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Home My WebLink About940850.tiff RESOLUTION RE: APPROVE AGREEMENT FOR SPONSOR OF CHILD CARE CENTERS BETWEEN FENWC AND COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 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 an Agreement for Sponsor of Child Care Centers between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Family Educational Network of Weld County (FENWC) , and the Colorado Department of Public Health and Environment, Child and Adult Care Food Program, with 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 Agreement for Sponsor of Child Care Centers between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Family Educational Network of Weld County (FENWC) , and the Colorado Department of Public Health and Environment, 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 b the following vote on the 12th day of September, A.D. , 1994. M444 BOARDOF COUNTY COMMISSIONERS ATTEST: WELD COUNTY, COLORADO I , Weld County Clerk to the Board ')i I) AC );I/ W. H. Webster, C irm BY:Aput Tito the Board Sr Dale K. Hall, Pro m APPROVED AS TO FORM: _ 7l ^Zz/tea ,/Geor eZBaxter.(I- -? lid County At-forty Constance' L. Harbert yer / O dbara J. Kirk 940850 et; /is gilAfeLgatil • u.vivv„? Chat Adulteartfo0d.Pinian. Certificate and Statement of Authority Check Correct Box: ® NonProfit Organization U Church U For Profit Organization I, (We), the undersigned, state that the child care center(s) listed on Schedule A of the Agreement (CACFP 300) is an integral part of, and therefore under the direct control of, the governing body of the Weld County Division of Human Services' Family Educational Network of Weld County (Name of the Organization.Business or Church) whose address is 1551 North 17th Avenue, P.O. Box 1805, Greeley, Colorado 80632 - (Street or Route) (City) (Zip Code) ( 303 ) 353-3800 (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 re- ceived. The individual(s) whose name and signature appears below is authorized to sign the Claim for Reim- bursement. AUTHORIZED REPRESENTATIVE(S)1. CR.Gtr ' l Signature (I Tere Keller-Amara � 111 Sign e / n una-Fla er Print Name Print Name Director of FENWC Site 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 fully-empowered to enter into any agreement with the Colorado Department of Public Health &Environment CACFP and may act for the above-mentioned center or sponsor in preparing and signing documents and reports pertaining to the management of the CACFP. When there is a change of Authorized Representative,it shall be the responsibility of the center or sponsor to request from this office, Colorado Department of Public Health & Environment CACFP,forms to register the change. The signature of the Authorized Representative on the Claim for Reimbursement must match the signature on this form or the Claim cannot be processed and your reimbursement will be delayed. THIS BOX MUST BE SIGNED I(we) understand that the information on this form is being given in connection with the receipt of Federal funds and that all of the provisions of the Agreement (CACFP 300) apply. (/74W A/ /aj W.H. Webster Chairperson Signature of Chair of the Board of DDiriectorsog/ f 4/ Print Name Official Title or Pastor,or Executive Director,or Owner c glare/4 Date • (CDPHE•CACFP 306 8/94) 940850 Child &Adult Care Food PA J FOURTH MEAL DOCUMENT Please put sponsordr ...kcn"-teinteelabtUlietteia 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 individual child,you must ❑ 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 beginninn 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. See current reimbursement rates for snack.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 dine-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. ❑ NO,a fourth meal will nor be claimed. X❑ YES,a fourth meal will be claimed (One of the 4 meals must be a snack.) Type of meal Dinner Time of meal Effectivedate 6/20/95 — Sept 30, 1995 Migrant Head Start Only ❑ We keep time-in/time-out records. OR X The end of the first meal and the beginninn of the 4th meal are 8 hours apart When does first meal END? 8:00 AM When does 4th meal DEGIN? 4:30 PM (CDP}{F CACFP 8/94) 940R5o COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS Y*S NO Billie Martinez CHILDREN/INFANTS ON A REGULAR BASIS? 341 14th Avenue WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? _ Greeley, Colorado 80631 TELEPHONE NO.: ( 303 ) 351-1312 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES X NO COUNTY: We 1 d Shift care means that children are coming and going at all times of the day so that Inn total number of children attending the renter on a daily basis may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER cacacay. 8. HOURS OF OPERATION Dorothy Perez FROM 6:30 a.m. To 6:00 p.m. 3. x HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING .-Z--MIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR 52 HOW MANY HEAD START CLASSROOMS DO YOU HAVE?_ 40 HOW MANY ARE AM? 20 HOW MANY ARE PM? 20 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? 9 Aiirin€ 1r'grant STARTING ENDING NUMBER OF CHILDREN IN EACH CLASSROOM 1J Is your Head Stan 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 as session? YES_2;_NO— AND SNACKS FOR REIMBURSEMENT (Include dates of closing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN FROM 6 wks TO 5vrs N/A 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO p13, . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THROUGH 12 MONTHS? xCHANGED? WILL YOU CLAIM THESE INFANTS ON THE CACFP? x YES X 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 YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR Y (SUNDERIT CO TOFRACTR WI H LOCAL SCHOOL SYSTEM EACH MEAL? UUNDER CONTRACT WITH FOOD SERVICE CATERER YES x NO (SUBMIT COPY 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.) NUMEER 0= I YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF iN I IN THIS FOOD SERVICE DUTIES THIS POSITION(POSITION, As required by Distri ;t Contract 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 692-231,) X NONPRICING In a pricing program.centers establish a charge senamtP 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 no pncing 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 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 months claim for reimbursement 20.CIVIL RIGHTS 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 ADDfTION.GIVE THE ACTUAL RACIAL'ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL American Indian or Alaskan Native .05% Asian or Pacific'manner 1n' Black(not of Hispanic ongin) •85% Hispanic 71Z White (not of Hispanic ongin) 287< 'Visual identification may be Wed by centers or spormors to detemkne the child's re®Uethnic category.A&sld may be included in the group to wars he or sne appears to beroryiI,I identities with or is regarded in the community as belonging.Parents/Guardians may be asked to identify the racial/ethnic group of their own child after a has been explained.and they as • well as we understand that the collection of this intonation*strictly for drlatcal reporting requirements and has no effect on the determination of their eligibility to receive nenefes under the Program.As new children are enrolled,you will reed to determine their racial/ethnic background and keep the Information In a confidential place. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 94OR co COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YES NO Madison CHILDREN/INFANTS ON A REGULAR BASIS? 24th Avenue, & 6th Street WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? Greeley, Colorado 80631 — TELEPHONE NO.: ( ?O? ) ?S y_?79A 7.00 YOU CARE FOR CHILDREN IN SHIFTS? YES X NO— COUNTY: ma Shift care means that children we corning and going at as times d the®y so that the total nur der of quicken attending the oink*,on a obey Hass may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER capapay. B.HOURS OF OPERATION • Teresa Gutierrez FROM 6:30 a.m. TO 6:00 n.m. 3. x HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING -IL MIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR 52 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 HOW MANY ARE AM? 20 HOW MANY ARE PM? 90 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? 2 during Migrant STARTING NUMBER OF CHILDREN IN EACH CLASSROOM ENDING _15__ is your Head Start site licensed as a child rare center by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during times when Head Stan n not in session? AND SNACKS FOR REIMBURSEMENT YES$NO_ (Include dates of closing and 4.AGE RANGE OF ENROLLED CHILDREN reopening) FROM 6 wks TO 5yrs 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 THE CACFP? X YES X 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 YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR Y UNDER COPY TRACOF CilTnWI H LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMUNDER CONTRACT WITH FOOD SERVICE CATERER YES X NO (SUBMIT COPY OF CONTRACT) 17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program fooa service functions in this center.) NuMSER OF I YEARS NAMEOF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN\ IAN THIS FOOD SERVICE DUTIES THIS POSITION I POSITION' As per District Contract • • i • 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 691-233')) _ NONPRICING In a pricing program.centers establish a charge generate from tuncn for meals in order to make w the difference between the reimbursement provided by the CACFP and the actual cost or serving the meals.In a norpnong program,families pay a general tutlon charge that covers an areas of child care services provided by the center.Induaing meas.There is no identifiable separate charge for meals served to any children an 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 montn s claim for reimbursement. 20.CIVIL RIGHTS 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 ADDrTION.GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL American Inman or Alaskan Native .05% Asian or Pacific Islander Black(not of Hlspanuc ongm) .u5h Hispanic 71% White (riot of Hispanic ongin) 28% 'VnWI identllcaoon may be used by careers or sponsors to determine the chits racial/ethnic category.A olio may be included in the gmtp to wrc,he or she appears to beann. identifies with or e regarded in the community as belonging.Parents/Guamans may be asked to identify the racal/Ph=group of their own child after it naa been encored.and they as well as we urmenstan d that the coladlon of the aHomatuon is strictly for statistical reporting requirements and has no effect on the aelemimarnn of thaw ellgt uity to!acme canons under the Program.As new children ere enrolled,you will need to detrnrine emir radatlamnlc reground and kip this Ines aden Ina cenlfeemal Were. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 940> 50 COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS YYS NO Dos Rios CHILDREN/INFANTS ON A REGULAR BASIS? 2201 34th Street WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? Evans, CO 80620 TELEPHONE NO.: ( 'i0'1 ) vin-37911 7.00 YOU CARE FOR CHILDREN IN SHIFTS? YES X NC Weld Shift care means that children are coming and going at at times of the say so that the COUNTY: total minder of children meantime the renter on a dally basis may exceed Inc nfense 2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacM. 8. HOURS OF OPERATION Pat Sandoval FROM 6:30 a.m. TO 6:00 D.M. 3.X HEAD START PROGRAM 9. NUMBER OF OPERATING 10. NUMBER OF OPERATING EMIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR 52 HOW MANY HEAD START CLASSROOMS 00 YOU HAVE? 40 HOW MANY ARE AM? 20 HOW MANY ARE PM? 20 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING ENDING NUMBER OF CHILDREN IN EACH CLASSROOM —1.5..— Is your Head Start see licensed seached rare caner by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during tunes when Head Stan a rot n session? AND SNACKS FOR REIMBURSEMENT YES NO_ (Include dates of dosing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN N/A FROM 6 wks TO 5vrs 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 x NO 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 UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? )SUBMIT COPY OF CONTRACT) 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 and Adult Care Food Program food service functions in this center NUMBER C HEARS i NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN I N THIS l FCOD SERVICE DUTIES THIS POSLTIC\!FCSITION' As per District Contract I ! 