER OF CHILDREN
indicated on this contract.
The times will be
...., -4•
Due to an error, item #1 on page one is incomplete. It should read
as follows:
1. It will comply with Title VI of the Civil Rights Act of 1964
(P.L. 88-352) and all requirements imposed by the Regulations
of the Department of Agriculture (7 CFR Part 15) , Department
of Justice (28 CFR Parts 42 & 50) , and FNS directives or
regulations issued pursuant to that Act and the Regulations,
to the effect that, no person in the United States shall, on
the grounds of age, sex, handicap, color, race, or national
origin, be excluded from participation in, or be denied the
benefits of, or be otherwise subject to discrimination under
any program or activity for which the applicant received
Federal financial assistance from the Department; and HEREBY
GIVES ASSURANCE THAT it will immediately take any measures
necessary to effectuate this agreement.
THIS ASSURANCE IS given in consideration of and for the
purpose of obtaining any and all Federal financial assistance,
grants and loans of Federal funds, reimbursable expenditures,
grant or donation of Federal property and interest in
property, the detain 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, or 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 applicant by the Department. This
includes any Federal agreement, arrangement, or other contract
which as one of its purposes the provision of assistance such
as food, food stamps, cash assistance far the purchase o=
food, and any other financial assistance extended in reliance
on the representations and agreements made in this assurance.
BY ACCEPTING THIS ASSURANCE, the center or sponsor agrees to
compile data, maintain records and submit reports as required,
to permit effective enforcement of Title VI and permit
authorized CDH personnel during normal working hours to review
such records, books and accounts as needed to ascertain
compliance with Title VI. If there are any violations of this
assurance, the Department of Health, Nutrition Services, shall
have the right to seek judicial enforcement of this assurance.
This assurance is binding on the center or sponsor, its
successors, transferees,and assignees as long as it receives
assistance or retains possession of any assistance from the
State Agency. ,
301.'33
SCHEDULE B
Requirements for Meals — Child d Adult Care Food Program
•
Each institution participating in the Program shall serve one or more of (2) Lunch or supper-1/2 cup of milk;1 ounce(edible portion as
the following types of meals.as provided in its approved application:(1) served)of lean meat.Poultry,
or fish.or 1 ounce of cheese,or
Breakfast (2) Lunch, (3) Supper, (4) Snacks served between such ry•
other meals. 1 egg, or 1/4 Cup of Cooked dry beans or peas:or 2 table-
spoons of peanut butter 1/1/4 cup of vegetables or fruits or
both consisting of two or more kinds; 1/2 slice of bread or
1. Except as otherwise provided in this section,and 11 any appendix to bread alternate, or 1/4 cup of cooked enriched or whole-
this part, eaen meal snail contain, as a minimum, the food corn- grain rice- macaroni, noodles,or other pasta products.
ponents as follows:
a A breakfast shall Contain: (3) Snack—select two of the following four components-1/2
CPO of milk; 1/2 ounce of h
(1) A serving of fluid milk as a beverage,or on cereal,or used in includes 2 ounces or 1/4 cup of meaty gr meat alternatepjuice,e,or
part for each purpose. equivalent quantity of fruit,or vegetablest);:i/2 slice f b bread
or bread alternate- or 1/4 cup (volume) or 1/3 ounces
(2) A serving of vegetaolelsl or fruit or full-strength vegetable or (weight), whichever is less. of Cereal.or 1/4 Cup of cooked
fruit juice, or an equivalent Quantity of any combination of pasta pr or whole-grain rice, macaroni. noodles or other
these footle. pasta products.
(3) A serving of whole-grain or enriched bread:or an equivalent b. Age 3 up to 6:
serving of cornbread.biscuits,rolls,muffins.etc_made with (1) Breakfast-3/4 cud of milk, 1/2 cup of juice or fruit or
whole-grain or enriched meal or flour:or a serving of wnole- vegetables: 1/2 slice of bread or bread alternate.or 1/3 cup
grain or enriched or fortified cereal; or a serving of cooked (volume)or 1/2 ounce(weight),whichever is less of cereal or
whole-grain or enriched pasta or noodle products such as an equivalent quantity of both Dread and cereal.
macaroni,or cereal grains sucn as rice,bulgur,or corn gets:
or an equivalent quantity of any combination of any of
These 10005. (21 Lunch or SUOper-3/4 cup of milk 1 1/2 ounces(edible por-
tion as served)of lean meat,poultry,or fish.or 1 1/2/2 ounces
b. Both lunch and supper snail contain: of cheese,or 1 egg,or 3/8 cup of cooked dry beans or pees.
or 3 tablespoons of peanut butter, 1/2 cup of vegetables or
(1) A serving of fluid milk as a beverage. fruits or both consisting of two or more kinds, 1/2 slice of
bread or bread alternate,or 1/4 cup of cooked enriched or
(2) A serving of lean meat.poultry or fish;or cheese:or an egg;or whole-grain rice, macaroni, noodles or other pasta
cooked dry beans or peas; or nuts or nut butters; or an products.
equivalent quantity of any combination of these foods-These
foods must be served in a main dish,or in a main dish and one (3) Snack—select two of the following Components-1/2 cup of
other menu item,to meet this requirement.Cooked dry beans milk: 1/2 ounce of meat or meat alternate(which includes 2
or dry peas may be used as the meat alternate or as part of the ounces or 1/4 Cup of yogurt); 1/2 cup of juice or an
vegetable/fruit component but not as both food components equivalent quantity of fruit or vegetables: 1/2 slice of bread
in the same meal. or bread alternate;or 1/3 cup(volume)or 1/2 ounce(weight).
whichever is less,of cereal,or 1/4 Cup of cooked enriched or
(3) A serving of two or more vegetables or fruits,or a combination whole-grain rice,macaroni,noodles,or other pasta products.
of both.Full-strength vegetable or fruit juice may be counted
to meet not more than one-half of this requirement c. Age 6 through 12
(4) A serving of whole-grain Or enriched bread; or an equivalent (1) Breakfast-1 CUp of milk; 1/2 cup of juice or fruit or
serving of cornbread. biscuits, rolls, muffins, ate:, made of vegetables;me)or 1 slice (weight),ght)or bread hv r is srles& or 3/4 cup
whole-grain or enriched meal or flour;or a serving of cooked (volume) t1 ounceof bread
and Iasi Of cereal or
whole-gram or enriched pasta or noodle products such as equivalent quantity both cereal.
macaroni,or cereal grains such as rice.bulgur,or corn grits:or
an equivalent quantity of any combination of these foods. lean(2) Lunch or —1 cup of milk;2 ounces(edible portion as
served)of lean mea4poultry,or fish.or 2 ounces of cheese
c Snack shall be served between other meal t or 1 egg,or 1/2 cup of cooked dry beans or peas,or 4 table-
of the following four components: types and contain two spoons of peanut butter;3/4 cup of vegetables or fruits or
both consisting of two or more kinds: 1 slice of bread or
(1) A serving of fluid milk as a beverage,or on Cereal.Cr used in bread alternate- or 1/2 cup of cooked enriched or whole-
part for each purpose. grain rice. macaroni, noodles or other pasta products,
(21 A serving of meat or meat alternate. (3) Snack—select two of the following four components-1 cup
of milk; 1 ounce of meat or meat alternate(which includes 4
(3) A serving of vegetable(s)orfruft(s)or full-strength vegetable ounces or l/2 cup of yogurt);3/4 juice or equivalent quantity
or fruit juice-or an equivalent quantity of any combination of3/4 of fruit or vegetables; 1 slice of bread or bread is less.ts or
these foods.Juice may not be served when milk is served as car cup(volume)or 1 coked e whichever isriof
e,
the only other component
Careai or 1/2 Cup of cooked, enriched or whole-grain rice,
macaroni,noodles or other pasta product&
(4) A serving of whole-grain or enriched bread:or an equivalent
serving of cornbread.biscuits,rolls,muffins,etc.made with d. nee s and o deer.oys and Adult-sized portions based on the grsatarfootl
needs wholerain or enriched meal or flour or a serving of whole.
of older bri and gwhole-grain
grain or enriched or fortified cereal;or a serving of cooked
whole-grain or ennched pasta or noodle products such as 0. Infant meal patterns:
macaroni,or cereal grains such as rice,bulgur,or corn grits; (1) 0 through 3 months;
or an equivalent quantity of any combination of these
foods. (a) Breakfast-4e fluid ounces of Iron-fortified infant
formula.
2. Except as otherwise provided in this section the minimum amounts
of component foods to serve at meals as set forth in subparagraphs (b) Lunch or Supper-4.6 fluid ounces of iron-fortified
(b)(11, (2),and (3) of this section areas follows: infant formula
a Age 1 up to 3;
(C) Snack-4-6 fluid ounces of iron-fortified infant formula
(1) Breakfast-1/2 cup of milk 1/4 cup of juice or fruit or
vegetables,1/2 slice of bread or bread alternate,or 1/4 cup (2) 4 through 7 months;
(volume)or 1/3 ounce(weight),whichever is less Of cereal or '
an equivalent quantity of both bread and cereal. (a) Breakfast fluid ounces of Iron-fortified infant for-
mule. 0.3 tablespoons of iron-fortified dry infant cereal
PAGE FOUR (optional),
_ a Breakfast
(b) Lunch formula:r 0.3ptabtes000nsoof coosn forttifiedrt dry infant
cereal(optional);0-3 tablespoons of fruit or vegetable of (1) Include as often as practical an egg,or a 1-ounce servince
g appropriate n erved)ot(optional). of(edible
consistency or a combination of both heese;too as 2 s tablespoons meat,
ofpoultry
pea utfish:
butter or or nan
(optio • equivalent quantity of any combination of these foods.
(c) Snack-4-6 fluid ounces of iron-fortified infant formula (2) Additional footle may be served as desired.
(3) 8 months up to the first birthtlaY. b. Lunch or supper-Additional foods may be served as desired
(a) Breakfast-6-8 fluid ounces of iron-fortified infant fomule of meat or alter-
toro ifi fluid infant cereal:r1.4�tablespoo2-4 ns ofs of iron-fruit or c.
nate such as peanut buttelc Include as often r or cheese or other foods needed to
fortified thy
vegetable Of appropriate consistency oracombination of satisfy appetites.
both.
5. If emergency conditions prevent an institution normally having a
of milk from ily(b) Lunch or supper-6-8 fluid of,the State
formula,or 6.8 fluid ounces whole milk;2.4 ta of lbie:moons agfied infant ency,may approve the err lice of breakfasts,lunches,or suppers
of iron-fortified dry infant cereal and/or 1-4 tablespoons without milk during the emergency period.
of meat, fish, poultry,egg yolk or cooked dry beans or
peas,or 1/2.2 ounces(weight)of cheese or 1.4 ounces 8. Substitutions may be made in food fisted in paragraphs(b),(t),(2).
(weight or volume)of cottage cheese or cheese food or and(3)of this section if individual participating children are unable,
cheese spread of appropriate consistency. and 14 because of medical or other special dietary needs. to consume
tablespoons of fruit or vegetable of appropriate consis- such foods.Such substitutions shall be made only when supported
tency or a combination of both. brecommended fr ment om a re o tidy d medical authonry which includes
te(c) Snack-2-4 fluid ounces of iron-fortified infant formula,
whole fluid milk or full-strength fruit juice,0.1/2 slice of
crusty enriched or wholegrain-bread (optional). or 0-2 STATE AGENCY AND CENTER OR SPONSOR FURTHER
cracker-type products loptional)made from whole grain AGREE THAT:
or enriched meal or flour and which are suitable for an
infant for use as a finger food. The center or sponsor shall accept full responsibility for providing
proper accountability,storage,and use of USDA commodity foods and
Breast milk,provided by the infants mother.may be served in place of in so doing,shall promptly provide awritten response to claims that mis-
infant formula from birth through 11 months of age. However, meals handlings, diversions, and/or losses resulting from improper use or
containing only breast milk do not qualify for reimbursement. Meals storage have occurred,
containing breast milk served to infants 4 months of age or oloer may be The center or sponsor shall use USDA commodity foods received under
claimed for reimbursement when the other required meal component or
components are supplied by the child care facility. tnis Agreement solely for the benefit of those persons served or assist-
ed
nsor and ot otnenvise 3. For the purpose of this section, a cup means a standard mea-
commodity foods w w the center or ithout prior written approval Of the dispose State Agency.
suring cup.
4. To improve the nutrition of participating children additional foods
may be served with each meal as follows:
SIGNATURE ON BEHALF OF CENTER OR SPONSOR
I certify that the information on this form is true and correct to the best of my knowledge.I understand that this information is being given in con-
nection with the receipt of Federal funds, and that deliberate misrepresentation may subject me to prosecution under applicable State and
..._. ____Federal criminal tpt.a. - —
Signature //
Tere Ke1Ter-Amaya 'Director of FENWC _
Date
Pnnt Name Tine
.Please complete, sign, and return both agreements to the Colorado.-,aartmenf of Health Child 3 Adult Care Food Program.
SIGNATURES ONCOLORADO T OF HEALTH
CHILD & ADULT CARE FOOD PROGRAM
For the Executive Director,Colorado Depamnent of Health
Date
Administrator.CACFP
rue Date
f Center or Sponsor will receive for its child care centers. Head
TO BE FILLED OUT ADULT COLORADO CARE DEPARTMENTDPROGRAM: HEALTH, • Start Centers, outside school hours centers,or For Profit Title
' CHILD & FOOD XX Centers: -
❑ Regular Donated Commodities
OR
❑ Cash-in-lieu of Commodities(with bonus commodities)
PAGE FIVE Q_ {�c+
0::Ja
I
COLORADO DEPARTMENT OF HEALTH CHILD & ADULT CARE FOOD PROGRAM
•
APPLICATION FOR CHILD CARE CENTER I
1
INSTRUCTIONS: Complete in duplicate. If a sponsored facility,the original (and required attachments) must be submitted with CACFP 3021
(Application for Sponsor of Child and Adult Care Centers). Type or print clearly.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS YES NO
Billie Martinez Elementary CHILDREN/INFANTS ON A REGULAR BASIS? _X-
341 WILL YOU CLAIM THESE CHILDREN/INFANTS
ON THE CACFP? X
Greeley,th Avenue
CO 80631
TELEPHONE NO.: ( 303 ) 351-x1317 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES _X—.NO —
Weld Shift care means that children are coming and going at all times of me day so tnat the
COUNTY: total numder of cntidren ahendmg the center on a daily basis may exceed the license
2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. Double Session
8. HOURS OF OPERATION
To Be Hired FROM 7:00 a.m. To 5:00 n.m,
3._L—HEAD START PROGRAM 9. NUMBER OF OPERATING 110.NUMBER OF OPERATING
-2S_MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR 50
HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 2
HOW MANY ARE AM? HOW MANY ARE PM? 111.ANNUAL DATES OF OPERATION
HOW MANY ARE FULL DAY? t STARTING October 1st ENDING Santamhcr "21c+
)UMBER OF CHILDREN IN EACH CLASSROOM 1
Is your Head Start site licensed as a child care center by the Colorado Department 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
of Social Services during times when Head Stan is not in session? AND SNACKS FOR REIMBURSEMENT •
YES NO— (Induce dates of closing and reopening)
4.ACE RANGE OF ENROLLED CHILDREN N/A
FROM 0TO 5 5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER
THROUGH 12 MONTHS? X CHANGED?
WILL YOU CLAIM THESE INFANTS ON YES NO X 66
THE CACFP? -
14. METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? '
PREPARATION AT FEEDING LOCATION YES X NO •
•
PREPARATION AT CENTRAL KITCHEN
(WHEN YOUHAVE,I7 MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR '
X ISNaDL1TT eggh FRTSTnAOnTH LOCAL SCHOOL SYSTEM EACH MEAL?
UNDER(`nNTRA(;T 1NITH FOOD SERVICE CATERER YES X NO
(SuBWT C6PV OF CONTRACT) .
17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.)
NUMBER OF I YEARS
NAME OF POSITION I NAME OF PERSON SPECIFIC CACFP STAFF IN I IN THIS
1 FOOD SERVICE DUTIES I THIS POSITION!POSITION
I
As required per Distritt Contract
Teacher/Teacher Aide located on site ceratfdg children fondi 4 I vary
Lunch Aide located on site serving children fond 9 i varv ',
18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 331-8351) 1,
X NONPRICING
In a pricing program.centers establish a charge sanaratn fmm tuttion for meals in order to make up the difference Demean the reimbursement provided by the CACFP and tne
actual cost of serving the meals.In a nonpnpng program.families pay a general tuition charge that covers all areas of child care services provided by tne center,inclining
meals.There is no identifiable separate charge for meals served to any children in care.
19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money shall not exceed a typical montns rate of reimbursement and shall be deducted from that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:If you are a single,inaeoendem center,complete the Preaward Compliance Review rather tnan this section.
PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA,
HOUSING AUTHORITY DATA,ETC,IN ADDITION,GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
ESTIMATE ACTUAL
American Indian or Alaskan Native ***NOTE: Actual varies according to
Asian or Pacific Islander o Program Head Start vs Migrant
Black of Hispanic origin) 7N Head Start
HisspanicDanic
White (not of Hispanic ongin) Z b
'ACFP-301 (4/92) WHITE-CDH-CACFP YELLOW- APPLICANT
9Z(3_ 93
COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate. If a sponsored facility,the original land required attachments) must be submitted with CACFP 302'
(Application for Sponsor of Child and Adult Care Centers). Type or print clearly.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS YES NO
Madison Elementary CHILDREN/INFANTS ON A REGULAR BASIS? _ _
24th Avenue & 6th Street WILL YOU CLAIM THESE CHILDREN/INFANTS
ON THE CACFP? x
Greeley, Colorado $0631
TELEPHONE NO: ( .0..1 ) 353-2796 7. 00 YOU CARE FOR CHILDREN IN SHIFTS? YES IL_NO
COUNTY' Weld Shift care means that children are coming and going at all times of the day so that the
total numoer of children attending the center on a daily basis may exceed the license
2.NAME AND TITLE OF CONTACT PERSON AT CENTER capacity- Double Session
8. HOURS OF OPERATION
To Be Hired •
. FROM 7:00 a.m. To 5:00 n.m.
3.2—.-EAD START PROGRAM 9.NUMBER OF OPERATING ' 10. NUMBER OF OPERATING
-yam MIGRANT HEAD START PROGRAM DAYS PER WEEK S WEEKS PER YEAR 50
HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 2
HOW MANY ARE AM?_,i;IOW MANY ARE PM? 2 1 11.ANNUAL DATES OF OPERATION
HOW MANY ARE FULL DAY, CC STARTING October 1st ENDING Seotemher 31st
NUMBER OF CHILDREN IN EACH CLASSROOM 15
is your Head Start site ilcenseo as a child care center oy me Colorado Department 12.LIST ANY MONTHS DURING'WHICH YOU WILL NOT CLAIM MEALS
of Soaal Services dung times wnen Head Start is not in session?
YES NO •
AND SNACKS FOR REIMBURSEMENT
Ilncluce Gates of closing and reopening)
4.ACE RANGE OF ENROLLED CHILDREN
FROM 0 TO 5 /4
5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER 1
THROUGH 12 MONTHS? X CHANGED?
WILL YOU CLAIM THESE INFANTS ON
THE CACFP? X YES NO X 1
14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
PREPARATION AT FEEDING LOCATION YES X NO
PREPARATION AT CENTRAL KITCHEN
;WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
X 'LJNDF 1 CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL?
.sUBMIT CoPY OF CONTRACT)
i4N? 1 CONTRAOyCT WITH FOOD SERVICE CATERER YES X NO
oil 1 L P OF C TRACn
17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.)
NUMBER OF j YEARS
NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN ! IN THIS
7-000 SERVICEDUTIES THIS POSITION!POSITION
As required per Distrilct Contact
Teacher/Teacher Aide I located on site cArvinn rhilrlrep ford n vary
Lunch Aide lnratert nn cites scrvingchildren fond 9 vary
18.IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further Instructions at 331-8351)
X NONPRICING
In a prang program.centers establish a charge separate from tuition for meals in order to make up the difference between the reimbursement provided by the CACFP and the -
actual cost of serving the meals.In a nonpnang program,lamses pay a general tuition charge that covers all areas of child care services provided by the center,including
meals.There is no identifiable separate charge for meals served to any children in care.
19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money shall not exceed a typical month's rate ot reimbursement and shall be deducted from that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:If you are a single,independent center,complete the Preaward Compliance Review rather man this section.
PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBUC SCHOOL DATA,
HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
IM ESTATE ACTUAL
American Indian or Alaskan News 17
Asian or Pacific lslender 1;0 ***"N0TE: Actual varies according to
Black(not of Hisparkc origin) 3,o Program Head Start vs Minrant
Hispanic 70% Head Start
White (not of Hispanic origin) 25%
CACFP-301 (4/92) WHIM-CDHGCFP YELLOW- APPLICANT
920L:39
COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in auplicate. If a sponsored facility,the origina)(and requires attachments) must be submitted with CACFP 302-
(Application for Sponsor of Child and Adult Care Centers).Type or print ceahy.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YES NO
Dos Rios Elementary CHILDREN/INFANTS ON A REGULAR BASIS? X
2201 34th Street WILL
THE U CLAIM THESE CHILDREN/INFANTS XON -
Evans , CO 80620
TELEPHONE NO.: i 3Q3' 2Q-1220 7. DC YOU CARE FOR CHILDREN IN SHIFTS? YES .ENO
Shan care means that cnnaren are=mute and going at all times of the say so mat me
COUNTY: I1F1 D 'oral number of cmIoren attending me center an a dairy basis may exceed me license
! 2.NAME AND TITLE OF CONTACT PERSON AT CENTER .;acaurv. !)Ouhle S essi Ons
.i a. 7CURS OF OPERATION
To Be Hired FROM 7:00 a.m. TD 5:0x1 n.m.