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) -77-NONPRICING CING(Please contact our office for further instructions at 632-2aa'J) In a prong Program.centers establish a charge cumernte trnm tueion for meals in order to make up the difference between the reimbursement provided by the CACFP and the actual cost of serving the meals.Ina rorpnong program,families pay a general tuition charge that covers all areas of child care services provided by the center.Inducing 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 repuested monthly by filling out an advance tone.Tne 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 PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBLIC SCHOCL DATA HOUSING AUTHORITY DATA,ETC.IN ADDITION.GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROU MENr. ESTIMATE ACTUAL American Indian or Alaskan Native .05% Asian or Pacific islsnder Black(not of Hispanic ongtn) .OS% Hispanic 7 1 ///, While (not of Hispanic origin) 28/ 'Visual identification may be used by centers a Sporeois to determine the chins raca1/atnc category.A onto may be included in the group to which he or she appears to bepm. dentares with.or is regarded in the community as belO gag.ParentSGUWIarl may be asked to identify the recEl/ethvic group of their own child after if has been expenea and trey as I well as we understand that the collection of the nlormaton re airway for statistical reporting requirements and has no effect on the determination or thee elgbilsy to receive remiss I under me Program.As new children are enrolled.you will need to dstormi r their raCLlletnnic background and keep this Information Ina confidential pace. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 940F50 COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YjS NO Centennial CHILDREN/INFANTS ON A REGULAR BASIS? 1400 37th Street WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? Evans, CO 80620 TELEPHONE NO.: ( 101 ) rig_-ins 5 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES X NO_I She care means that children are coming and going at all times a me cat so trial the I COUNTY: Weld total nunoer of children attend rig the center on a daily basis may exceed the license l 2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. I 8.HOURS OF OPERATION Delia Vasquez FROM 6:30 a.m. TO 6:00 id.m. 3. X HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING —.L.—MIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR 52 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 HOW MANY ARE AM? 20 HOW MANY ARE PM? 20 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING ENDING NUMBER OF CHILDREN IN EACH CLASSROOM 15 is your Head Stan sae licensed as a rnlld are center by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services aunrg tines when Heat Stan a not in session? AND SNACKS FOR REIMBURSEMENT YES$NO— (Include dates of closing and reopening) 4. AGE RANGE OF ENROLLED CHILDREN • N/A FROM 6 wks TO 5yrs • 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 I CHANGED? I WILL YOU CLAIM THESE INFANTS ON YES X NO 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.....1I____NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR - UNDErR COv TRACT WWITH 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 and Adult Care Flood Program food service functions In mis center.) NUVEE;Cr I `EARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STA=;iN I N THIS FOOD SERVICE DUTIES THE CSTIC\I POSITION I As per District Contract 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 631-233')) —X NONPRICING In a pricing program.centers establish a charge sax mte from tuition for meals in order to make uo the dmerence between the reimbursement provided by the CACFP and the I actual cost of serving the meals.In a noflpnang program.Ramses pay a general tuition charge that covers ad areas of cmld care services provided by the center.Inauamg meals.There is no identifiable separate charge for meals Served to any children in care. 19.All parto:paling centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form. Toe amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that months claim for re.moursement. 20.CIVIL RIGHTS 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 RACIAL,ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. • ESTIMATE ACTUAL American Indian or Alaskan Native •05% • Asian or Pectic Islander • Black(not of Hispanic origin) 57. Hispanic 71% White (not of Hispanic origin) 28% I 'Vassal identification may be used by centers or sponsors to determine the Child's racist/antic category.A dial may be included in the group to whorl he or she appears to beam. canaries with ore regarded In the community as belonging.ParelnGuantans may be asked to identity me recelethnic group of their own child alter it has been weaned.are tnev as I ten as we understand that the collodion of this ntormatan Is strictly for statistical reporting requirements and has no effect on the detehnrnetvh or their elgonnv to raceme benefits I under me Program.As new children are enrolled,you will need to determine their racial/ethnic background andttsp mu Information in a confidental pace CACFP-30I(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 940F5{) • COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6. DO YOU RF YES NO Jet tenon 1315 4th Avenue WILL YOU CLAIM THESE CHILDREN/INFANTS Greeley, CO 80631 ON THE CACFP? TELEPHONE NO.: ( 303 ) 356-7408 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES X NO COUNTY: Weld Shan care means that children are coning and going at all times of the say so that the total number of children wending the center on a daily oasts may exceed Ina license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. 8. HOURS OF OPERATION Nelly Macias FROM 6:30 a.m. TO 6:00 p.m. 3. X HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING EMIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR 52 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 HOW MANY ARE AM? 20 HOW MANY ARE PM? 20 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING ENDING NUMBER OF CHILDREN IN EACH CLASSROOM 15 is your Head Stan site licensed asachild rare center byttb Colorado Department 12,LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS or Soaal Services dung times when Head Stan a not in session? AND SNACKS FOR REIMBURSEMENT YES g NO 4. AGE RANGE OF ENROLLED CHILDREN (Include Bates of closing and reopening) FROM 6 wks TO 5y re 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 WILL YOU CLAIM THESE INFANTS ON CHANGED? THE CACFP? x YES x 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 YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR Y. UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMIT COPY OF CONTRACT) 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 and Adult Care Food Program food service(unctions In this center. NUMEEER CR I `EARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN I .N THIS I FOOD SERVICE DUTIES THIS POSITION IPOSITION' As per District Contra:t 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 692-2330) —5C—NONPRICING In a pricing Program,centers establish a charge ittltiViilltit from tuition for meals in order to make LID the difference between the reimbursement provided by the CACFP and me actual cost of serving the meals.In a norpnorg program.tamales pay a general tutlon change that covers all areas Of child care services provided by the center.including meals.There is no identifiable separate charge tot meals served to any dtiklren n®re. 19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance ronn. Tne amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that months claim for reimbursement. 20.CIVIL RIGHTS 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 RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT ESTIMATE ACTUAL American Indian or Alaskan Native .05% Asian or Paatic Islander Back(not o1 Hispanic ongn) .QS% Hispanic 71��qq While (not of Hispanic ongn) 28%6 -Vial ederefaaaon may be used by centers a sponsors to daemons the child's relsavrhrac category.A child may be nduded in the group to anon he or ere appears to beang. semen with.a ts regarded in the commonly as belonging.ParrusiGu3R1®ns may be asked to identify the raceUethnc group of their own chid alter It has been emalned.and wrev as see as we understand that the collodion of this intomatton is strictly for statistical reporting requirements and has no effect on the detemwiatoh of their eligibility to receive reheats under the Program.As new children are enrolled,you will reed to determine their redallemnld background and keep this information In a confidential pace. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT g4oFcn COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) • 6.DO YOU CARE FOR SPECIAL NEEDS YES NO East Memorial CHILDREN/INFANTS ONAREGULAR BASIS? _ WILL YOU CLAIM THESE CHILDREN/INFANTS 614 East 1 20thg Street ON THE CACFP? • TEL P�Ig11 lt.C(p 3096)3 1 352-9478 j 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES X NC COUNTY' We 1 d Shat care masse that children coming coming and gang al all times of the clay so trial the total nurrner of midriff,attending the center on a way basis may exceed me license 2, NAME AND TITLE OF CONTACT PERSON AT CENTER Caber-ay. 8. HOURS OF OPERATION Annette Sandoval-Cline FROM 6 :30 a.m. TO 6:00 o.m. 3. ._HEAD START PROGRAM 9. NUMBER OF OPERATING 10. NUMBER OF OPERATING -MIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR 52 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 HOW MANY ARE AM? 20 HOW MANY ARE PM? 20 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? NUMBER OF CHILDREN IN EACH CLASSROOM � STARTING ENDING Is your Head Start she licensed stationed care center by the Colorado Department 12 LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during tines when Head Stan is not in session? AND SNACKS FOR REIMBURSEMENT YES I NO_ (Include dales of closing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN • FROM 6 wks TO 5yrs 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 THE CACFP? X YES X 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 YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR v UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? (Slain"COPY OF CONTRACT) UNDER CONTRACT WITH FOOD SERVICE CATERER YES X NO (SUBMIT COPY OF CONTRACT) 17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perlomt Child and Adult Care Food Program food service functions in this center. NUMSER OF I YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF iN I N THIS FOOD SERVICE DUTIES HIS PCSITIC\!POSITION! As per District Contract • I8. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 692-2330) -r-NONPRICING In a oncing program.centers establish a charge cenerete from notion for meals n order to make ub the difference between the reimbursement provided by the CACFP and the actual mat Of Serving the meat In a nonpnong program,families pay a general tuition charge that rovers all areas of child Care services Provided by the center,inoucing heat There is no immutable 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 lone. Tile amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that months claim for reimbursement. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACLAUETHNIC 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 been or Alaskan Native .05% Asian or Psalm'server Black(not of Hispanic ongm) .857, Hispanic 71e/y} Write (not of Hispanic origin) 2S%s • 'Vt1181 iderlofi®Wn may be used by Centers or Spore=to determine the chats raoaUrraac category.A chid may be included in the groin to wallah he or she appears to belong. identities with,or a regarded in the coMnsmity as belonging.ParontsGauamtana may be asked to identity the raceuethnn group of their own child aver it has been exbamed.and tries as i wet as we understand that the colleclpn of the information is strictly for statistical reporting requirements and has no effect on the determeeinn of their elgouM to receive amens under the Program.As new en wren are enrolled,you will ren to determine their racial/ethnic background and kip this'Nominee'In a eonederalal pace. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT: • 4&f ccn • COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS IS NO Island Crove CHILDREN/INFANTS ON A REGULAR BASIS? _ 119 14th Avenue(Head Start Only) WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? i Greeley, CO 80631 — TELEPHONE NO.: ( 383 ) 352-2675 7. 00 YOU CARE FOR CHILDREN IN SHIFTS? YES X NO—j COUNTY' Weld She care means that children are coming and going at all times or the ay so that the total simper of children amenldng the center on a dairy basis may exceed IM Iainse 2. NAME AND TITLE OF CONTACT PERSON AT CENTER arlanly. 