3.X-HEAD START PROGRAM 9. \LMBER CF OPERATING 10. NUMBER OF OPERATING
:AIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR 50
HOW MANY HEAD START,LASSROOMS DO YOU HAVE?
22
HOW MANY APE AM? i W MANY ARE PM? ,.ANNUAL DATES OF OPERATION
HOW MANY ARE FULL DAY? 15 STARTING October 1Ct ENDINGSPntambEr 11.st
NUMBER OF CHILDREN IN EACH CLASSROOM
Is your Heat Stan site licensed as a wr1 care center oy me Cataraoo Department 12._ST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
of Social Services aunng times wean read Start is not in session? AND SNACKS FOR REIMBURSEMENT
YES 1_NO_ -Rude sates of closing and reooenmg)
4. ACE RANGE OF ENROLLED CHILDREN N/A
FROM 0 TO C
5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13.. 7AS THE NAME OF THE CENTER OR SPONSOR OR OWNER
THROUGH 12 MONTHS? X CHANGED?
WILL YOU CLAIM THESE INFANTS ON X vc5 X NO '
THECACFP?
15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
14.METHOD BY WHICH MEALS WILL BE PROVIDED
PREPARATION AT FEEDING LOCATION YES X NO
(WHEN YOU HAVVE MAORCENTRALTHAN SK�)CHEN 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
X ' tulliE cbvQ of cl TT WW H LOCAL SCHOOL SYSTEM EACH MEAL?
ycs X NO
1.UNDE'RCPONTRACrn WITH FOOD SERVICE CATERER
17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.)
NUMBER OF I YEARS
NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN I THIS
rOCD SERVICE DUTIES ITHIS POSIONI POSITION
I
As required per Distrilct Contract
Teacher/Teacher Aide lnrated on cite servina children food 1 vary
Lunch Aide I located on site servinn children food I ' I vary
18.IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE)_PRICING(Please contact our office for further instructions at 331.8351)
X NONPRICING
In a prang program.centers esaaan a Charge segaiatato=a1=for meals in order to make up the difference between me reimbursement provided by the CACFP and me
actual cast of seising me meas in a nonpnci g program,tamest pay a greral tuition alarge that covers all areas of child care services provided by me center,indduceig
meals.There is no identifiable mama charge tot male served to any children in care.
19.All parbapatirg centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money snail not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimbursement
•
20.CIVIL RIGHTS PLEASE NOTE:It you are a single•independent center. .arUe*the Preaw°N Compliance Review rather than this sacem. .
PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBLIC SCHOOL DATA.
HOUSING AUTHORITY DATA.ETC.IN ADDITION.GIVE THE ACTUAL RACIA/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
E,S)7MATE ACTUAL
American Indian or Alaskan Nam" 1 ***NOTE: Actual varies according to
Ben'Motor of Hipancar % Program Head Start vs t'
BlrA Mot of Hispanic anon' �-, _ _ ti Drant
Hispanic 703/-. Head Start
White (not of Hispanic orgln) 25`<
CACFP-301 (4/92) WHrrE-CDH-CACFP YELLOW- APPLICANT
3 ..39
COLORADO DEPARTMENT OF HEALTH CHILD & ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate. If a sponsored facility,the onginai (and required attachments) must be submitted with CACFP 302'
(Application for Sponsor of Child and Adult Care Centers). Type or print clearly.
L.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 5. DO YOU CARE FOR SPECIAL NEEDS YES NO
Centennial Elementary CHILDRENi INFANTS ON A REGULAR BASIS? — —
WILL YOU CLAIM THESE CHILDREN/INFANTS
1400 7th ON THE CACFP? X
Evans, CO 30620
TELEPHONE NO.: ( 3Q3 ) 332_'tr]R5 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES XX_NO
Shift care means that children are coming and going at all times of the day so that the
COUNTY: '•1F I n !oral numoer oLcoilawep attending the center on a daily basis may exceed the license
2. NAME AND TITLE OF CONTACT PERSON AT CENTER GanaaN. JOun Ie Session
8. HOURS OF OPERATION
To Be Hired FROM 7:Qn a m TO S•nn n n.
3._X—..HEAD START PROGRAM 9. NUMBER CF OPERATING 10. NUMBER CF OPERATING
_Y_MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR get
HOW MANY HEAD START Ci A5sROOMS DO YOU HAVE? 2
HOW MANY ARE AM?_...2- HOW MANY ARE PM? 2 �' 11.ANNUAL DATES OF OPERATION
HOW MANY ARE FULLDAY?,_2_ STARTING October 1st ENDING SPnteplbPr " 1st
NUMBER OF CHILDREN IN EACH CLASSROOM—
Is your Head Start site licensed as a child care center oy the Colorado Depanmem 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
of Social Services outing times when Head Stan is not in session? AND SNACKS FOR REIMBURSEMENT
YES- NO_ 'Irciuoe dates of closing and reopening)
4.ACE RANGE OF ENROLLED CHILDREN
FROM 0 TO 5 N/A
S.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSCR OR OWNER
THROUGH 12 MONTHS? X CHANGED?
WILL YOU CLAIM THESE INFANTS ON YES NO X
THE CACFP? ___X___ I
14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
PREPARATION AT FEEDING LOCATION YES X NO
PREPARATION AT CENTRAL KITCHEN
!WHEN YOU
HAVE MORE THMI ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
tUNDErR CO OF TRAA fTTRWIITH LOCAL SCHOOL SYSTEM EACH MEAL?
UNDER CONTRACT WITH FOOD SERVICE CATERER YES X NO
(SUBMIT COPY OF CONTRACT)
17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child ana Adult Care Food Program food service functions in this center()
NUMBER OF YEARS
NAME OF POSITION NAME OF PERSON SPECIFIC CACFP ' STAFF IN j IN THIS
I FOOD SERVICE DUTIES- THIS POSITIONI POSITION
As required per Distrlict Contract •
Teacher/Teacher Aide located on site Iservinn childrpn fond I 4 var+r-
I
unch Aide lnratai nn sit ice • " ' 'dren fe9d ' a t
18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE)_PRICING(Please contact our office for further instructions at 331-8351)
X NONPRICING
In a pnang program.centers establish a charge eenmate tmm tuition for meats in order to make up the difference between the reimbursement provided by the CACFP and the
actual cost or serving the meats.In a nonpnang program,families pay a general tuition charge that covers all areas of child care services provided by me center,including
meals.There is no identifiable separate charge for meals served to any children in cam.
19.All pantapating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:If you are a single,independent center,complete the Preawerd Compliance Review rather than this section.
PROVIDE AN ESTIMATE OF THE RACIAL/ETHINIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBLIC SCHOOL DATA,
HOUSING AUTHORITY DATA.ETC.IN ADDITIO$N.GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
Amencanlndian or Alaskan Native E.I.A) ACTUAL
***N0TE: Actual varies accordin0 to
Arian or Paafic Islander 1°' Pronram Head Start vs rlinrant '
Black(not of Hispanic origin) 3�° Head Start
Hispanic
Whyte (notot Hispanic origin) 25°/
CACFP-301 (4/92) WHITE-CDH-CACF•P YELLOW- APPLICANT
COLORADO DEPARTMENT OF HEALTH CHILD Sc ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in auplicate. If a sponsored facility,the original(and required attachments) must be submitted with CACFP 302
(Application for Sponsor of Child and Adult Care Centers). Type or pnnt clearly.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS YES NO
CHILDREN/INFANTS ON A REGULAR BASIS? X _
East Memorial Elementary WILL YOU CLAIM THESE CHILDREN/INFANTS x
614 East 20th Street ON THE CACFP?
TELEkIS 13$$.r (Colorado 30631 (303) 352-9478 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES X N0
COUNTY: 4Je l d Shift care means mat children are coming and going at all times of the clay so that the
'.. total numoer oLcnildren attending the center on a daily basis may exceed the license
2. NAME AND TITLE OF CONTACT PERSON AT CENTER capaorv. Double session
To Be Hired 8. HOURS OF OPERATION
7:Do a.m. 5:01) n.m.
FROM TO
3.-.Y HEAD START PROGRAM 9. NUMBER CF OPERATING i 10. NUMBER OF OPERATING
-X.MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR l
HOW MANY HEAD STAR CLASSROOMS CLASSROOMS DO YOU HAVE; 2
HOW MANY ARE AM? L HQW MANY ARE PM? L 11.ANNUAL CATES OF OPERATION
HOW MANY ARE FULL DAY?
Z STARTING October 1st ENDING .enter'Iher �1St
NUMBER OF CHILDREN IN EACH CLASSROOM 1 5
Is your Head Stan site licensed as a child we center oy the Colorado Department ! 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
of Social Services dunng times wnen Heap Stan is not in session? AND SNACKS FOR REIMBURSEMENT
YES_.Z_NO_
I Include cafes of closing ana reopening)
4. ACE RANGE OF ENROLLED CHILDREN ! ,)/A
FROM 0 TO
5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER
THROUGH 12 MONTHS? X
WILL YOU CLAIM THESE INFANTS ON CHANGED?
THE CACFP? X YES NO X
; 14. METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
PREPARATION AT FEEDING LOCATION YES X NO
PREPARATION AT CENTRAL KITCHEN
!WHEN YOU HAVE MORE THAN ONE SITE( 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
X `�NOErRCONTRAOPY OF CTRAIW H LOCAL SCHOOL SYSTEM EACH MEAL?
' `UNDE>RcCONTRAACTT WITTH FOOD SERVICE CATERER /ES NO
17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child ana Adult Care Food Program food service functions in this center.)
I NUMBER OF I YEARS
NAME OF POSITION I NAME OF PERSON SPECIFIC CACFP STAFF IN IN THIS
FOOD SERVICE DUTIES THIS POSITION'POSITION
I
As required per District Contract
Teacher/Teacher Aide located on site serving children food d I vary
Lunch Aide l located on site cprvinn children food o I r_v_
18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE)_PRICING(Please contact our office for further instructions at 331.8351)
. -_NONPRICING
In a pricing program,centers establish a charge StniKare�m n amen for meals in order to make up the difference Between the reimbursement provided by the CACFP and the
actual cost of serving the meats.In a nonpnorg program,tamlhes pay a general tuition charge that covers all areas of child care services provided by the center.including
meals.There is no identifiable separate charge for meals served to any chikken in care.
19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:II you are a single.independent Center,complete the Preaward Compliance Review rather than this section. '
PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA.
HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAUETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
ESTIMATE ACTUAL •
Americanlndian or Alaskan Native 1j ***NOTE: Actual varies accordinn to
Allan or Pacific Islander 11 Program Head Start VS Minrant
Black(not of Hispanic ongin)
Hispanic /D Head Start
White (not of Hispanic ongin) 2 ri°!
CACFP-301 (4/92) WHITE-CDH-CACFP YELLOW- APPLICANT
COLORADO DEPARTMENT OF HEALTH CHILD & ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate. If a sponsored facility,the original (and required attachments)must be submitted with CACFP 302'
(Application for Sponsor of Child and Adult Care Centers). Type or print clearly.
1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS YES NO
Jefferson Elementary CHILDREN/INFANTS ON A REGULAR BASIS? X
Avenue WILL YOU CLAIM THESE CHILDREN/INFANTS
1315 4th
Greeley CO 80631 ON THE CACFP? X
TELEPHONE 1JO:• 303 I , 356-7408 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES X_NO
COUNTY: Weld Shift care means that children are coming and going at all times of the day so that the
'dtal number of children attending the center on a daily basis may exceed the license
2. NAME AND TITLE OF CONTACT PERSON AT CENTER capaafl. Double Sessjnn
To Be Hired S. HOURS OF OPERATION
FROM 7:00 a.m. TO S.Do n m
3.-I.--nEEAD START PROGRAM 9. NUMBER OF OPERATING '10. NUMBER OF OPERATING
�_MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR 55r)
NOW MANY HEAD START CLASSROOMS DO YOU HAVEZ? 3
HOW MANY ARE AM?___ 2 HOW MANY ARE PM? 11.ANNUAL DATES OF OPERATION
HOW MANY ARE FULL DAY? 2 October 1st Spr)ten-tber 31¢t
NUMBER OF CHILDREN IN EACH CLASSROOM 15 STARTING ENDING
is your Head Start see uaensed as a cnld care center oy the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
of Social Services dung times when Head Stan is not in session?
V ES ENO_ AND SNACKS FOR REIMBURSEMENT
4. ACE RANGE OF ENROLLED CHILDREN (Include dates of closing and reopening;
FROM D TO 5 I
.1/A
5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO r 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER
THROUGH 12 MONTHS? CHANGED?
WILL YOU CLAIM THESE INFANTS ON X
THE CACFP? ____ YES NO
14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
PREPARATION AT FEEDING LOCATION YES X NO
PREPARATION AT CENTRAL KITCHEN
'WHEN F YOU
HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
X uNDE_C CPO TRAAOF CT WIITH LOCAL SCHOOL SYSTEM EACH MEAL?
,SUBMITUNDER&ONTRACT WITH FOOD SERVICE CATERER YES X NO
. UBMI C P CF CONTRA T)
17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child ana Adult Care Food Program food service functions in this center.)
I NUMBER OF I YEARS
NAME OF POSITION NAME OF PERSON SPECIFIC CACFP I STAFF IN I IN THIS
FOOD SERVICE DUTIES- THIS POSITIONI POSIT''CN
As required per District Contract i
Teacher/Teacher Aide inratPd nn site servino children god 4 VA r"
Lunch Aide located on site serving chiidreir feed 9 Var'r
18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 331-8351)
NONPRICING
In a prong program.centers establish a charge carman,from tuition for meals in order to make up the difference between the reimbursement provided by the CACFP and the
actual cost of serving the meals.In a nonpnang program,families pay a general tuition charge that covers all areas at child care services provided by the center,including
meals.There is no identifiable separate charge for meals served to any children in care.
19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The .
amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:tf you are a single,independent center,complete the Preaward Compliance Review rather than this section.
PROVIDE AN ESTIVATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBUC SCHOOL DATA.
HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
ESTrATE ACTUAL
American Indian or Alaskan Native ***NOTE: Actual varies according to
Asian or Pacficlswder L'/, Drogram Head Start vs minrant
Sleek(not of Hispanic organ)
�c 6o Head Start
White snot of Hispanic orgin) 25°/-
CACFP-301(4/92) WHITE-CDH-CACFP YELLOW- APPLICANT li
COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate. If a sponsored facility,the original (and required attachments) must be submitted with CACFP 302'
;Application for Sponsor of Child and Adult Care Centers). Type or print dearly.
II.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) i 6. DO YOU CARE FOR SPECIAL NEEDS YES NO
Gil cres t Elementary CHILDREN/INFANTS ON A REGULAR BASIS?
1175 Birch WILL YOU CLAIM THESE CHILDREN/INFANTS
ON THE CACFP?
Silcrest, CO 80623
TELEPHONE NO.: ( 303 ) 737-2774 7. DC YOU CARE FOR CHILDREN IN SHIFTS? YES X NO _
1 Shift care means mat children are coming and going at all times of the day so that the
COUNTY: 7(P 1 d total numoer of children attending the center on a daily oasts may exceed me license
2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. Double Session
8. HOURS OF OPERATION
To Be Hired FROM 8:00 a.m. TO 5:00 n.m.
3._.b--HEAD START PROGRAM '� 9. NUMBER OF OPERATING '10. NUMBER OF OPERATING
MIGRANT HEAD START PROGRAM 1 DAYS PER WEEK 5 WEEKS PER YEAR 37
HOW MANY HEAD START CLASSROOMS DC YOU HAVE? I
HOW MANY ARE AM?____1_10OW MANY ARE PM?_ 1 11. ANNUAL DATES OF OPERATION
HOW MANY ARE FULL DAY? 1 STARTING September 1st ENDING May 31st
NUMBER OF CHILDREN IN EACH CLASSROOM 18 I
Is your Head Stan site licensed as a avid care center oy the Colorado Deoanment 12. UST ANY MONTHS DURING'WHICH YOU WILL NOT CLAIM MEALS
of Social Services ounng times wnen Heao Stan is not in session? AND SNACKS FOR REIMBURSEMENT
ES X___NO—
Ilndude dates of nosing and reopening)
4.ACE RANGE OF ENROLLED CHILDREN
FROM 4 TO 5 _ N/A
3. CO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER
THROUGH 12 MONTHS? - X CHANGED?
WILL YOU CLAIM THESE INFANTS ON YES NO X '
THE CACFP'r
14. METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
PREPARATION AT FEEDING LOCATION YES _2L NO
PREPARATION AT CENTRAL KITCHEN
WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
X iNDF�R�QI FclaT WITH LOCAL SCHOOL SYSTEM EACH MEAL?
UEM P F CONTMCT)
IUNDE i CONTRACT WITH FOOD SERVICE CATERER YES X NO
U MI C P OF CO TRACT)
?. FOOD SERVICE STAFF PATTERN(Only enter staff who will pertorm Child ana Adult Care Food Program food service functions in this center.)
I NUMBER OF I YEARS
NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN IN THIS
FOOD SERVICE DUTIES THIS POSMONI POSITION'.
I
As required per Distrilct Contract I
Teacher/Teacher Aide i located at site serving children food . 9 I vary
Lunch Aide I located at site SPrvinn children food I 1 vary
18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 3314351) •
NONPRICING
In a pricing program,centers establish a charge Aervrete Irrtm(Union for meals in order to make up the difference oetween the reimbursement provided by the CACFP and the '
actual cost ct serving the meats.In a nonpnong program.families pay a general tuition charge that covers all areas of child care services provided by the center.including
meals.There is no identifiable separate charge for meats saved to any Ctiloren in care.
19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The •
amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:It you are a single.independent canter.complete the Preaward Compliance Review rather than this secion.
PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA,
HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
ESTIMATE ACTUAL
Amencan Indian or Alaskan Native 1 to
Asian or Pectic Islander °l
Black(not of Hispanic origin)
Hispanic 70b/
White (not of Hispanic origin) 25%
CACFP-301 (4/92) WHITE-CDH-CACFP YELLOW- APPLICANT
920:33
COLORADO DEPARTMENT OF HEALTH CHILD & ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate. If a sponsored facility,the original (and required attachments)must be submitted with CACFP 302'
(Application for Sponsor of Child and Adult Care Centers). Type or print clearly.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS YES NO
Kersey Elementary CHILDREN/INFANTS ON A REGULAR BASIS? X
510 Clark WILL YOU CLAIM THESE CHILDREN/INFANTS
ON THE CACFP? X
Kersey, CO 80644
TELEPHONE NO.: ( 3f13 I 351_7z Z9 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES X__,t4O
COUNTY' Shift care means that children are coming and going at all times of the day so that the
\e 1 d !Dial number of cnitdren attending the center on a daily basis may exceed the license
a`-'2. NAME AND TITLE OF CONTACT PERSON AT CENTER a`'n'' tlni i51 a Sessi tan
To Be Hired 8. HOURS OF OPERATION
FROM 8:00 a m TO 5.00 n m
3.—X_—HEAD START PROGRAM j 9. NUMBER CF OPERATING 10. NUMBER OF OPERATING
—MIGRANT HEAD START PROGRAM ! DAYS PER WEEK 5 WEEKS PER YEAR 4F
HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 1
HOW MANY ARE IOW MANY ARE PM?._,1,_ 11.ANNUAL CATES OF CPERATICN
HOW MANY ARE FULL DAY? STARTING September 1st ENDING "Isar 31st
NUMBER OF CHILDREN IN EACH CLASSROOM I Ci
Is your Head Start site licensed as a child care center oy the Colorado Department ! 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
at Social Services during times wnen Head Start is not in session? AND SNACKS FOR REIMBURSEMENT
YES NO_X_ I Include dates or closing and reopening)
4.ACE RANGE OF ENROLLED CHILDREN
FROM 4 TD 5 N/A
5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR CR OWNER
THROUGH 12 MONTHS? CHANGED? •
WILL YOU CLAIM THESE INFANTS ON
THE CACFP? X YES NO X
14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
PREPARATION AT FEEDING LOCATION YES X NO
PREPARATION AT CENTRAL KITCHEN
,WHEN YOU NAVE MORE THAN ONE Slit • 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
X iND;R frSNTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL?
I UBMI C P OF CONTRACT
INLETR agNTRACTT WITH FOOD SERVICE CATERER YES X NO
YaU MI C P OF CO TRACT]
17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.)