8. HOURS OF OPERATION Nelly Macias FROM 6:30 a.m. TO 6:00 D.m. 3. X HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING MIGRANT HEAD START PROGRAM DAYS PER WEEK 6 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 WEEKS PER YEAR 52 HOW MANY ARE AM? 20 HOW MANY ARE PM? 20 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? NUMBER OF CHILDREN IN EACH CLASSROOM_15— STARTING ENDING Is your Head Start she 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 Danes when Head Start a not in session? YESgND_ AND�N�Aees04cFOR IosingaREIMBURSEMENT 4.AGE RANGE OF ENROLLED CHILDREN reopening) FROM 6 wks TO 5vrs 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? !F[ WILL YOU CLAIM THESE INFANTS ON THE CACFP? x YES X 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 YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM .EACH MEAL? SSUBMIT COPY OF CONTRACT) 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 and Adult Care Food Program fooa service functions in this center.j NAME OF POSITION NAME OF PERSON SPECIFIC CACFP ST AFFAFF NS . I I ;N THIS `ETHI ,:. S FOOD SERVICE DUTIES THIS POSiTC\IPOSITIOV As per District Contralct • • 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 691-23),J) — X NONPRICING In a oncmg program.centers esabssh a charge sate from t ininn for meals in order to make Up the dlaerence between the reimbursemMm provided by the CACFP and the I actual cost of serving the meals.In a norpnag progam.tamales pay a general tuition charge that covers all areas of child care services provided by ire center.'naming meat.There is no hdentitable separate charge tot 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. Tne amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month s claim for retmoursement 20.CIVIL RIGHTS 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 ENROLLMENIT. ESTIMATE ACTUAL Amercan Indian or Alaskan Native ,05% Asian or Pacific Islander • Black(not of Hispanic ongm) .867,, Hispanic 71 4 • White (not 01 Hispanic ongin) 2f83 lists Icerdlabon may be used by centers or sponsors 10 datemons the fields renal/ethnic category.A crib may be inducted in the gmtp to Mein he or she appears to beam. • identities with or a retarded in the community as belonging.Pareras,Guarmmns may be asked to identity me racaliethnc group of Them own child art has been amalned.and Bey as • Well as we urderstand that the collection of this overman Is strlddy for statistical reporting requirements and has no effect on the determination d heir esgcuM to receive cenelas Under the Program.As new children are enrolled,you will need to dawning their ractallothnlc background and keep this Information In a confidential place. CACFP-30I(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT oA EICCfl COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YYS NO Frederick CHILDREN/INFANTS ON A REGULAR BASIS? _ 340 MapleWILL YOU CLAIM THESE CHILDREN/INFANTS Frederick,CO 80530 ON THE CACFP? TELEPHONE NO.: ( 303 ) 833-2230 7.00 YOU CARE FOR CHILDREN IN SHIFTS? - YES X NO COUNTY: we 1 R Shift care means trot Weren are coning and goingat au times d Ine clay so thattrhe total number of merlin attendng the center on a catty oasts may exceed Ins license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER rapacay. To Be Determined 8.HOURS OF OPERATION FROM 6:30 a.m. To 6:00 o.m. 3. X HEAD START PROGRAM 9. NUMBER OF OPERATING 10. NUMBER OF OPERATING -.M.-MIGRANT HEAD START PROGRAM 40 DAYS PER WEEK 6 WEEKS PER YEAR 52 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? HOW MANY ARE AM? 20 HOW MANY ARE PM? 20 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAYS NUMBER OF CHILDREN IN EACH CLASSROOM 2 STARTING ENDING Is your Head Stan sae licensed as a due 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? YES.g NO_ AND SNACKS FOR REIMBURSEMENT (Include dates of closing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN FROM 6 wks TO 5vrs 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 THE CACFP? x YES X 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 YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR y UNDERO TOFRACTAWI H LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMIT CUNDER CONTRACT WITH FOOD SERVICE CATERER YES X NO • (SUBMIT COPY 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 C7 IYEEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF,N I .N THIS FOOD SERVICE DUTIES THIS POS.TICN I POSITIONi As per District Contract • 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 6si-2339) X NONPRICING In a pricing program.centers establish a charge gAnnmte from tuition for meals in order to make up the deference between the reimbursement provided by the CACFP and he actual Coe of serving the meas.In a ndnpnorg program.families pay a general tuition large that covers ell areas of child care services provided by the center.including meas.There is no Identifiable separate charge for meas served to any children in ave. 19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance torn. Tne amount of advance money shall not exceed a typical month's rate of reimbursement and snail be deducted from that mono s claim for reimoursement. • 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBLIC SCHOOL DATA I HOUSING AUTHORITY DATA,ETC.IN ADDITION.GIVE THE ACTUAL RACIALETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL American Indian or Aiasion Native .05% • Asian or Padlte[Slangier • n Black(not of Hispanic ongin) .(}D"/, • Hispanic 71T Whee (not of Hispanic origin) 2St -Usual kfenteicefhon may be used by ceders or spore=to ddemhee the cold's racaweniuc category.A one may be included in the group to veal he or she appears to belong. Identifies witlt or is recardea In the community as belonging.ParentaGuardsrs may be asked to identify the rdcel ethnic group of then own chid after I has been elpsirea.and they as • well as we understand that the collection of this i to/Rstlon is strictly tee statistical reporting requirements and nes no effect on the determinalpn of thew eigdlity to receive fiend as under the Program.As new children are enrolled.you will need to determine their reaMVehne bedegrounn and keep this Intomatlon Ina ccondentlel pace. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 4antcn COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YS NO Hudson CHILDREN/INFANTS ON A REGULAR BASIS? 300 Beech WILL YOU CLAIM THESE CHILDREN/INFANTS Hudson, CO 80642 ON THE CACFP? _ - TELEPHONE NO.: ( 303 ) 536-0440 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES X NO She care means that children are coming and going at all times a the aav so that me COUNTY: We 1 d ( total number of children wending the center on a say basis may exceed the ncense 2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. B.HOURS OF OPERATION Jildi Gentry • FROM 6:30 a.m. TO 6 :00 p.n. 3. X HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING EMIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR 52 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 HOW MANY ARE AM? 20 HOW MANY ARE PM? 20 11. ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING ENDING NUMBER OF CHILDREN IN EACH CLASSROOM--1-i_ to your Bead Sun site tcersed asadad care center by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Soda)Services during tunes amen Head Stan s not in session? AND SNACKS FOR REIMBURSEMENT YES.IL NO_ I (Include dates of closing and reopenig) 4.AGE RANGE OF ENROLLED CHILDREN NSA FROM 6 wks TO 5vrs • 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 x NO 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..._z____NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR v UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMITCOPY OF CONTRACT, 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 and Adult Care Food Program food service'unctions in this center.) NUMEEP:= Iv'EARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STA:F.r, I N THIS FOOD SERVICE DUTIES HIS PcS,tC\IPOSITION! As per District Contract 18. IS THIS A PRICING OR NONPRICING PROGRAM? (CHECK ONE) PRICING(Please contact our office for further instructions at 6)l-2010) X NONPRICING In a pricing program.centers establish a charge q inarat0 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 heals.In a nonpnorg program.families pay a general tuition serge that covers ae areas of child care services provided by Inc center.Inoudmg mean.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 aavance torn Tne 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 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. ESTIMATE ACTUAL American When or Alaskan Native .05% Asian or Pacific Islander • Black)not of Hispanic ongm) . 54 Hispanic 71 i W . (not of Hispanic origin) 28% 'Visual iderWicalen may be used by carters or sponsors to determine the child's ra iaLaresc category.A chid may be included in the group to whin he or she appears to mono I identifies with or s regarded in the connunay as belongs o.Parents/Guardians may be asked to nentiy the raceirethnk:group of mew own child after it has been expained and tnev as well as we understand that the collemon or Ins intonation is st tctiy for ateWLnl reporting requirements and has no effect on the detennlrelia,al melt etgdlay to receive oenel as under the Program.As new children are enrolled,Ku will need to determine their teclalletenlc background and seep this Information In a confidential pace. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 940S50 COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YS NO Milliken CHILDREN/INFANTS ON A REGULAR BASIS? (Head Start Only) WILL YOU CLAIM THESE CHILDREN/INFANTS 300 Broad ON THE CACFP? Milliken, CO 80543 587-2888 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES R NO TELEPHONE NO.: ( in-k1 Shift care means that children are wrong and going at as times ce rile day so Irai the COUNTY: Wel rl total:writer of dlllchen anendng the center on a daily bass may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacM. 8.HOURS OF OPERATION Elizabeth Segura FROM 6:30 a.m. TO 6:00 p.m. 3. x HEAD START PROGRAM 9. NUMBER OF OPERATING 10. NUMBER OF OPERATING -11-MIGRANT HEAD START PROGRAM 40 DAYS PER WEEK 5 WEEKS PER YEAR 52. HOW MANY HEAD START CLASSROOMS LAS HAVE? HOW MANY ARE AM? HOW MANY ARE PM 20 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING ENDING NUMBER OF CHILDREN IN EACH CLASSROOM 15 Is your Head Start site licensed as a mild care center by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services dung times when Head Start is not in session? AND SNACKS FOR REIMBURSEMENT YES_1L NO- (Include dates of closing and reopening) 4. AGE RANGE OF ENROLLED CHILDREN N/A FROM 3vrs TO 5yrs S.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THROUGH 12 MONTHS? x I CHANGED? WILL YOU CLAIM THESE INFANTS ON YES X NO 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 v UNDER CO oTRACiTTP WITH LOCAL SCHOOL SYSTEM EACH MEAL? • sNDMER CONTRACT WITH FOOD SERVICE CATERER YES X NO IT COPY17. 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 ,EARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF iN I .N THIS FOOD SERVICE DUTIES THIS FCS:TICN IPCSITION1 As per District Contrakt 1 I I 18. IS THIS A PRICING OR NONPRICING PROGRAM? (CHECK ONE) PRICING(Please contact our office for further instructions at 6 2-2d d'l) -NONPRICING In a pricing program centers establish a charge cementite from utiJ l for meals in order to make uo the difference between the reimbursement provided by be CACFP and the actual cost of serving the meals.In a rorpnong program.families pay a general tuition charge that covers ad areas of child care services provided by the center.Including meals.There is no identifiable separate ctarge for meals served to any children n care. 19.All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance torch. Tile 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 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 RACIAL/ETHNIC L BREAKDOWN OF YOUR CURRENT ENROLLMENT ESTIMATE ACTUA.05% American Indian or Alaskan Native Asian or Pacific Isanoer .057. Sack(not of Hispanic origin) 1 Hispanic 771% White (not dl Hsparuc ongm) -Visual ldentaicelon may be used by centers or sponsors to detemmra the chtld'9 re®Ydlwc category.A cruet may be included in the group to whorl he or tine appears to beam. identifies with,or is regarded in the community as belonging.ParemsRwardata may be asked to identity the racalethnc group of their own child after it nes been esDained.and may as well as we understand that to collection of Ins informationw f for statical aIr g reporting requirebmentsand no effect e Ina In a and has on the confidentialwndac to receive menetas children m under the Program.As new are oiled.you will reedto CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 940S59 COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6. DO YOU CARE.FOR SPECIAL NEEDS YES NO Gilcrest (Head Start Only) CHILDREN/INFANTS ON A REGULAR BASIS? 1175 Birch WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? Cilcrest, CO 80623 TELEPHONE NO.: ( 303 ) 737-2774 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES K NO shin care means that children are coming and gang at as times a Inc clay so that to COUNTY. Weld total turroer of ctildren attending to center on a oaay base may exceed ine license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. 8.HOURS OF OPERATION Lorraine Venzor FROM 6:30 a.m. To 6:00 D.In. 3. 