NUMBER OF I YEARS
NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF ' IN THIS
ROOD SERVICE DUTIES- I
N THIS POSITIONI POSITION
As required per District Contract
Teacher/Teacher Aide located on site i servinq children food ? vary
Lunch Aide located on site servinq children food I 1 vary
18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 331-8351) -
X NONPRICING
In a pricing program,centers establish a charge ten-wets from tuition for meals in order to make up the diderence between the reimbursement provided by the CACFP and the
actual cost of serving the meals.In a nonpna g program,families pay a general tuition charge that covers all areas of child care services provided by the center.including
meas.There is no identifiable separate charge for meals served to any children in tars.
19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:It you area single,independent center,complete the Preaward Compliance Review rather than this section.
PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA,
HOUSING AUTHORITY DATA,ETC.IN ADDITION.GIVE THE ACTUAL RACIAIJETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
F§TIMATE ACTUAL
American Indian or Alaskan Native 1/o
Asian or Paaric Islander )°v,
Black(not of Hispanic onein) e
Hispanic /'J/J
White (not of Hispanic origin) 75%
CACFP-301 (4/92) WHITE-CDH-CACFP YELLOW- APPLICANT 920L:93
•
• COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate. If a sponsored facility,the original (and required attachments) must be suomitted with CACFP 302'
(Application for Sponsor of Child and Adult Care Centers). Type or print clearly.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6.CHIL YOU CARE DREN/YOU CA E FS ON ORSPECIAL REGULAR BASIS? YX
ES NO
I s and Grove WILL YOU CLAIM THESE CHILDREN/INFANTS X
119 14th Avenue ON THE CACFP? -
Greeley, Colorado 80631 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES NO
TELEPHONE NO.: ( 303 ) 252-2A27 ENO ____
care means that=Ocean are coming and going at all times of the day so that the
COUNTY' Wel d total number of children attending sip center on a daily basis may exceed the license
2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. Double Session
8. HOURS OF OPERATION
To Be Hired i
FROM 8:`)/1-a.m. TO 5:02 n.m.
3. _HEAD START PROGRAM ! 9. NUMBER CF OPERATING 10.NUMBER OF OPERATING
—MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 i WEEKS PER YEAR 39
' HOW MANY HEAD START CLASSROOMS DO YOU HAVE?_.-1-- i
HOW MANY ARE AM?__i— HOW MANY ARE PM? 1 111.ANNUAL DATES OF OPERATION
HOW MANY ARE FULLDAY?_1._ STARTING October 1st ENDING "ay 31st
'NUMBER OF CHILDREN IN EACH CLASSROOM 1 R I
• Is your Head Stan site licensed as a child rare center oy the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
of Social Services during times when Head Start is not in session? AND SNACKS FOR REIMBURSEMENT
YES_NO_ Include dates of closing and reopening)
4.ACE RANGE OF ENROLLED CHILDREN N/A
FROM 4 TO 5
5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER '
THROUGH 12 MONTHS? X CHANGED?
WILL YOU CLAIM THESE INFANTS ON YES NO X t
THE CACFP? _..X__.
14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
PREPARATION AT FEEDING LOCATION YES X NO
PREPARATION AT CENTRAL KITCHEN
(WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
iN DE_R CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL?
1
',JNDEq((�NTRA[`T�A/ITH FOOD SERVICE CATERER YES X NO
ISUBMIT COPY OF COt7TRACT)
17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child ana Adult Care Food Program food service functions in this center.)
NUMBER OF I YEARS
NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN IN THIS
FOOD SERVICE DUTIES THIS POSITIONI POSITION
As required per District Contract
Teacher/Teacher Aide located on site serving children fnnd 9 vary
j lunch Aide located on site serving children fnnd I 1/ V.,./
18.IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 3318351)
—X NONPRICING
In a pricing program,centers establish a charge ssmrare from tuition for meals in order to make up the difference between the reimbursement provided by the CACFP and the
actual cost of serving the meals.In a nonpnang program,families pay a general tuition charge that covers ail areas of child care services provided by the center,including
meals.There is no identifiable separate charge for meals served to any children in care.
19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
•
amount of advance money shall not exceed a typical month's rare of reimbursement and shall be deducted from that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:if you are a singW,independent center,complete the Preaward Compliance Review rather than this section.
PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA,
HOUSING AUTHORITY DATA,ETC.IN ADDITION.GIVE THE ACTUAL RACIAIJETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
ESTIMATE ACTUAL
American Indian or Alaskan Native 1`'/
Asian or Pacific Islander 1
Black(not of Hispanic origin)
Hispanic � '
White (not of Hispanic origin) 2 et- j
CACFP-301 (4/92) WHITE-CDH-CACFP YELLOW- APPLICANT
3x0:;93
COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate. If a sponsored facility,the original (and required attachments) must be submitted with CACFP 302
(Application for Sponsor of Child and Adult Care Centers).Type or print clearly.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6. DO YOU CHILDREN/EIN FORS OE II L NEEDR BASIS?AL NEEDS YES NO
•
Frederick WILL YOU CLAIM THESE CHILDREN!INFANTS
340 Maple ON THE CACFP? X
•
Frederick, CO 80642 7, DO YOU CARE FOR CHILDREN IN SHIFTS% Y'ES y_110
TELEPHONE NO.: ( 303 ) R'i4-92' 0
We 1 d Shift care O means that R CHI are coming SHIFTS at all times E the day N that the
COUNTY: total number of chitoren attending the center on a caw basis may exceed the license
2.NAME AND TITLE OF CONTACT PERSON AT CENTER
capacity, Double Session
8.HOURS OF OPERATION
To Be Hired FROM 7:00 a.m. To 5:00 D.M.
3,...X--MIGRANT AHEAD PROGRAM RT PROGRAM g DANUYS PER WEEK ER OF E RATING 5 10.NUMBER EFR YAR OPERATING !i!
HOW MANY HEAD START CLASSROOMS DO YOU HAVE? L
HOW MANY ARE AM?_..-1-- HOW MANY ARE PM? 1 11.ANNUAL DATES OF OPERATION
HOW MANY ARE FULL DAY?__ STARTING October 1st ENDING Sentember 31st
NUMBER OF CHILDREN IN EACH CLASSROOM I R
Is your Head Start site licensed as a child care center by the Colorado Depanment 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS 'I
of Social Services dunng times when Head Start is not in session? AND SNACKS FOR REIMBURSEMENT
YES 2_NO— (Include dates of closing and reopening)
4.ACE RANGE OF ENROLLED CHILDREN FROM 0 TO 5 N/A
/i
5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER
THROUGH 12 MONTHS? X 113. .
CHANGED?
WILL YOU CLAIM THESE INFANTS ON
THE CACFP? X YES NO
14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
jl PREPARATION AT FEEDING LOCATION YES X NO
PREPARATION AT CENTRAL KITCHEN
(WHEN YOU
HAVE A1 MORE
THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
X (AUBM NDE C_O TRCONTRACT)
i H LOCAL SCHOOL SYSTEM EACH MEAL?
IT Coriap(; ttra7 y,/ITH FOOD SERVICE CATERER YES X NO
(&Ue5.TT COP OF COtITMCT)
17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.)
I NUMBER OF I YEARS
NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN I IN THIS
FOOD SERVICE DUTIES ITHIS POSITION'POSITION
I
As required per Distri :t Contract I
Teacher/Teacher Aide located on cite I carving children food 4 vary
Lunch Aide located on site serving children food 2 vary
18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 331-8351)
X NONPRICING
In a pricing program.centers establish a charge separate frnm tuition for meals in order to make up the difference between the reimbursement provided by the CACFP and the
actual cost of salving the meals.In a nonprigng program,families pay a general tuition charge that covers all areas of thud care services provided by the center.including
meals.There is no identifiable separate charge for meals served to any children in care.
19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:U you are a single,independent center,complete the Preaward Comohance Review rather man this section.
PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBLIC SCHOOL DATA,
HOUSING AUTHORITY DATA,ETC.IN ADDITION.GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
ESTIM57E ACTUAL
Amencanlndian or Alaskan Native 1 � ***NOTE: Actual varies according to I
Asian or Pacific Islander 73 G Program Head Start vs "'11 Ordnt
Black(not of Hispanic origin) 0�Wh Head Start
White (nn ot of Hispanic origin) 25a%
WHITE-CDH-CACFP YELLOW- APPLICANT n 'T' '..
l " .1,,,{�3 e
CACFP-301(4/92) c
COLORADO DEPARTMENT OF HEALTH CHILD & ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate. if a sponsored facility, the original and required attachments) must be submitted with CACFP 302!
(Application for Sponsor of Child and Adult Care Centers). Type or print clearly.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS •(ES NO
Milliken CHILDREN/INFANTS ON A REGULAR BASIS? X
300 Broad WILL YOU CLAIM THESE CHILDREN, INFANTS
Milliken, CO 80530 ON THE CACFP X •
TELEPHONE We
( 303 ) 587-2388 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES 1LNO
COUNTY: Nf?1 d Shift care means that children are comma and going at all times or the day so that the ;
total numoer of children attending the center on a daily basis may exceed the license
2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. DOub 1 P Session
8. HOURS OF OPERATION
To Be Hired FROM 8.00 a m TO 5•on n r2
3.-ç_ HEAD START PROGRAM 9.NUMBER OF OPERATING • IC. NUMBER OF OPERATING
--MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEA.R 37
HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 1 •
•
•
HOW MANY ARE AM? 1 HOW MANY ARE PM?_.1._ 11.ANNUAL DATES OF OPERATION '
HOW MANY AREFULLDAY?�_ September 1stE May •
NUMBER OF CHILDREN IN EACH CLASSROOM 1R
STARTING LADING 31st
Is your Head Start site licensed as a child care center by the Colorado Department 12. LIST ANY MONTHS DURING'WHICH YOU WILL NOT CLAIM MEALS
of Social Services ounng times when Head Stan is not in session?
rE5_NO AND SNACKS FOR REIMBURSEMENT
(Include dates of closing and reopening)
4.ACE RANGE OF ENROLLED CHILDREN
FROM 4 TO 5 N/A
5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER
THROUGH 12 MONTHS? X CHANGED?
WILL YOU CLAIM THESE INFANTS ON a
THE CACFP? X YES NO X
14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? '
PREPARATION AT FEEDING LOCATION YES X NO i
PREPARATION AT CENTRAL KITCHEN ,
(WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
•
—amErR g ftpciao2CTTRWITH LOCAL SCHOOL SYSTEM EACH MEAL?
UNDER CONTRACT ITH FOOD SERVICE CATERER YES X NO
(SU6MT COPY of CONTRAWn
17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child ano Adult Care Food Program food service functions in this center.)