8 HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING .I EMIGRANT HEAD START PROGRAM DAYS PER WEEK 5J' WEEKS PER YEAR 52 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 HOW MANY ARE AM? 20 HOW MANY ARE PM? ?0 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING ENDING NUMBER OF CHILDREN IN EACH CLASSROOM 15 Is your Head Stall she 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 a not in session? AND SNACKS FOR REIMBURSEMENT YES_,Z._NO_— (Include dales of closing and reopening) 4. AGE RANGE OF ENROLLED CHILDREN N/A FROM 6 wks TO 5yrs i 5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THROUGH 12 MONTHS? CHANGED? WILL YOU CLAIM THESE INFANTS ON YES X NO 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 ,c NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU NAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR x UNDER CONTRACT TRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? YES X NO UNDER CONTRACT WITH FOOD SERVICE CATERER (SUBMIT COPY 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 I NUMeE=.C= I YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP S'A.77. %I HISN IN THIS • I THIS FOOD SERVICE DUTIES :C I As per District Cnntrtrt I • 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 6r2-2) 'i) —NONPRICING In a pricing program,centers establish a charge eemVAte nom tuition for meals in order to make uo the difference between the reimbursement provided by Ire CACFP and the I actual cost of serving the meals.In a erpnang program.tamales pay a general tuition charge that covers all areas of child care services provided by ine center including mess.There is no identifiable separate charge for meals served to any children in care. 19.All participating centers or sponsors am eligible to reeerve advance payments. Advances are requested monthly by filling out an advance form Tne amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that months claim for relmnursement. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBL:C SCHOOL DATA. HOUSING AUTHORITY DATA.ETC.IN ADDITION.GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE DACTUAL American Indian or Alaskan Native 5% Asian or Pacific mender Black(not of Hispanic anoint .05% Hispanic 71 / While (not of Hispanic Origin) 20/66 'Visual kbnlsk is may be used by centers a suoreoms to damming the Wad's ray b easxe category.identity A lad may th is group in le begroup to weal he or sac appears to beuM. Wealth's with.or is regarded in the comet nky as beio gang.ParMis/Guwata14 may be asked to identity Vie racavethhc group of melt own cried apex it has been ensei bed.and they as well as we understand that me collection of the narration is cooly for statistical reporting requirements and has no elfec on the de(enNreien of tea elgem to receive neneles under the Program.As new children are enrolled,you will need to determine their racial/ethnic background and keep this Intonation Ina mhndential pace. CACFP-301 (4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 940S 50 COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER I.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YjS NO Platteville CHILDREN/INFANTS ON A REGULAR BASIS? WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? - - TELEPHONE NO.: ( ) 7. DO YOU CARE FOR CHILDREN IN SHIFTS' YES X NO Sn41 care mere that children are coning and going at as times of me clay so mat the COUNTY: Weld total number of cn,cren attending Inc center on a cagy bases may exceed the manse I 2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. 8.HOURS OF OPERATION Lorraine Venzor FROM 6:30 a.m. TO 6:00 p.m. 3.%HEAD START PROGRAM 9. NUMBER OF OPERATING 10. NUMBER OF OPERATING _X_MIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR 52 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 HOW MANY ARE AM? 20 HOW MANY ARE PM? 70 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING ENDING NUMBER OF CHILDREN IN EACH CLASSROOM — is your Head Start site lecereed as a chid care center by the Colorado Department 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of soaal Services during tunes when Head Start s not in session? AND SNACKS FOR REIMBURSEMENT YES NO— (Include dates of closing and reopening) 4. AGE RANGE OF ENROLLED CHILDREN NSA FROM 6 wks TO 5yrs 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 X NO 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 `L UNDErRcoO TRACTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? YES X NO UNDER CONTRACT WITH FOOD SERVICE CATERER (SUBMIT COPY OF CONTRACT) I 17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Cam Food Program food service functions in this center., NUMBER CF i 'rEARS NAME OF POSITION NAME OF PERSON FOOD SPECIFIC STAFF SERVICE DUTIES THIS POSI ICN IPCSITIC\' As per District Contrzct . • 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING NOCING(Pee(Please contact our office for further instructions at 6'2-2330) _� in a pncmg program,centers establish a charge aenarate fmm tuition for meals in order to make uo the difference between the reimbursement provided by the CACFP and he actual cost of serving the meals.In a rionpndrg program.families pay a general tuaeon large that covers all areas of child care services provided by the center.including meals.There is no identifiable seoarate charge for meats served to any children in care. 19.All participating centers or sponsors are eligible to receive aavarce payments.Advances are reauested monthly by filling out an advance tome.Tne amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that monm s claim for reimbursement. 20.CIVIL RIGHTS 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 .oA5 ACTUAL Amencan Indian or Alaskan Native Asian or Pacific Islander .0 Black(not of Hispanic ongm) 71'/ Hispanich$b; White (not of Hispanic origin) L /6 1O wheal or sne to I den)drxh r is r may be usd in dthe comnuhy as beamging.ParentaGuardara may be asked to identity me raelaued =group of Mew owy careers or spored's to cletenTiins the&Ws recsalreithrec category.A chid may be included in the nchildafter a has bee�ae wsd and theyas I wemitaawuhernd that t I *gnaws We undelstafd that the f:Oibdlon of the information is strictly for atatMlrJl mooning requirements and hat no titled on the daremratdn of)ties eNgdlay to receive ceriNns I Under the Program As new Children are reroaed,you will need to determine their rraallethnic background and keep this Int rwadon Inc camldental macs. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT • 940850 • • COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YFYS NO Ft. Morgan (Migrant Only) CHILDREN/INFANTS ON A REGULAR BASIS? Site to be Determined in May 1995 WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? _ TELEPHONE NC.: ( ) 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES X NO COUNTY: Shift tet care means stthat t children are coning and center at as times m the asy so that Ina attending may bass may exceed me t tense 2. NAME AND TITLE OF CONTACT PERSON AT CENTER caparay. To Be Determined 8.HOURS OF OPERATION FROM 6:30 a.m. TO 6:00 g.m. 3. x HEAD START PROGRAM 9.NUMBER OF OPERATING 10.NUMBER OF OPERATING _X-MIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR 16 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 HOW MANY ARE AM? 20 HOW MANY ARE PM? 20 11. ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING June 19 ' 95 ENDING October 7 ' 95 NUMBER OF CHILDREN IN EACH CLASSROOM—15— Is your Head Start sae licensed as a cam are center by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of social Services during times when Head Stan a na n session? AND SNACKS FOR REIMBURSEMENT YES NO— (Include dates of closing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN N/A FROM 6 wks TO 5yrs 5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO 113. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THROUGH 12 MONTHS? x CHANGED? WILL YOU CLAIM THESE INFANTS ON THE CACFP? x YES X 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 YOU HAVE MORE THAN ONE SITE) • 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR Y UNDER CONTRACTRWI H LOCAL SCHOOL SYSTEM EACH MEAL? M UNDER CONTRACT WITH FOOD SERVICE CATERER YES x NO (SUBMIT COPY OF CONTRACT) i 17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.I I NUMSEF on I YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF iN I .N THIS I FOOD SERVICE DUTIES THIS POS:TICN IPOSITIONM As per District Contract • • • I I 18, IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 632-233/0 --X NONPRICING In a oncng program.centers estabbsh a charge sanarefe tmm radian for meals in order to make un the difference between the reimbursement provided by the CACFP and the actual cost of seMrlg the meals.In a notprlang program.families pay a general notion charge that covers all areas of child care services provided by rte center.including meals.There a no Identifiable separate charge for meals served to any children n care. 19.All particIpaung centers or sponsors are eligible to receive advance payments. Advances are requested monthly by filling out an advance torn. Trio 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 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 RACIALJETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL American Irian or Alaskan Native .05% Asian or Pacific Islander Black(not of Hispanic ongn) •05% Hispanic 7„1�//} White (not of Hispanic origin) 20% ' -Vela)identification may be used by centers or sponsors to determine the duds raaaverxac category.A dab may be included in the grow to amen he or sae appears to betom. identifies with.ore regarded in the corona:nay as belonging.ParentsGuaNBM may oe asked to identity the racebahnic group of thee'own child ater a has bean explained.arid they as well as we urteratand that the cotbalon of the kaornation Is strictly for statistical reporting requirements and has no eltect on the oelemwetnxh of their elgdley to raceme oenelns under the Program As new children are enrolled.you will need to determine their racial/ethnic background and keep the information to a consdemel dace. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 94055{) COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM • APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS vgs NO Olathe, Colorado (Migrant Only) CHILDREN/INFANTS ON A REGULAR BASIS? Site to be Determined May 1995 WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? TELEPHONE NO.: ( ) 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES X NO COUNTY: Shit care means that children are coming and going at all times of the aav so that me total number of e n:Iran attending the center on a may basa may exceed tne ucsnse 2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. 8. HOURS OF OPERATION To Be Hired FROM 6:30 a.m. TO 6:00 D.M. 3. X HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING -X-MIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 T HOW MANY ARE AM? 20 HOW MANY ARE PM? 20 11. ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING June 19 ' 95 ENDING October 7 ' 95 NUMBER OF CHILDREN IN EACH CLASSROOM-1S__ � is your Head Stan sae tensed as a chid tare senor try me Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during tones when Head Start a not n session? AND SNACKS FOR REIMBURSEMENT YES S NO— (Include dates of closing and reopening) 4. AGE RANGE OF ENROLLED CHILDREN FROM 6 wks TO 5vrs N/A 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 73. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THR OUGH 12 MONTHS? x CHANGED? WILL YOU CLAIM THESE INFANTS ON THE CACFP? x YES X 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 YOU HAVE MORE THAN ONE SITE 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR _ x UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? I (SUBMIT COPY OF CONTRACT) UNDER CONTRACT WITH FOOD SERVICE CATERER YES x NO (SU MI COPY 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 NEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN I N TH S FOOD SERVICE DUTIES THIS POSITICN IPOSIT:C\ As per District Contract • 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 692-233r.) X NONPRICING In a pricing program,centers establish a charge'Answers tmm tuition for meals in order to masa up the difference between the reimbursement provided by the CACFP and Ine I actual cost of serving the meals.Ina norgnang program.families pay a general tuition charge that covers all areas of child care services Wwded by the center.inducing 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 aavance payments.Advances are requested monthly by filling out an advance torn. Inc amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that mono,s claim for reimbursement. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO SE 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 .05% Asian or Pacific Islander Black(not of Hispanic origin) .8)7. Hispanic 71 T White (not of Hspanic ongn) 28i 'Visual identification may be used by centers pr sparrows to determine the chadb rada1rroac category.A dad may be induced in the group to vice he or sne appears to mono. identifies with or s regarded in the comnundy as beio gtrg.ParentsGuaroans may be asked to identity the racer/ethnic grotto of des own child aver a Ms been explained and mev as well as we urnderstard that the collection of this aeonatio n le strictly for etadsecal reporting requirements and has no effect on the detemanant i of their elgauty to receive oeneJns unser the Program.As new children are enrolled.you will need to determine their raaat/edrnc background and neap tits Information in a cdnfdsntal place. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 940S5') COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YS NO Grand Junction (Migrant Only) CHILDREN/INFANTS ON A REGULAR BASIS? Site to be Determined in May 1995 WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? TELEPHONE NO: ( ) 7.DO YOU CARE FOR CHILDREN IN SHIFTS', • YES X NO Snit care means that children ere coming and good at as times of the day so trot the COUNTY: total number of children attending the center on a caw bass may exceed Ina license 2. NAME AND TITLE OF CONTACT PERSON AT CENTERt1'. 8.HOURS OF OPERATION To Be Hired FROM 6:30 a.m. TO 6:00 D.M. 3. X HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING --IL-MIGRANT HEAD START PROGRAM DAYS PER WEEK 6 WEEKS PER YEAR _��_ HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 40 - HOW MANY ARE AM? 20 HOW MANY ARE PM? 70 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING_J11n e 19 ' 95 ENDING October 7 2,_a5 i NUMBER OF CHILDREN IN EACH CLASSROOM _1,1_ Is your Head Start site licensed as a cold rare center by the Colorado Department 12 LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services durng times when Head Start is not in session? AND SNACKS FOR REIMBURSEMENT YES_L.NO_ (Include dates of Meng and reopening) 4. AGE RANGE OF ENROLLED CHILDREN N/AFROM 6 wks TO 5vrs 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13..HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THROUGH 12 MONTHS? CHANGED? WILL YOU CLAIM THESE INFANTS ON THE CACFP? x YES x 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 YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR Y UNDER CO TRACT WITH 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 and Adult Care Food Program food service functions in this center. NUMEER OF I '•EARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF N 15 THIS FOOD SERVICE DUTIES THIS POSITION IPOSITIONI As per District Contract • I • 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further instructions at 6f2-21r,) —R—NONPRICING In a pricing program.centers estabash a charge venamte tram tuition for meals in order to make up the difference between the reimbursement provided by the CACFP and the actual cost of semng the meat.In a nortpnang program•families pay a general tunun charge that covers as areas of child rare services provided by the center.inducing meat.There is no warmness separate charge for meals served to any children in fare. 19.All participating centers or sponsors am eligible to receive advance payments.Advances are requested monthly by filling out an advance to rm.Trio amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that months claim for reimbursement. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAUET NIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBLIC SCHOC-DATA. HOUSING AUTHORITY DATA,ETC.IN ADDITION.GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL American Indian or Alaskan Native .05% Asian orPaafic'sander Black Mot of Hispanic origin) '0570 Hispanic 71! 9} While (not of Hispanic ongm) 28% 'Visual ics*icetlon may be used by centers or sponsors to determine the child's rarrarfnc category.A clad may be included in the group to'On=he or she appears to beam genuses with.ors retarded in the community as belolgag.Parents/Guardians may be asked to'denary the racaerhne group of bad own child after n has been explained.arc trey as well as we uraar9tand that the collection of the IMomation S strictly for statistical reporting requirements and nes no enact on the defame:sum of'hex eligibility to receive nenetns under the Program.As new cfnldren are enrolled.you will need to detrmine teen rWeUeenle beatgrourid and keep this Information Inc confidential place. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 940W-30 COLORADO DEPARTMENT HEALTH AGREEMENT NUMBE CHILD & ADULT CARE FOOD PROGRAM APPLICATION FOR . 65103-05 1 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-governmental) Weld County Division of Human Services YES NO x Family Educational Network of Weld County Give name and title of Owner of For Profit Title XX Center OR Chair of the P.O. Box 18Q5 Organization Governing Board OR Chair of the Church Governing Board: 1551 North 17th Avenue Greeley, Colorado 80632 Chairperson, Weld County TELEPHONE NO:( 303 ) 353-3800 W.H. Webster Board of Commissioners Weld NAME TITLE COUNTY: 2. DO YOU PARTICIPATE IN THE HEAD START PROGRAM? 7. NUMBER OF CACFP-PARTICIPATING CENTERS UNDER YOUR ADMINISTRATION YES X 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? 11 HEAD START CENTERS YES__ NO_ 11 MIGRANT HEAD START CENTERS (If "yes,"give name of program(s) and dates of participation.) B. TOTAL NUMBER OF CHILDREN ENROLLED AT CACFP-PARTICIPATING CENTERS UNDER YOUR ADMINISTRATION • NONPROFIT CHILD CARE CENTERS 4. DO YOU PARTICIPATE IN THE COLORADO PRESCHOOL PROJECT? OUTSIDE-SCHOOL-HOURS CENTERS YES X NO 5. NAME AND TITLE OF ADMINISTRATOR FOR PROFIT TITLE XX CENTERS Tere Keller—Amaya, Director _ Name Title HEAD START CENTERS 585 NAME AND TITLE OF CONTACT PERSON MIGRANT HEAD START CENTERS 386 Tere Keller—Amaya, Director Name Title • 9. DO YOU REQUEST ADVANCE PAYMENTS? TELEPHONE NO:( 303 ) 353-3800 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 Service 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 Policy 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 Office for payment and recording purposes. CACFP-302(5/90) Page 1 940850 DESCRIBE YOUR SYSTEM FOR DISBURSING CACFP REIMBURSEMENT TO YOUR CENTERS WITHIN 5 DAYS OF RECEIPT FROM CDH-CACFP.(Reim- bursement cannot exceed the CACFP meals claimed for that center by the sponsor) All centers are operated under the direction of the Head Start Program. Therefore, the CCFP reimbursement is made to the one program and does not need to be disbursed to the other facilities. Ail 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? YES X NO It yes,please give company name,address,and name of contact person and delivery procedures. Greeley/Evans School District 6 - Food is prepared at the central Location, delivered to Weld School District RE-3J the individual school cafeteria's and delivered to Weld School District RE-5J the classroom. Proper storage and food transport are used St. Vrain School District RE-1J - Food is prepared at the High School and transported to the classroom, using proper storage and food transport 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 purposes. DESCRIBE YOUR PROCEDURE FOR CONDUCTING PRE-APPROVAL VISITS TO NEW CENTERS. IF AVAILABLE,ATTACH A COPY OF YOUR PREAP- PROVAL EVALUATION FORM. The pre-approval evaluation form will be used at each site. PROVIDE A SCHEDULE FOR MONITORING FOOD SERVICE OPERATIONS AT YOUR CENTERS. Monitoring of food service operations is done in November 1994, February 1995, May 1995, June 1995, and August 1995 If problems are discovered during a monitoring review,what corrective procedure will you follow? An action plan will be written and follow-up in thirty (30) days. CACFP-302(5/90) 94U Sig e 2 SPONSOR STAFFING PATTERN FOR CACFP(List all sponsor personnel who will be involved in administering the CACFP in the chart below.Complete chart as specified,recording duties of personnel listed in ADMINISTRATIVE DUTIES directly related to the CACFP.Administrative duties include managing finances and operation of CACFP. Attach additional sheets if necessary.) 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 or) SALARY POSITION CACFP DUTIES with"" ") DUTIES other) ONLY A B C D E F G (DXEXF) • ADMINISTRATOR • (or equivalent) ASSISTANT ADMINISTRATOR (or equivalent) CLERICAL (or equivalent) COOK OTHER (specify) ANNUAL CACFP ADMINISTRATIVE BUDGET TOTAL CACFP-FUNDED LABOR $ —�— (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 20C) TELEPHONE OFFICE RENTAL/MORTGAGE PAYMENT AND MAINTENANCE UTILITIES FOR OFFICE AREA , OTHER(Specify) TOTAL CACFP ADMINISTRATIVE BUDGET $ �� ANNUAL CACFP BUDGET FOR FOOD SERVICE OPERATIONS AT FACILITIES UNDER YOUR ADMINISTRATION (ENTER CACFP PORTION ONLY) FOOD PURCHASES $ FOOD SERVICE LABOR(Salaries of staff preparing or serving meals) FOOD SERVICE CONTRACTOR FEE 150,000 NONFOOD SUPPLIES(Napkins,straws, dishwashing detergent,etc.) MAINTENANCE FOR FOOD PREPARATION,STORAGE AND SERVICE AREAS RENT/MORTGAGE PAYMENT FOR FOOD PREPARATION,STORAGE AND SERVICE AREAS UTILITIES OTHER(Specify) TOTAL FOOD SERVICE OPERATING BUDGET $ 150,000 LIST SOURCES OF CASH INCOME SPECIFICALLY FOR THE FOOD SERVICE OTHER THAN CACFP REIMBURSEMENT. NONE I certify that the information on this application and the attached form CACFP-301 is true to the best of my knowledge:that I 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 participants:that the CACFP will be available to all eligible participants without regard to race,color.sex 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 this informa- tion is being given in connection with the receipt of Federal funds and that deliberate misrepresentation may subject me to prosecutioh under applicable State and Federal criminal statutes. 8/24/94 SIGNATURE OF ADMINIST ATOR OR AUTHORIZED REPR NTATIVE DATE C CACFP 302(5/90) 940(^'r93 COLORADO DEPARTMENT OF PUBLIC HEALTH 08-65103 AND ENVIRON IT Agreement Num'" CHILD AND ADULT CARE i JD PROGRAM AGREEMENT FOR CHILD CARE CENTER Family Educational Network of Weld Coutv Name of sponson0g Organization SPONSOR OF CHILD CARE CENTERS compile data maintain records and submit reports as required, to In order to carry out the purpose of Section 17 of the National permit effective enforcement of Title VI and permit authorized School Lunch Act, as amended. and the Regulations governing the CDPHE personnel during normal working hours to review such Child and Adult Care Food Program (CACFP) issued thereunder records books and accounts as needed to ascertain compliance (7 CFR Part 226) the Colorado Department of Public Health and with Title VI. If there are any violations of this assurance. the Environment (referred to as the State Agency), and the Center or State Agency shall have the nght to seek judicial enforcement of Sponsor, whose name appears above, agree as follows: this assurance. Subject to the renewal requirements for the second year, This assurance is binding on the center or sponsor, its succes- this Agreement made this 15th day of August 1994 shall be sore, transferees, and assignees as long as it receives assistance effective during the periodcommencing October 1 1994 or retains possession of any assistance from the State Agency. and ending September 30 1995 unless terminated earlier as herein provided. 1 he State Agency may renew this Agreement 2. The governing body is responsible for the administration of the by notice in writing given to the center or sponsor, for such period centers listed on Schedule A of this Agreement, or it is an as funds are available for carrying out the Program.is The State agency to which the centers listed on Schedule A have dele- Agency Agreement to reimburse the center or sponsor contingent gated authority for the operation of the food service program. upon the continued availability of funds appropnated for CACFP in a sufficient amount, and no legal liability on the part of the 3. In order to qualify for reimbursement under this Agreement. it Government for the payment of any money shall arise unless and shall conduct the Pro ram in accordance with regulations until such appropriation shall have been provided. The State's goveming the CACFP(g7 CFR Part 226), appropriate MB O cir- financial liability is limited to the timely disbursement of the Federal culars State regulations, State Agency policies, and funds available for the CACFP in Fund Number 100, Appropriation specifically, shall conform to the following requirements: Code 657. • Operate a nonprofit food service using all of the income The Agreement may be terminated upon thirty (30) days written received from the CACFP solely for the operation or notice on the part of either party hereto, and the State Agency may improvement of such service. terminate this Agreement immediately after receipt of evidence that the terms and conditions of this Agreement and of the regulations • Serve meals which meet the minimum nutritional require- governing the Program have not been fully complied with by the ments specified in Schedule B of this Agreement. center or sponsor. Any termination of this Agreement by the State Agency shall be in accord with applicable laws and regulations - Serve the same meal at no separate charge from tuition (Federal Regulations 7CFR Part 226.6(c). No termination or expire- to enrolled children who are in attendance at meal time tion of this Agreement, however, shall affect the obligation of the (nonpricing institution) and so designate on Application center or sponsor to maintain and retain records and to make such Form and Nondiscrimination Policy Statement and abide records available for audit. A center or sponsor may appeal a by the terms of the Nondiscrimination Policy Statement termination according to procedures outlined in 7 CFR Part 226.5(k). and Program Verification Rules(Regulations 226.23 h.1). The terms of this Agreement shall not be modified or changed in -0R- any way other than by the consent in writing of both parties hereto. - Have an identifiable separate charge from tuition for THE STATE AGENCY AGREES THAT: meals served to enrolled children (pricing institution)and so designate on Application Form and Nondiscrimination To the extent of