1 I NUMBER OF I YEARS
NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF iN : IN THIS
FOOD SERVICE DUTIES THIS POSITIONI POSITION I
As required per Distri :t Contract
Teacher/Teacher Aide located on site servinn children food f vary
Lunch Aide located on site serving rhildrpn fonri 1 wary •
18.IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE)_PRICING(Please contact our office for further instructions at 331-8351) I
X NONPRICING
In a pricing program,centers establish a charge senaratn from tuition for meals in order to make uo the difference between the reimbursement provided by the CACFP and the I
actual cost of serving the meals.In a nonpnang program,families pay a general tuition charge that covers all areas of child care services provided by the center,including
meals.There is no identifiable separate charge for meals served to any children in care.
19.All participating centers or sponsors are eligible to receive advance payments.Advances are reeuested monthly by filling out an advance form. The
amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:If you are a single,independent center.complete the Preawara Compliance Review rather than this section.
PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBLIC SCHOOL DATA,
HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAUETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
dIMATE ACTUAL
Amencan Indian or Alaskan Native ll
Asian or Pacific Islander �j
Black(not of Hispanic ongin)
I
Hispanic
R/0
°
White (not of Hispanic ongin)•
CACFP-301 (4/92) WHITE-CDH-CACFP YELLOW- APPLICANT Ql d1 %3
COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate. If a sponsored facility,the-original (and required attachments) must be submitted with CACFP 302
(Application for Sponsor of Child and Adult Care Centers).Type or print dearly.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS Yp NO
Ft. Morgan (Migrant Only) CHILDREN/INFANTS ON A REGULAR BASIS? =
WILL YOU CLAIM THESE CHILDREN/INFANTS
Site to Be Determined in May 1992 ON THE CACFP?
i___
TELEPHONE NO.: • 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES ENO
Shift care means that cnildren are coming and gong at all times of me day so mat me
I COUNT'', NiO rclan - ,.otal numoer of cmlaren attending the center on a daily basis may exceed the license
2.NAME AND TITLE CF CONTACT PERSON AT CENTER =man..
a. HOURS OF OPERATION
• To Be Hired FROM 7:00 a.m. To 4:00 n.m.
3.--EAC START PROGRAM • 3. NUMBER OF OPERATING 10.NUMBER OF OPERATING
_'.nGRANT HEAD START PROGRAM DAYS PEP WEErK WEEKS PER YEAR
HOW MANY HEAD START CLASSROOMS DO YOU HAVE?_
i HOW MANY ARE AM?_ _ HOW MANY ARE PM?___3__ '.1.ANNUAL DATES OF OPERATION
HOW MANY ARE FULL DAY? 3 STARTING May 31st ENDING August 31st
NUMBER OF CHILDREN IN EACH CLASSROOM will vary '
Is your mead Stan she licensed as a mid ore center by the Colorado Department 19. ..:ST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
of Social Services curing nines wren Help Start is not in session? AND SNACKS FCR REIMBURSEMENT
YES v0_ • •Incude Cates at closing and reopening)
4.ACE RANGE OF ENROLLED CHILDREN I N/AFROM D TO 5
5.00 YOU CARE FOR INFANTS FROM BIRTH YES NO 13.. HAS THE NAME OF:HE CENTER OR SPONSOR CR OWNER
THROUGH 12 MONTHS? X - CHANGED?
•
WILL YOU CLAIM THESE INFANTS ON YES X NO i
THE CACFP? __X-,
14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
-PREPARATION AT FEEDING LOCATION YES __X__NO
PREPARATION AT CENTRAL KITCHEN
- WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
X ',0NDEi CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL?
>UBIAIT COPY OF CONTRALTI
YES X NO
',)NOE9 CONTRACT WITH FOOD SERVICE CATERER
UeMll`COPY OF CO TRACT)
17. F000 SERVICE STAFF PATTERN(Only enter staff who will pertorm Child and Adtui Care Food Program food service functions in this center.)
j NUMBER OF i YEARS
•
NAME OF POSITION NAME OF PERSON SPEC:FIC CACFP i STAFF IN ! IN THIS
=DOD SERVICE DUTIES THIS POSITIONI POSfO"I
As required per District Contract
Teacher/Teacher Aide j located on site serving children food I 7 vary
1
18.IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE)—PRICING(Please contact our office for further Instructions at 331-8351)
__X_NONPRICING the CACFP and the
In a onong program.centers estaOlian a champ sap sn 1mIDA76100for meals in order to make uo the difference penmen the rein bur»ment provided by
aural cast of serving the meals.In a naipnarng program,tansies pay a general tunny;charge that covers all areas C child care swvios provided by the center,Intudi g
meals.There Is no idenolieole smarms charge for meals served to any Children in ore.
19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money shad not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimbursement
20.CIVIL RIGHTS PLEASE NOTE:It you are a angle.imdapaord career,comPtats the Preewerd ComQaanda Review rather man the"dal '
PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBUC SCHOOL DATA,
HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
TE ACTUAL
Arrencan Indian or Alaskan Native 1(
Man or Putt Islander 91170Black(not of Hispanic ongin)
Hispanic
Norte (not at Hispanic origin)
CACEP-301(4/92) WHITE-CDH-CACFP YELLOW- APPLICANT .)
COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM
•
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate. If a sponsored facility,thebhginal (and required attachments) must be submitted with CACFP 302
(Application for Sponsor of Child and Adult Care Centers). Type or onnt clearly.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS YES NO
St. Augustine's (Migrant Only) CHILDREN/INFANTS ONAREGULARBASIS? ..2-..-
675 Edgbert WILL YOU CLAIM THESE CHILDREN/INFANTS Brighton, CO 80601 ON THE CACFP? 25,_ -
TELEPHONE.NO.: 303 659-7167 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES ) ,'!.ICI
COUNTY:
Shift care means that cm oren are coming and going at all times of me clay so that me
co LINTY: Adams Ural numoer of children aherning the center on a daily basis may exceed me license
2.NAME AND TITLE CF CONTACT PERSON AT CENTER cacacuty.
3. HOURS OF OPERATICN
To Be Hired FROM 7:00 a.m. TO 4:00 O.M.
3.—.-EAC START PROGRAM 3. NUMBER CF OPERAr'G 10. NUMBER OF OPERATING
V MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 • WEEKS PER YEAR 1?
H LA
OW MANY HEAD START OSSROOMS DO YOU HAVE' 4
.IOW MANY ARE AM?_ 4 HOW MANY ARE PM? '1 ••. ANNUAL DATES OF -PERATICN
:-IOW MANY ARE FULL DAY, STARTING May 31st October 1st
NUMBER OF CHILDREN IN EACH CLASSROOM Will vary
ENDING
:s your Head Stan site licensed as a cm°care center try me Galarado Oeoartment 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
of Social Services clung times when Head Stan is not in session? • AND SNACKS FOR REIMBURSEMENT
YES�—NO— ,Include awes of closing anti reopening)
4.ACE RANGE OF ENROLLED CHILDREN i N/A
FROM 0 TO 5 ,
5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE ENTER OR SPONSOR OR OWNER
THROUGH 12 MONTHS? X CHANGED?
WILL YOU CLAIM THESE INFANTS ON YES NO
•
THE CACFP'r X
•
14.METHOD BY WHICH MEALS WILL BE PROVIDED F 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL'
PREPARATION AT FEEDING LOCATION YES X NO
PREPARATION AT CENTRAL KITCHEN
--(WHEN YOU NAVE MORE THAN ONE SITE) ' 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
X SueMlEr c6iR 0FRCAON W7H LOCAL SCHOOL SYSTEM j EACH MEAL?
'illER `7NTRACIT WITH FOOD SERVICE CATERER YES X NO
UEMifP OF CO TRACT •
7. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child arm Adult Care Goad Program moo service functions in this center.)
i NUMBER OF i YEARS
NAME OF POSITION I NAME OF PERSON SPECFC CACFP I STAFF IN I IN THIS
r000 SEPVICE D'JT:ES [THIS POSIONI POSmCN
As per District Contrsct i
Teacher/Teacher Aide located -on site . I servinn children food in vary
Lunch Aide i lnratari nn 5yta I servin0 children food 1 van/
• 18.IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE)_PRICING(Please contact our office for further Instructions at 331.8351)
X NONPRICING
In a Dnang program,centers sauollsh a charge S9aarn(mm.LNID0a fee meals in order to make up the difference penmen me reimbursement Wwlded by the CACFP and the
actual cost of serving the meals.In a nanoncflg program,tannin par a goners'baton charge that covers all areas of child care services provided by the center.including
meals.There is no identifiable saoYate energy ler mete served to any dtldren in pate.
19.All partapau g centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance tom.The
amount of advance money shall not exceed a typical mondrs rate of reimbursement and shall be deducted horn that month's claim for reimbursement.
20.CIVIL RIGHTS PLEASE NOTE:If you as a angle.independent Center.laontpete the Preaward Compliance Re'^ew rather than this semon. .
PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBUC SCHOOL DATA.
•
HOUSING AUTHORITY DATA,ETC.IN ADDITION.GIVE THE ACTUAL.RACIAUETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT.
ESTIMATE ACTUAL •
American Indian or Alaskan Native 5°I
Awn or Paafle Islander
Bladt(nal of Hispanic ongm)
Hispanic 90,°
White (not of Hispania ongfn)
CACFP-301 (4/92) WHITE-CDH- ACFP YELLOW- APPLICANT
COLORADO DEPARTMENT OF HEALTH CHILD & ADULT CARE FOOD PROGRAM
APPLICATION FOR CHILD CARE CENTER
•
•
INSTRUCTIONS: Complete in duplicate. if a sponsored facility the
Poriginclal and required attacnmentsl must be submitted 5 lrn CACFP 302i
(Application for Sponsor of Child and Adult Care Centers).Type
ly.
1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6. DO YOU CHILDREN/INFARE NTS ON SPECIAL NEEDS
REGULAR BASIS? '20 ,I
Hudson Elementary WILL YOU CLAIM THESE CHILDREN/INFANTS X -
300 Beach ON THE CACFP?
CO 80642 NO
Hudson, 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES X� -
3Q3 536-0440 Shift care means tnat cnildren are coming and going at all times or the day so that the
TELEPHONE NO.: children
Jesslon
total numoer of chit en n din the center on a°ally basis may emcee°the license
COUNTY: capacity.
2. NAME AND TITLE OF CONTACT PERSON AT CENTER 8.HOURS OF OPERATION 5:00 O.m
To Be Hired FROM
7:QQ a.m. TO --
9.NUMBER OF OPERATING 10. NUWEEBER OF KS PER OPERATINGYEAR
3..-MIGRANT START PROGRAM DAYS PER WEEK 5
HOW HEAD START PROGRAM
li HOW MANY HEAD START CLASSROOMS DO YOU HAVE?C 11.ANNUAL DAT S OF OPERATION S en teRlber 31s t
HOW MANY ARE AM? 2 1�OW MANY ARE PM? DATES 1st ENDING
HOW MANY ARE FULL DAY? L STARTING
•NUMBER OF CHILDREN IN EACH CLASSROOM-J.5--
, 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
!s your Heao Stan site licensed as a child care center by the Colorado Department AND SNACKS FOR REIMBURSEMENT
of Social Services dun 1
g times wnen Heaa Start is not in session? (Include dates of closing aria reopening)
YES ULNO—
( 4.ACE RANGE OF ENROLLED CHILDREN N/A
FROM°_TO
5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER
X CHANGED? X
THROUGH 12 MONTHS?