funds available, it shall reimburse the institution for Policy Statement and abide by the terms of the Non- creditable meals served to eligible children at child care centers discnmination Policy Statement and Program Verification listed on Schedule A attached hereto, during the effective period of Rules (Regulations 226.23 h.2). this Agreement. During any fiscal year, the amount of Collect family size and income information on the Income reimbursement paid to the center or sponsor shall be based on • Eligibility Form(IEF)for children enrolled at all centers listed actual count of meals served l by eligibility category. on-Schedule A to determine which children are from families THE CENTER OR SPONSOR AGREES THAT: meeting the income eligibility guidelines for Free or Reduced meals. Children for whom family size and income informa- l. It will comply with Title VI of the Civil Rights Act of 1964 (P.L. tion is not available shall be reported under the Paid (not 88-352)and all requirements imposed by the Regulations of the eligible for Free or Reduced meals) category only. An IEF Department of Agnculture (7 CFR Part 15), Department of Jus- Is valid for 12 months from the first day of the month in tice (28 CFR parts 42 & 50), and FNS directives or regulations which the parent or guardian signed it. Free or issued pursuant to that Act and the Regulations, to the effect Reduced meals may be claimed for reimbursement that, no person in the United States shall, on the grounds of • beginning with that date. The IEF is never retroactive age, sex, handicap, color, race, or national origin be excluded from this date. Meals claimed after the expiration date i from participation n, or be denied the benefits of, or be can only be claimed in the Paid category. otherwise subject to discrimination under any program or activity • Claim reimbursement only for meals served to eligible for which the applicant received Federal financial assistance enrolled children in each income category within the limits from the Department; and HEREBY GIVES ASSURANCE THAT of the license or registration certificate. No more than 2 it will immediately take any measures necessary to effectuate meals and 1 snack per child shall be claimed. However, if this agreement. a child is in care over 8 hours an additional meal or snack This assurance is given in consideration of and for the purpose may be claimed per child. In this case, sign-in/sign-out of obtaining any and all Federal financial assistance, grants and sheets must show attendance of 8 or more flours or 8 or loans of Federal funds, reimbursable expenditures, grant or more hours must elapse between the end of the first meal donation of Federal property and interest in property, the detain and the beginning of the fourth meal. of Federal personnel, the sale and lease of, and the permission Submit Claims for Reimbursement in accordance with fu sh, Federal property o interest in property or the • cedures established by the State Agency. Claims that are pro- furnishing of services rt without hih reduced e nominal received by the State Agency after noon on the 10th of the pu eration, st at a cr cipent,ion which is oftfor the month shall be processed for payment the following month. t tofo assisting the sucht, or in recognition, rof the public o Only original final claims received within 60 days following interest to t served by such sale, lease, n furnishing services to the recipient, or any improvements made with the close of the claim month shall be eligible for Federal financial assistance extended to the applicant by the reimbursement. Revised claims requiring an upward Department. This includes any Federal agreement, arrange- adjustment to the prior amount paid must be submitted ment, or other contract which as one of its purposes the within 90 days of the end of the claim month. Revised provision of assistance such as food, food stamps, cash claims requinng a downward adjustment can be submitted assistance for the purchase of food, and any other.financial anytime. assistance extended in reliance on the representations and • Store, prepare, and serve food in conformance with all agreements made in this assurance. applicable State and local health laws and regulations. By accepting this assurance, the center or sponsor agrees to CACFP 300 (8/94) Page 1 of 7 940F50 • Use cash-received-in-lieu-of corr _lities for the purchase of terms of the Bement. The center or sponsor must submit food. a copy of thi itract to the State Agency. • Maintain full and accurate records of the Program, and retain 4. The State Agency will annually make available on behalf of the such records for a period of three years and four months after center or sponsor to the local media serving the area from the end of the fiscal year to which they pertain. which the center or sponsor draws its attendance, a public release announcing the availability of meals to all eligible • Make all accounts and records pertaining to the Program enrolled children without regard to race, color, sex, national available to the State Agency and to USDA-for audit or review origin, age, or handicap. at a reasonable time and place. 5. For the purposes of this Agreement, the following terms shall • Provide adequate supervisory and operational personnel for mean, respectively: overall monitoring and management of each food service operation, and to promptly take such actions that are neces- "Children" means (a) persons 12 years of age and under, (b) sary to correct deficiencies found at the time of any onsite children of migrant workers 15 years of age and under, and (c) visit, review, or audit. mentally or physically handicapped persons as defined by the State Agency,enrolled in an institution or child care facility serving • If a sponsor, monitor all centers at least 3 times each year, a major ty of persons 18 years of age and under. including once during the first 6 weeks of CACFP operation. These reviews cannot be more than 6 months apart. All "Enrolled child" means a child whose parent or guardian has outside-school-hours centers must be monitored at least 6 submitted to the center or sponsor a signed document which times each year, including once during the first month of indicates that the child is enrolled for child-care. CACFP operation. These reviews cannot be more than 3 months apart. "Milk" means pasteurized fluid types of unflavored or flavored whole milk, lowfat milk, skim milk, or cultured buttermilk which • Schools operating outside-school-hours centers must monitor meet State and local standards for such milk except that, in the each site 3 times per year. meal pattern for infants (8 months up to the first birthday),."milk" means unflavored types of whole fluid milk or an equivalent 4. It is a public organization or a nonprofit organization which has quantity of reconstituted evaporated, milk which meets such tax exempt status such as under section 501(a) of the Internal standards. All milk should contain vitamins A and D at levels Revenue Code of 1954 or is moving toward compliance with the specified by the Food and Drug Administration and be consistent requirements of the aforementioned section in accordance with with State and local standards for such milk. Section 226.15 of the Program Regulations. 'Verification" means a review of the information reported by the -OR- center or sponsor to the State Agency regarding the eligibility of enrolled children for free or reduced meals. If a For Profit Title XX center, it certifies that it receives funds under Title XX of the Social Security Act for at least 25 percent RECORDKEEPING REQUIREMENTS of each center's enrolled children or license capacity, whichever is less, during the month preceding application to or renewal of The center or sponsor must keep full and accurate records per- the Program and shall continue to certify such information in taming to its food service as a basis for the Claim for Reimburse- each succeeding claim month. The institution shall not claim ment and for audit and review purposes. The records to be kept reimbursement for meals served in any For Profit center for any include the following: month during which the center receives Title XX funds for less than 25 percent of its enrolled children or license capacity. 1. Menus and food production records indicating quantities of foods prepared, number of persons prepared for, and serving 5. All child care centers listed on Schedule A have a valid license sizes. The food production records must include the number or registration certificate for providing child care. of adults served. 6. It provides organized child care in nonresidential situations. 2. Daily record of meals served to children broken down by name, by type of meal (breakfast, lunch, super, or snack), 7. It accepts full and final financial and administrative responsibility and by income category - Free, Reduced, or Paid (Record of for all CACFP operations for each child care center under its Meals Served form). jurisdiction. 3. Approved IEFs for enrolled children categorized as Free or 8. It understands and agrees that any material developed with Reduced. Program funds by the center or sponsor may be freely repro- duced, produced, or otherwise used by the USDA Food and 4. Documentation of income to the food service operation from Nutrition Service,the Colorado Department of Public Health and funds to subsidize food service program, from State Agency Environment, or by other sponsors and centers under the Child CACFP reimbursement, from payments for adult meals and and Adult Care Food Program. from all other sources, including loans and donations to the 9. Shall perform its duties hereunder as an independent contractor food service program. and not as an employee. Neither the center or sponsor shall be 5. Invoices or receipts from food service operation purchases or shall be deemed to be an agent or employee of the state. including bills from food service management companies, The center or sponsor shall pap when due all required payroll records including fringe benefits, equipment costs employment taxes and income tax withholding snau provide and maintenance and repairfees, office costs, utilities costs and keep in force worker's compensafion (and show proof of such other administrative costs. insurance) and unemployment compensation insurance the amounts required by law. the center or sponsor will be solely This documentation shall ensure that all reimbursement funds are responsible for its acts and the acts of its agents, employees, used: (1) solely for the conduct of the food service, or (2) to servants, and subcon-tractors during the performance of this improve such food service opperations_principally for the benefit of contract. the enrolled children. DOCUMENTATION OF ALL COSTS PERTAINING TO THE OPERATION OF THE CACFP MUST BE THE STATE AGENCY AND CENTER OR SPONSOR SPECIFICALLY ITEMIZED. DOCUMENTATION MUST MUTUALLY AGREE THAT: CLEARLY SHOW THAT THE FOOD SERVICE IS NONPROFIT BASED ON ALL CACFP INCOME AND EXPENSES. 1. Schedule A,listing centers approved for participation and meals to be claimed for reimbursement, shall be a part of this Agree- 6. License, registration, or certification documentation. ment. Centers or meals may be added to or deleted from Schedule A as the need arises. All such changes must be 7. Documentation of visits to child care centers to monitor com- confirmed in writing and sent to the State Agency. All such pliance. This requirement pertains only,to sponsors who references to Schedule A shall be deemed to include such administer more than one child care center in accordance with Schedule as supplemented and amended. Federal Regulation 226.16(d). 2. The State Agency shall notify the center or sponsor of any 8. Documentation of enrollment. change in the minimum meal requirements or in the applicable rates of reimbursement as soon as possible after it receives 9. Documentation of attendance (rollbooks or sign-in/sign-out notification from USDA. sheets). • 3. The center or sponsor may contract with a local school food 10. Documentation of Civil Rights racialethnic data. authority or with a food service management company for the preparation and delivery of meals or meal components. The 11. Documentation of staff training pertaining to CACFP. center or sponsor shall remain responsible for fulfillment of the (Recordkeeping Requirements continued on page 5) • • • Page 2 of 7 910E 50 SCHEDULE A (CDH-CACFP Fiscal Year 1994) 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.) NAME &ADDRESS TYPE OF LICENSE MEALS TO BE CLAIMED OF CENTER CENTER C-child Car. N.".ad s^ CAPACITY LICENSE WRITTEN LICENSE Schoonkwn p.pw pfom NUMBER ON EXPIRATION LICENSE DATE BREAKFAST SNACK LUNCH PM SNACK SUPPER Billie Martinez H 81834 30 TIMES OF MEALS 341 14th Avenue 7 3f3. 