WILL YOU CLAIM THESE INFANTS ON x YES NO
THE CACFP?
14.METHOD BY WHICH MEALS WILL BE PROVIDED
15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
YES __X-NO
AT FEEDING LOCATION
PREPARATION AT CENTRAL KITCHEN-- 5u DfP cb�I OF 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR
(WHEN YOUr[H�ANVE MORE THAN ONE SITE)
ACT WITTH LOCAL SCHOOL SYSTEM EACH METAL? NO
N4fAY &et�TRAw V�ITH FOOD SERVICE CATERER
� u Ica FcoTtun
NUMBER OF I YEARS
17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program rood service functions in this center.)
SPECIFIC CACFP STAFF IN .N THIS
NAME OF POSITION
NAME OF PERSON FOOD SERVICE DUTIES THIS POSITION/POSITIOt
As re uired er Distri vary
Teacher/Teacher Aide located on site s r '
Lunch Aide PRICING(Please contact our office for further instructions at 331.83511
t B.IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE)__X—NONPRICING
In a o program program families pay a general tuition charge that covers all areas of child care services provioee by the center,including
centers establish a charge senate from tuition for meals in order to make up the difference between the reimbursement Provided by the CACFP and t e
cing actual cost Theret serving the meets.In a charge for meals served to any children in care.
All participating identifiablenteor pons 9 payments.Advances are requested monthly by filling out an advance form.The
I'I 19.All centers e shall n are eligible typicalto re ion advance
amount of advance money shall not exceed a month's rate of reimbursement and shall be deducted from that month's claim for reimbursement.
it 20.CIVIL RIGHTS PLEASE NOTE:If you are a single.independent center,complete the Preaward Compliance Review rather than tnis section.
PROVIDE AN HOUSING AUTHORITY DATA, RCAL/ETFINIC MAKEUP OF THE CHILDREN TO BE SERVED FROM
GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF SOURCES
CURRENT ENROLLMENT.DATA.PUBLIC SCHOOL DAT,
ES,TtMATE ACTUAL
1. ***NOTE: Actual varies according to
American Indian or Alaskan Native ,o �_ program Head Start VS Mieran
Asian(n Pacific Islander _�— Head Start
Black(not of Hispanic origin) —_
White (not
�
-------
White (not of Hispanic origin) ---
WHITE-CDH-CACFP YELLOW- APPLICANT 920:33
CACFP-301 @192)
STATE OF COLORADO
DEPARTMENT OF SOCIAL SERVICES oeC24,0
1575 Sherman Street e �C9•
Denver, Colorado 802 03-1 714 m�-r-
Phone (303) 866-5700 '\+v
.787E%
Roy Rorner
Covernor
Irene M. IbarrR
Executive Dnecor
May 9 , 1990
Ms . Terri Keller
Weld County Head Start Migrant Program
520 13th Ave.
Greeley, Co. 80631
Dear Ms . Keller:
Subject: License No. 58236
This letter is in response to your recent inquiry regarding the
status of the license for Weld County Head Start Migrant Program..
Rule 7 . 701. 32-B of the Licensing Rules of General applicability
states that:
If the completed and signed application for renewal of the
license and appropriate fee are received by the Department
before expiration of the license, the application is timely
and the license continues valid until licensing action is
taken by the Department.
The child care license was to expire on August 11, 1988 .
However, a renewal application was received on June 7 , 1939 so
the license continues valid until licensing action can be taken.
An inspection visit will be made in the future. The license will
be renewed only after the licensing evaluation can be conducted
and any areas found in violation of licensing regulations can be
corrected.
Sincerely,
Sharon Chavez
Licensing Specialist
Office of Child Care Services
9
COLORADO DEPARTMENT OF SOCIAL SERVIC
Cws-A7 (REV. 8:75'REPORT OF INSPECTION 7 .J %J�'7 /C./ /7/
DEPARTMENT ` .0 f�ffG7 t •F SOCIAL =maces
L NSING UNIT , D
AooREss 1575 SHERMAN STREET ��v
DENVER COLORADO 80201
FACILITY NAME
4,a in: FrILLtane. il Al_e_71(_th,(ir i (Lid 4a.-7-(1,/ -27ta-dc-rai-j, Ma/85,
FACILITY .40053E-C;
LICENSIN REPRESENTATIVE
75CXL RSO S L r
DATE PERSON'S; INTERVIj:w O 77
a5 5) _ AM ; r Hk iyl
AN INSPECTION WAS MADE OF THE ABOVE-NAMED FACILITY-13i ACCORDANCE ITN 266107 C.R.S. 1973 AS AMENDED. INSPECTION
THE FACILITY DESIGNATED ABOVE DISCLOSED THE FOLLOWING LICENSING JANDARD VIOLATIONS WHICH ARE ITEMIZED BELOW,A LG
Must BE CORRECTED BY THE DATE INDICATED:
Type of license to be issued: / /ltd.,_ __ /j�.�,//�/cp ,--1-
Date of issuance: (7C7i,c J ,---, . . 7(/,/ix iAl_'-� `4� ^�� --S__--
Capacity: <=-9G
Age range: 6 t. ;. _, - _.-?/- 1'res:,, _/
/dim A-ac.,A, -3/-;x...; IC
Please complete all items listed on the enclosed report of inspection as
indicated. Upon completion of all items, submit a written verification of
compliance to the State Department of Social Services by 712.7,2,
in your written report of compliance, specifically address each item listed
on the enclosed report of inspection.
Further corents:
i ..� (7//irte 2"4,„ 75„c}2.4-7" Zy2-4-1"-- 7///-2/44-ela-31-k- /'
4 - +
i,�� Fyn 7 - ( /- -
r 75
// <1_6C,C am-to
L""" Z.J.7/ / .tta_c-7 l j.'72.)Ve,0 -art r' Ay-K___ r _7 .,.5
WHEN CORRECTIONS HAVE BEEN COMPLETED.PLEASE INFORM THIS OFFICE IN WRITING
$20899
COLORADO DE R_AR WENT OF SOCIAL SERVICE'
CwS-A7 I RE V. 8:751
REPORT OF INSPECTION / I , , J2 ,7L),-(1. /:;-( 'C
! / /Lit Cif-A� ., `P /,-f//.
DEPARTMENT Lr4 DEHl. 'OF SOCIAL $E� � S
LICENSING UNIT Ct� ,7, _ : "
ADDRESS 1575 SHERMAN STREET — CITY �i l
DENVER COLORAtz R0703
FACILITY NAME
1
/ / r
, —
FACILITY ADDRESS,
•;�'�- 1 �._L.. �. / _..._ �i
/
LICENSING-REPRESENTATIVE
GATE PERSONISI INTERVIEWED ^
-
i�6
AN INSPECTION WAS MADE OF THE ABOVE NAMED FACILITY IN ACCORDANCE WFTN 346107 C.R.S. 1973 AS AMENDED. INSPECTION OF
`
THE FACILITY DESIGNATED ABOVE DISCLOSED THE FOLLOWING LICENSING STANDARD VIOLATIONS WHICH ARE ITEMIZED BELOW AC
N
MUST DE CORRECTED BY THE DATE INDICATED:
Type of license to be issued: •
Date of issuance: _
Capacity: - -
Age range: -- -
Please complete all items listed on the enclosed report of inspection as
indicated. Upon completion of all items, submit a written verification of
compliance to the State Department of Social Services by
In your written report of compliance, specifically address each item listed
on the enclosed report of inspection.
•
Further comments:
1.
( /--/[1, �/ �.'):T,,. ;l_l ;./ �1••� �7s_.ti--tom_ 1 �/n_.—/1�
i
IRECTIONS NAVE BEEN COMPLETED. PLEASE INFORM THIS OFFICE IN WRITING
920
8.99
EF 1 COUNTY: 01 ADAMS
- STATE OF COLORADO
L.PARTMENT OF SOCIAL SERVICES
a +• 1575 SHERMAN STREET
*W.* DENVER, COLORADO 80203
*
1876 *
PROVISIONAL CHILD CARE LICENSE
WHEREAS It appears from the application and the supporting information thereto, of
ID: 77738
ST AUGUSTINES MIGRANT HEAD START
520 13 AVE LICENSEE LOCATION:
GREELEY, CO 80631 675 EGBERT, BRIGHTON
Who appears to be temporarily unable to satisfy certain requirements for license and the said applicant has sub-
mitted a plan for meeting the said requirements which has been approved by the Department of Social Services,
and which is within the discretion of the said department, the said applicant is:
HEREBY GRANTED A PROVISIONAL LICENSE,subject to the provisions of"Exhibits"herein,to operate for a term
of six months commencing 04-16-1992 and expiring 10-16-1992unlessthis license is sooner
surrendered or revoked, a DAY CARE CENTER at 675 EGBERT,
BRIGHTON , Colorado, upon said premises only, and is authorized to receive children for
care, under the supervision of the Department of Social Services subject to the following terms and conditions,
and/or restrictions:
The provisions of the Child Care Act,and the rules,regulations and standards of the Department of Social Services
shall be complied with by the licensee at all times.
This license shall be displayed in a conspicuous place upon the licensed premises and shall be surrendered by
the licensee to the Department of Social Services upon expiration, revocation or suspension.
This license is not transferable.The licensed premises and the records thereof shall be open to inspection at all
times to the Department of Social Services or its authorized representatives.
Other Conditions or Restrictions:
The number and age of children cared for upon said premises shall at no time exceed:
10 INFANTS OF THE AGE 2 MONTHS TO 1 YEAR 6 MONTHS
9 TODDLERS OF THE AGE 1 YEAR TO 3 YEARS
31 CHILDREN OF THE AGE 2 YEARS 6 MONTHS TO 4 YEARS
Exhibits: Codes below are conditions of the provisional license.
COMPLETE STAFF MEMBERS' FILES
INSTALL OUTSIDE PLAY EQUIPMENT
REVISE WRITTEN POLICY STATEMENTS
SUBMIT WRITTEN POLICIES
PREVIOUS LICENSE CONTINUED VALID DUE TO RECEIPT OF TIMELY APPLICATION.
IN TESTIMONY WHEREOF,at Denver,Colorado,This 24TH APRIL day of 19 92 by offi-
cial act, the Department of Social Services, a part of the Executive Department of the State of Colorado, the
authorized officers of said department have hereunto subscribed their hands.
DEPARTMENT OF SOCIAL SERVICES
Attest:
n
/V.
Administrator of Licensing
POST IN f PR )MIN7N- LOCA71DN •
920899
COLORADO DEPARTMENT OF SOCIAL SERVICE
CwS-A7 I RE V. 81751
REPORT OF INSPECTION f `'R/
DEPARTMENT O DEPT. F SOCIAL SEAI/1C ES
LICENSING UNIT -1tt ---/
ADDRESS 1575 SHERMAN STREET CITY
DENVER COLORADO 8O703
F ACIL IT NAME
'
FACILITY ADDRESS 7
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LICENSING REPRESENTATIVE
DATE PERSONISI INTERVIEWED
AN INSPECTION WAS MADE OF THE ABOVE-NAMED FACILITY IN.ACCORDANCE WITH 26-6-107 CR.S. 1973 AS AMENDED. INSPECTION OF
THE FACILITY DESIGNATED ABOVE DISCLOSED THE FOLLOWING LICENSING STANDARD VIOLATIONS WHICH ARE ITEMIZED BELOW ANC.
MUST BE CORRECTED BY THE DATE INDICATED:
Type of license to be issued: _
Date of issuance: ,
Capacity
Age range: .
Please complete all items listed on the enclosed report of inspection as
indicated. Upon completion of all items, submit a written verification of
compliance to the State Department of Social Services by - -
In your written report of compliance, specifically address each item listed
on the enclosed report of inspection.
Further comments:
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WHEN CORRECTIONS NAVE SEEN COMPLETED. PLEASE INFORM THIS OFFICE IN WRITING 92O398
CPD:79 (9/80)
COLORADO DEPARTMENT OF HEALTH
SANITATION SURVEY /U-7 F
CHILD CARE CENTERS /9 - T ,y
FOOD SOURCESt
ids LI. Cain �CwLn'-- /- 29
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Name: I
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if,Ict A ) Address: ?Qty ,&ttc:. G _JC✓7
Operator: r tN ti , f i/ fie' :4/a, ' Rix[mitt
An inspection of your operation on this date revealed the follow ag defects fetch you are he by
ordered to correct.
I TEYI
1. molests sue auluuu (C) S
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Date: ( w 21 : �� ��ti 9..'n
o ���"'\\\ Derator Sanitarian
COLORADO DEPARTMENT OF SOCIAL SER Vic-cS r
CWs•a7 (REV. 81751
REPORT OF INSPECTION /I I L L 3,_// ����
F_SOC1Al SOMME- 4.._ LICENSING UNIT - - ) • • ze %P oQi
ADDRESS ._1575 SHERMAN STREET - . CITY
—DENVER COCORAbQ RO2O1
FACILIT NAME —
•
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.a FAC,LI Y AODR 5 (.1C'
LICE ``l!REPRESENTATIVE r/ ,c.�/
DATE. PERSONISI ICIRVI EO -Jain i/eL
'�0 I
AN INSPECTION WAS MADE OF THE ABOVE-NAMED FACILITY IN ACCORDANCE WITH 266107 C.R.S. 1971 AS AMENDED. INSPECTION OF
THE FACILITY DESIGNATED ABOVE DISCLOSED THE FOLLOWING LICENSING STANDARD VIOLATIONS WHICH ARE ITEMIZED BELOW ANC
MUST BE CORRECTED BY THE DATE INDICATED:
Type of license to be issued: 6 /t7i;,i y_/ fJrr/i,li,,k,e/
Date of issuance: 60/ 4 ,2,j c'`- ../t_z /}uc— &- Q/r<n4za-# atifi iJ
O 6) / /.
Capacity - Q -
Age range , 1, i S --3/ rnrA- ---/htr-.t le6_4_ - /0/4,t iS
%„'14 i. Mm a/r.,n/R - 36 ma /o
Please_complete all items listed on_the enclosed report of inspection as
- indicated.--'Upon..completion of all items,-submit a written verification of - - - -
sa ---._ 7-e2S'9z -
comnliance to the -State-Department of Social Services by
-In your written report of compliance, specifically address each item listed
_Lost the enclosed report-ofinsDection
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WHEN CORRECTIONS HAVE BEEN COMPLETED, PLEASE INFORM THIS OFFICE IN WRITING
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COLORADO OEPARTMENT OF SOCIAL SERVIC'
CWS-A1 IREv. 81131
REPORT OF INSPECTION , d) (7 / (`Q.!? /�- 4. y/'.
CU DO DgRT. OF SOCIAL SERViCEs
DEPARTMENT
LICENSING UNIT fled._ . <7171,-2:
.OGRESS 1575 SHER?RAN STREET CITY
DENVER COIORAOO 802(11
FACILITY NAME
/
FACILITY
ADDRESS
/`'•-c<•'.2c�c. �/ !% / kb, / A,4 7. � .aiT�-rif;/k6 - ecel"
FACILITY AGGRESS
7
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LICENSING REPRESENTATIVE J+ �'�k�l
J \ • / ;L — -�
DATE PERSONISI INTERVIEWEE
AN INSPECTION WAS MADE OF THE ABOVE-NAMED FACILITY IN ACCORDANCE WITH 366101 C.R.S. 1913 AS AMENOED. INSPECTION OF
THE FACILITY DESIGNATED ABOVE DISCLOSED THE FOLLOWING LICENSING STANDARD VIOLATIONS WHICH ARE ITEMIZED BELOW ANC
MUST BE CORRECTED BY THE DATE INDICATED:
Type of license to be issued: ;
Date of issuance:
. ,
Capacity:
Age range:
Please complete all items listed on the enclosed retort of inspection as
indicated. Upon completion of all items, submit a written verification of
compliance to the State Department of Social Services by — , _ y
In your written report of compliance, specifically address each item listed
on the enclosed retort of inspection.
Further comments:
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WHEN CORRECTIONS NAVE BEEN COMPLETED. PLEASE INFORM THIS OFFICE IN WRITING �
920899
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COLORADO OE pARTMENT OF SOCIAL SER VII _ i M } - 'CwS-47 IRV., cif 79i } ,�
Y �( :.
REPORT OF INSPECTION r r ' r SOCIAL` ��/�/��r./cis /lT/ �-_r« a
DEPARTMENT F SOCIAL SEAV10ES !
LICENSING UNIT /-f<%� °/L�4'
ADDRESS 1575 SHERMAN STREET CITY J
DENVER COLORADO R071fl /
FACILITY NAuE _ ^ /
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FACILITY ADDRESS - , - /I�/
.-mss./ 7 - �, i , r/' ; -L/
LICENSaNG REPRESENTATIVE
DATE PERSONISI INTERVIEWED - II
-
E:
AN INSPECTION Ww5 MADE OF THE ABOVE-NAMED FwCILIYT IN ACCOROANCE NCE WITH Z66+07 C.R.S. 1973 AS AMENDED. INSPECTION OF
THE FACILITY DESIGNATED ABOVE DISCLOSED THE FOLLOWING LICENSING STANDARD VIOLATIONS WHICH ARE ITEMIZED BELOW ANC.
MUST BE CORRECTED BY THE DATE INDICATED:
Type of license to be issued: _ • - • _ .• •
_ -
/ n . ;^h ^ ...,^r .
Date of issuance: „ . . - •
Capacity:
Age range:
Please complete all items listed on the enclosed report of inspection as
indicated. Upon completion of all items, submit a written verification of
compliance to the State Department of Social Services by _a-.
In your written report of compliance, specifically address each item listed
on the enclosed report of inspection.
Further comments:
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STATE OF COLORADO
Department of Social Services a'
e7'
•
Office of Child Care Services
1575 Sherman Street.First Floor G'r ''
Denver.Colorado 80203-1714 j I
! THIS OFFICEIWNRITIMC :£y�
Roxanne Yates 7S
Licensing Specialist (303)866-4680
COLORADO OEPARTMENT OF SOCIAL SERVICE. ,C‘..4
CWS-.7 (REV. 8.151 ,J
REPORT OF INSPECTION /4Z( / . /JJ add % )i.
A, .1LPN r 3r ..
• .Q . 1 ..DEPARTMENT AII - F SOCIAL sonnets-1
LICENSING UNIT
ADDRESS 1575 SHERMAN STREET CITY
DENVER C0LORAb0 802(14
FACILITY NAME
/
J;YH, C. /�I,1cZ nay �, _ r 72�aMrn:1 -4 4
FACILITY ADDRESS
v,'
LICENSING REPRES�EnTATIVE / rt
-r/r ✓^rN•' it 1 :
DATE PERSONISI INTERVIEWED r
/j -77!_- , .;r1, <r- .grin - K torn// ;I�trr YLV:Z..-' - �c
AN INSPECTION WAS MADE OF THE ABOVE-NAMED FACILITY IN-ACCORDANCE WITH 76-6-107 C.R.S. 1913 AS AMENDED. INSPECTION OF
THE FACILITY DESIGNATED ABOVE DISCLOSED THE FOLLOWING LICENSING STANDARD VIOLATIONS WHICH ARE ITEMIZED BELOW ANC.
MUST BE CORRECTED BY THE DATE INDICATED:
Type of license to be issued:
Date of issuance: 7--, — y_ ',.,�
Capacity: • — '
Age range: /. - < - R, 2 _ �,I- :w = ,, ^
- rw -T-r-
r
Please complete all items listed on the enclosed report of inspection as
indicated. Upon completion of all items, submit a written verification of
compliance to the State Department of Social Services by 7-.j 3
In your written report of compliance, specifically address each item listed
on the enclosed report of inspection.
Further comments:
) 4 /:
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(Ii,fh rf1 ! / 7fRi. 4:24;1a-J)11-:--7 C./ 74, /n /7/1n.a?
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CI I' U 1 ,_/.,�
STATE OF COLORADO '
Department of Social Services
Office of Child Care Services , `
1575 Sherman Street, First Floor COO
Denver,Colorado 80203-1714
7a A•
INFORM THIS OFFICE IN WRITING
Rosanna Yates 92MM
Licensing Specialist (303)866.4ga -
7f AJ._YJJ.r S4c-o _ _.__ __
� c MEMORAnDU
�
Board of County Commissioners September 16, 1992
Illik To George Kennedy. Chairman Date
COLORADO From Walter J. Speckman, Executive Director, Human Resources (1J01 k
Purchase of Service Agreement between FENWC and Child and Adult
sonject:
Care Food Program
Enclosed for signature is an agreement between the Colorado Department
of Health, Child and Adult Care Food Program and the Family Educational
Network of Weld.County, for reimbursement to FENWC of meals served to
children. This is an on-going Agreement.
If you have any questions please call Tere Keller-Amaya at 356-0600.
920899
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