1530 2:30 4:30 I Greeley, CO 80631 NUMBER OF CHILDREN 30 60 30 30 Madison TIMES.OF MEALS 24th Avenue & 6th Street Greeley, CO 80631 H 81832 30 7 3D ' ONMatf130 2:30 4:30 NUMBER OF CHILDREN 30 60 30 30 Dos Rios TIMES OF MFAI S 2201 34th Street Evans, CO 80620 H 81829 30 7 30 .! LE 30 2:30 4:30 NUMBER OF CHILDREN 30 60 30 30 Centennial TIMES OF MEALS 1400 37th Street Evans, CO 80620 H 81833 30 73Q t1:3D 2:30 4:30' NUMBER OF CHILDREN 30 60 30 30 TIMES'OF MEALS Jefferson 1315 4th Avenue Greeley, CO 80631 H 81831 30 x;30 ! ZL:3( 2:30 NUMBER OF CHILDREN 30 60 30 30 This schedule is part of CACFP 300 signed Fiscal Year 1993. ( 940F59 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 of 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. 940850 SCHEDULE A (CDH-CACFP Fiscal Year 1994) 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.) NAME &ADDRESS TYPE OF LICENSE MEALS TO BE CLAIMED OF CENTER CENTER G CENd Corn H-Hood Start CAPACITY Gowen• LICENSE WRITTEN LICENSE School Hours NUMBER ON EXPIRATION R For PrvM LICENSE DATE BREAKFAST SNACK LUNCH PY SNACK SUPPER TIMES OF MEALS East Memorial 614 East 20th. Street F Greeley, CO 80631 H 81830 30 ? 3Q 1J :38 2:30 4:30 NUMBER OF CHILDREN 30 60 30 30 !, TIMES+OF MEALS Island Grove Village 119 14th Avenue � Greeley, CO 80631 (Head Start Only) H 85077 30 NUMBER OF CHILDREN 30 60 30 TIMES OF MEALS Frederick 340 Maple 7 3tt t 3Q 2:30 4:30 Frederick, CO 80530 H 66816 45 NUMBER OF CHILDREN 45 60 45 45 TIMES OF•MFAI'S Hudson 300 Beech Hudson, CO 80642 H 81828 30 1 :3L 2130 4:30 NUMBER OF CHILDREN 30 60 30 30 TIMES OF MEALS Milliken 300 Broad Milliken, CO 80543 (Head Start Only) H 85079 30 NUMBER OF CHILDREN, 30 60 30 This schedule is part of CACFP 300 signed Fiscal Year 1993. 940850 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 of 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. •._ 940850 SCHEDULE A (CDH-CACFP Fiscal Year 1994) 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.) NAME &ADDRESS TYPE OF LICENSE MEALS TO BE CLAIMED OF CENTER CENTER C-Child Car. N.Mead Mort CAPACITY a OMuwk school hours LICENSE WRITTEN LICENSE p.pot posh NUMBER ON EXPIRATION UCENSE DATE BREAKFAST SNACK LUNCH PM SNACK SUPPER Gilcrest TIMES OF MEALS • 1175 Birch • Gilcrest, CO 80623 (Head Start Only) H 85080 30 NUMBER OF CHILDREN `. 30 60 30 Platteville Elementary School New TIMES'OF MEALS Platteville Center • H In • Process Of NUMBER OF CHILDREN Licensing 15 15 TIMES OF MEALS Ft. Morgan l Site to be Determined H Migrant Head Start Only) 60 • Awaiting Licensing Number i NUMBER OF CHILDREN 60 60 60 60 Olathe TIMES QF MEALS Site to Be Determined H 95292 Migrant Head Start Only 45 NUMBER OF CHILDREN 45 45 45 45 Grand Junction TIMES OF MEALS Site to Be Determined H Migrant Head Start Only 42 Awaiting Licensing Number NUMBER OF CHILDREN , 42 42 I 42 42 • This schedule is part of CACFP 300 signed Fiscal Year 1993. 940850 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 of 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. 940850 COLORADO DEPARTMENT cc PUBLIC HEALTH AND ENVIROP-- VT Agreement Nun• 08-65103 CHILD AND ADULT CARE OD PROGRAM AGREEMENT FOR CHILD CARE CENTER Family Educational Network of Weld County Name of sponsoring o ganaatwn OR SPONSOR OF CHILD CARE CENTERS In order to carry out the purpose of Section 17 of the National compile data, maintain records and submit reports as required, to permit effective enforcement of Title VI and permit authorized School Lunch Act, as amended, and the Regulations governing the CDPHE personnel during normal working hours to review such Child and Adult Care Food Program (CACFP) issued thereunder records books and accounts as needed to ascertain compliance (7 CFR Part 226) the(referred ColortO as ado State DAepartment of Publicnd Health Cent a dr with Title VI. If there are any violations of this assurance, the Sponsor, whse name appears above, agree as follows: this assuranceshall have the right to seek judicial enforcement of Subject to the renewal requirements for the second year, This assurance is binding on the center or sponsor, its succes- this Agreement made this 15th day of August 1994 shall be son, transferees, and assignees as long as it receives assistance effective during the period commenting October 1 1994 or retains possession of any assistance from the State Agency, and ending September 30 1995 unless terminated earlier as herein provided. The State Agency may renew this Agreement 2. The governing body is responsible for the administration of the by notice in writing given to the center or sponsor, for such period centers listed on Schedule A of this Agreement, or it is an as funds are available for carrying out the Program.is The State agency to which the centers listed on Schedule A have dele- Agency Agreement to reimburse the center or sponsor contingent gated authority for the operation of the food service program. upon the continued availability of funds appropriated for CACFP in a sufficient amount, and no legal liability on the part of the 3. In order to qualify for reimbursement under this Agreement, it Government for the payment of any money shall arise unless and shall conduct the Program in accordance with regulations until such appropriation shall have been provided. The State's governing the CACFP(7 CFR Part 226), appropriate OMB cir- financial liability is limited to the timely disbursement of the Federal culars State regulations, State Agency policies, and funds available for the CACFP in Fund Number 100, Appropriation . specifically, shall conform to the following requirements: Code 657. • Operate a nonprofit food service using all of the income The Agreement may be terminated upon thirty (30) days written received from the CACFP solely for the operation or notice on the part of either party hereto, and the State Agency may improvement of such service. terminate this Agreement immediately after receipt of evidence that the terms and conditions of this Agreement and of the regulations • Serve meals which meet the minimum nutritional require- governing the Program have not been fully complied with by the ments specified in Schedule B of this Agreement. center or sponsor. Any termination of this Agreement by the State Agency shall be in accord with applicable laws and regulations - Serve the same meal at no separate charge from tuition (Federal Regulations 7CFR Part 226.6(c). No termination or ex ira- to enrolled children who are in attendance at meal time lion of this Agreement, however, shall affect the obligation of the (nonpricina institution) and so designate on Application center or sponsor to maintain and retain records and to make such Form and Nondiscrimination Policy Statement and abide records available for audit. A center or sponsor may a ppeal a by the terms of the Nondiscrimination Policy Statement termination according to procedures outlined in 7 CFR Part 2p26.6(k). and Program Verification Rules(Regulations 226.23 h.1). The terms of this Agreement shall not be modified or changed in -OR- any way other than by the consent in writing of both parties hereto. - Have an identifiable separate charge from tuition for THE STATE AGENCY AGREES THAT: meals served to enrolled children (pricing institution)and so designate on Application Form and Nondiscrimination To the extent of funds available, it shall reimburse the institution for Policy Statement and abide by the terms of the Non- creditable meals served to eligible children at child care centers discrimination Policy Statement and Program Verification listed on Schedule A attached hereto, during the effective period of Rules (Regulations 226.23 h.2). this Agreement. During any fiscal year, the amount of reimbursement paid to the center or sponsor shall be based on • Collect family size and income information on the Income actual count of meals served by eligibility category. Eligibility Form(IEF)for children enrolled at all centers listed on Schedule A to determine which children are from families THE CENTER OR SPONSOR AGREES THAT: meeting the income eligibility g guidelines for Free or Reduced meals. Children for whom family size and income informa- 1. It will comply with Title VI of the Civil Rights Act of 1964 (P.L. tion is not available shall be reported under the Paid (not 88-352)and all requirements imposed by the Regulations of the eligible for Free or Reduced meals) category only. An IEF Department of Agriculture (7 CFR Part 15), Department of Jus- is valid for 12 months from the first day of the month in tice (28 CFR parts 42 & 50), and FNS directives or regulations which the parent or guardian signed It Free or issued pursuant to that Act and the Regulations, to the effect Reduced meals may be claimed for reimbursement that, no person in the United States shall, on the grounds of beginning with that date. The IEF is never retroactive age, sex, handicap,,color, race, or national origin be excluded from this date. Meals claimed after the expiration date from participation in or be denied the benefits of, or be can only be claimed in the Paid category. otherwise subject to discrimination under any program or activity Claim reimbursement onl for meals served to eligible for which the applicant received Federal financial assistance y 9 from the Department; and HEREBY GIVES ASSURANCE THAT enrolled children in each income category within the limits it will immediately take any measures necessary to effectuate of the license or registration certificate. No more than 2 this agreement. meals and 1 snack per child shall be claimed. However, if a child is in care over 8 hours an additional meal or snack This assurance is given in consideration of and for the purpose may be claimed per child. In this case, sign-in/sign-out of obtaining any and all Federal financial assistance, grants and sheets must show attendance of 8 or more hours or 8 or loans of Federal funds, reimbursable expenditures, grant or more hours must elapse between the end of the first meal donation of Federal property and interest in property, the detain and the beginning of the fourth meal. of Federal personnel, the sale and lease of, and the permission Claims for Reimbursement in accordance with to use, Federal property or interest in such property or the • Submit s established by the State Agency. Claims that are pro- furnishing of services t without consideration n or ut a nominal received by the State Agency after noon on the 10th of the consideration, or at a consideration nt which is reduced for the9 cY purpose of assisting the recipient, or in recognition of the public month shall be processed for payment the following month. interest to be served by such sale, lease, or furnishing of Only original final claims received within 60 days.following services to the recipient, or any improvements made with the close of the claim month shall be eligible for Federal financial assistance extended to the applicant by the reimbursement. Revised claims requiring an upward Department. This includes any Federal agreement, arrange- adjustment to the prior amount paid must be submitted ment, or other contract which as one of its purposes the within 90 days of the end of the claim month. Revised provision of assistance such as food, food stamps, cash claims requinng a downward adjustment can be submitted assistance for the purchase of food, and any other financial anytime. assistance extended in reliance on the representations and • Store, prepare, and serve food in conformance with all agreements made in this assurance. applicable State and local health laws and regulations. By accepting this assurance, the center or sponsor agrees to CACFP 300 (8/94) • CPage 1 of 7 • 9406150 • Use cash-received-in-lieu-of corn: s for the purchase of terms of the - ment. The center or sponsor must submit food. a copy of the . .act to the State Agency. • Maintain full and accurate records of the Program, and retain 4. The State Agency will annually make available on behalf of the such records for a period of three years and four months after center or sponsor to the local media serving the area from the end of the fiscal year to which they pertain. which the center or sponsor draws its attendance, a public release announcing the availability of meals to all eligible • Make all accounts and records pertaining to the Program enrolled children without regard to race, color, sex, national available to the State Agency and to USDA for audit or review origin, age, or handicap. at a reasonable time and place. 5. For the purposes of this Agreement, the following terms shall • Provide adequate supervisory and operational personnel for mean, respectively: overall monitoring and management of each food service operation, and to promptly take such actions that are netts- "Children" means (a) persons 12 years of age and under, (b) sary to correct deficiencies found at the time of any onsite children of migrant workers 15 years of age and under, and (c' visit, review, or audit. mentally or physically handicapped persons as defined by t e State Agency,enrolled in an institution or child care facility serving • If a sponsor, monitor all centers at least 3 times each year, a majority of persons 18 years of age and under. including once during the first 6 weeks of CACFP operation. These reviews cannot be more than 6 months apart. All "Enrolled child" means a child whose parent or guardian has outside-school-hours centers must be monitored at least 6 submitted to the center or sponsor a signed document which times each year, including once during the first month of indicates that the child is enrolled for child-care. CACFP operation. These reviews cannot be more than 3 months apart. "Milk" means pasteurized fluid types of unflavored or flavored whole milk, lowfat milk, skim milk, or cultured butternilk which • Schools operating outside-school-hours centers must monitor meet State and local standards for such milk except that, in the each site 3 times per year. meal pattern for infants (8 months up to the.first birthday),."milk" means unflavored types of whole fluid milk or an equivalent 4. It is a public organization or a nonprofit organization which has quantity of reconstituted evaporated, milk which meets such tax exempt status such as under section 501(a) of the Internal standards. All milk should contain vitamins A and O at levels Revenue Code of 1954 or is moving toward compliance with the specified by the Food and Drug Administration and be consistent requirements of the aforementioned section in accordance with with State and local standards for such milk. Section 226.15 of the Program Regulations. "Verification" means a review of the information reported by the -OR- center or sponsor to the State Agency regarding the eligibility of enrolled children for free or reduced meals. If a For Profit Title XX center. it certifies that it receives funds under Title XX of the Social Security Act for at least 25 percent RECORDKEEPING REQUIREMENTS of each centers enrolled children or license capacity, whichever is less, during the month preceding application to or renewal of The center or sponsor must keep full and accurate records per- the Program and shall continue fo certify such information in taming to its food service as a basis for the Claim for Reimburse- each succeeding claim month. The institution shall not claim ment and for audit and review purposes. The records to be kept reimbursement for meals served in any For Profit center for any include the following: month during which the center receives Title XX funds for less than 25 percent of its enrolled children or license capacity. 1. Menus and food production records indicating quantities of foods prepared, number of persons prepared for, and serving 5. All child care centers listed on Schedule A have a valid license sizes. The food production records must include the number or registration certificate for providing child care. of adults served. 6. It provides organized child care in nonresidential situations. 2. Daily record of meals served to children broken down by name, by type of meal (breakfast. lunch, supper, or snack), 7. It accepts full and final financial and administrative responsibility and by income category - Free, Reduced, or Paid (Record of for all CACFP operations for each child care center under its Meals Served form). jurisdiction. 3. Approved IEFs for enrolled children categorized as Free or 8. It understands and agrees that any material developed with Reduced. Program funds by the center or sponsor may be freely repro- duced, produced, or otherwise used by the USDA Food and 4. Documentation of income to the food service operation from Nutrition Service,the Colorado Department of Public Health and funds to subsidize food service program, from State Agency Environment, or by other sponsors and centers under the Child CACFP reimbursement, from payments for adult meals and and Adult Care Food Program. from all other sources, including loans and donations to the food service program. 9. Shall perform its duties hereunder as an independent contractor and not as an employee. Neither the center or sponsor shall be 5. Invoices or receipts from food service operation purchases or shall be deemed to be an agent or employee of the state. including bills from food service management companies, The center or sponsor shall pay when due all required payroll records including, fringe benefits, equipment costs employment taxes ana income tax witltndlainq, snail provide and maintenance and repair ees, office costs, utilities costs and keep in force workers compensation (and show proof or such other administrative costs. insurance) ana unemployment compensation insurance the amounts required by law. The center or sponsor wili be solely This documentation shall ensure that all reimbursement funds are responsible for its acts and the acts of its agents, employees, used: (1) solely for the conduct of the food service, or (2) to servants, and subcon-tractors during the performance of this improve such food service operations principally for the benefit of contract. the enrolled children. DOCUMENTATION OF ALL COSTS PERTAINING TO THE OPERATION OF THE CACFP MUST BE THE STATE AGENCY AND CENTER OR SPONSOR SPECIFICALLY ITEMIZED. DOCUMENTATION MUST MUTUALLY AGREE THAT: CLEARLY SHOW THAT THE FOOD SERVICE IS NONPROFIT BASED ON ALL CACFP INCOME AND EXPENSES. 1. Schedule A,listing centers approved for participation and meals to be claimed for reimbursement, shall be a part of this Agree- 6. License, registration, or certification documentation. ment. Centers or meals may be added to or deleted from Schedule A as the need arises. All such changes must be 7. Documentation of visits to child care centers to monitor corn- confirmed In writing and sent to the State Agency. All such pliance. This requirement pertains only.to sponsors who references to Schedule A shall be deemed to include such administer more than one child care center in accordance with Schedule as supplemented and amended. Federal Regulation 226.16(d). 2. The State Agency shall notify the center or sponsor of any 8. Documentation of enrollment. change in the minimum meal requirements or in the applicable rates of reimbursement as soon as possible after it receives 9. Documentation of attendance (rollbooks or sign-in/sign-out notification from USDA. sheets). 3. The center or sponsor may contract with a local school food 10. Documentation of Civil Rights raciaVethnic data. authority or with a food service management company for the preparation and delivery of meals or meal components. The 11. Documentation of staff training pertaining to CACFP. center or sponsor shall remain responsible for fulfillment of the (Recordkeeping Requirements continued on page 5) • Page 2 of 7 940850 SCHEDULE A (CDH-CACFP Fiscal Year 1994) (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 & Adutt Care Food Program. (Attach additional sheets if necessary.) NAME &ADDRESS TYPE OF LICENSE MEALS TO BE CLAIMED OF CENTER CENTER C.Child Care N-wad ma CAPACITY O.Cowie LICENSE WRITTEN LICENSE P.schos Forp, n� NUMBER ON EXPIRATION LICENSE DATE WWWAtr sNaac Lug sporxf mnst Billie Martinez H 81834 30 TttctESOFMtJ1LS 341 14th Avenue *3eg 1.30 2:30 4:30: Greeley, CO 80631 ' NUMBER OF CHILDREN 30 60 30 30 Madison 176488'OF'IA�ei c 24th Avenue & 6th Street r Greeley, CO 80631 H 81832 30 t3G T1;3D 2:30 4::30 NUMBER OF CHILDREN 30 60 30 30 Dos Rios TIMES OF MEAL S 2201 34th Street Evans, CO 80620 H 81829 30 7:313 41:30 2:30 4:30 NUMBER OF CHILDREN 30 60 30 30 Centennial TIMES Or MEALS 1400 37th Street Evans, CO 80620 H 81833 30 7;3t3 11 30 2:30 4:30 NUMBER OF CHILDREN 30 60 30 30 TIMES OF MEALS Jefferson 1315 4th Avenue Greeley, CO 80631 H 81831 30 7130' 11:.3E 2:30 4:30 NUMBER OF CHILDREN 30 60 30 30 Page 3 of 7 - - 94O11511 SCHEDULE A (CDH•CACFP Fiscal Year 199' 'Does your organization have more than one licensed center? YES 7 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.) NAME &ADDRESS TYPE OF UCENSE MEALS TO BE CLAIMED OF CENTER CENTER Child Cars Hoed tart CAPACITY e LICENSE WRITTEN LICENSE p.Fee pram NUMBER ON EXPIRATIO UCENSE DATE BRuvAST SMACIC LUNCH PM SNACKJSUPPER East Memorial � Mme+ a h ; 614 East 20th. Street Greeley, CO 80631 H 81830 30 .2:301 4:30 NUMBER OF CHILDREN 1 30 60 30 I 30 HIES OF MEALS Island Grove Village 119 14th Avenue Greeley, CO 80631 (Head Start Only) H 85077 30 NUMBER OF CHILDREN 30 60 30 TIMES OF MEALS Frederick 340 Maple 7 3t ¶1:30 2•:30 4:30 Frederick, CO 80530 H 66816 45 NUMBER OF CHILDREN 45 60 45 45 TIMES OF MEALS Hudson 300 Beech 7:3t} 11:3C 2:30 4:30 Hudson, CO 80642 H 8182 30 NUMBER OF CHILDREN 30 60 30 30 TIMES OF MEALS Milliken 300 Broad Milliken, CO 80543 (Head Start Only) H 85079 30 NUMBER OF CHILDREN • 30 60 30 • 940850 Page 3 of 7 SCHEDULE A (CDH-CACFP Fiscal Year 199' 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.) NAME d ADDRESS TYPE OF LICENSE MEALS TO BE CLAIMED OF CENTER CENTER a aim Can M-used sun CAPACITY o OutsideLICENSE WRITTEN LICENSE School Moue P•For NUMBER ON EXPIRATION LICENSE DATE BREAKFAST AM SNACK LUNCH PM SNACICSUPPER Gilcrest TIMES OF MEALS 1175 Birch Gildrest, CO 80623 (Head Start Only) H 85080 30 NUMBER OF CHILDREN 30 60 30 ... ........... Platteville Elementary TIMES OF MEALS School New Center H In process of licensing NUMBER OF CHILDREN 15 15 TIMES OF MEALS Ft. Morgan H Site to be Determined 60 Migrant Head Start Only) # # Awaiting Licensing Number NUMBER OF CHILDREN 60 60 60 60 • TIMES OF MEALS Olathe Site to Be Determined Migrant Head Start Only H 95292 45 NUMBER OF CHILDREN 45 45 45 45 Grand Junction TIMES MEALS Site to Be Determined Migrant Head Start Only H 42 °c. Awaiting Licensing Number NUMBER OF CHILDREN 42 42 42 42 M. Page 3 of 7 940850 SCHEDULE A (CDH-CACFP Fiscal Yea tg iDoes your organization nave 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.) NAME&ADDRESS TYPE OF LICENSE MEALS TO BE CLA1MED OF CENTER CENTER C-Chun Can 1♦IISSS ShN1 - CAPACITY ec tieys LICENSE WRnTEN LICENSE p.pSr pmm NUMBER ON IBCPIRATION LICENSE DATE BW OAIT SNACK uNNON SNw+caS Billie Martinez -- • B .; 3 :b7t •OiLMEAtS,. 341 14th Avenue H 81834 30 Greeley, CO 80631 z K P.,30 2.30 30 NUMBER OF CHILDREN 30 60 30 3C Madison , : .7161E&>OIMEALq 24th Avenue & 6th Street � r a= Greeley, CO 80631 H 81832 30 �:I tE ${ 4. NUMBER OF CHILDREN 30 60 30 30 Dos Rios y�� ' .17MES'OF.MEALS 2201 34th Street y a w Evans, CO 80620 s . H 81829 30 7.',fQ 3w:302.30 4.3i NUMBER OF CHILDREN 30 60 30 30 Centennial TIMESpF,.MEALS 1400 37th Street � t Evans, CO 80620 H 81833 30 flitattmi eflgautiatr ' :2:34 4:3[ NUMBER OF CHILDREN 30 60 30 30 Jefferson TIMES OFi'MEALS 1315 4th Avenue A Greeley, CO 80631 H 81831 30 !:7,13(1f:!! 11';3( 2 30 4.3[ f NUMBER OF CHILDREN • I 30 60 30 30 Page 3 of 7 940850 SCHEDULE A (CDH-CACFP Fiscal Yearn .Does your organization have more than one licensed center? YES 7 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.) NAME &ADDRESS TYPE OF LICENSE MEALS TO BE CLAIMED OF CENTER CENTER CIWA Ciro Need flit CAPACITY LICENSE WRITTEN LICENSE per pew NUMBER ON EXPIRATION LICENSE DATE BRILWAsrar IMAM LUNCH si cx sune ast Memorial _ s �1Ji1ESWIREALS 614 East 20th. Street s •�F : Greeley, CO 80631 a 81830 30 �y �a31 2:3D 4r- NUMBER OF CHILDREN 30 60 30 3C - ?ei TIMESIO MEALS Island Grove Village ." 119 14th Avenue ` - "r " °'"' ' •' Greeley, CO 80631 (Head Start Only) H 85077 30 NUMBER OF CHILDREN 30 60 30 Frederick ltikES ze MEALS 340 Maple Frederick, CO 80530 H 66816 45 � L30 2:3D 4:3 NUMBER OF CHILDREN 45 60 45 45 Hudson TIMES OP MEALS: 300 Beech x Hudson, CO 8064211 r H 8182 30 AP305 1", 3 'i2:30 4e3( NUMBER OF CHILDREN 30 60 30 3C Milliken TIALES "MEA 300 Broad Milliken, CO 80543 (Head Start Only) H 85079 30 NUMBER OF CHILDREN 30 60 L30 Page 3 of 7 940850 SCHEDULE A (CDH-CACFP Fiscal Year tl 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.) NAME&ADDRESS TYPE OF LICENSE MEALS TO BE CLAIMED OF CENTER CENTER e-mail Cap !�Now awn CAPACITY CrCwW aehea sun LICENSE WRITTEN LICENSE p pot prom NUMBER EXPIRATION LICON ENSE DATE as .nmt aurae LUNQI sw�easune Gilcrest TIIS.OVc'11EALS £ 1175 Birch Gilcrest, CO 80623 (Head Start Only) H 85080 30 �6� NUMBER OF CHILDREN 30 60 30 Platteville Elementary 171iTEBQl /IEALS .. School , u" New Center g r«ice In process of licensing urn, mfor NUMBER OF CHILDREN 15 15 Ft. Morgan .TIt S OF 1Naa�c Site to be Determined Migrant Head Start Only) 60 Awaiting Licensing Number NUMBER OF CHILDREN 60 60 60 60 Olathe TIMES OF MEALS Site to Be Determined ` ee s Migrant Head Start Only H 95292 45 . s� NUMBER OF CHILDREN 45 45 45 45 Grand Junction TIMESOF;MEALS Site to Be Determined Migrant Head Start Only g 42 af7 x Awaiting Licensing Number NUMBER OF CHILDREN 42 142 42 42 • Page 3 of 7 940Asn __ :HEDULE B - CACFP Requirements for -- Is Each institution participating in the Progr.._.shall serve one or more spoons of peanut butter, 1/4 cup of vegetables or fruits or both of the following types of meals, as provided in its approved consisting of two or more kinds; 1/2 slice of bread or bread application: Breakfast, Lunch, Supper, Snacks served between alternate; or 1/4 cup of cooked enriched or whole-grain rice, such other meals. macaroni, noodles or other pasta products. 1. Except as otherwise provided in this section, and in any • Snack-select two of the following four components -1/2 cup appendix to this part, each meal shall contain, as a minimum, of milk; 1/2 ounce of meat or meat alternate (which includes the food components as follows: 2 ounces or 1/4 cup of yogurt); 1/2 cup of juice or equivalent quantity of fruit or vegetables; 1/2 slice of bread or bread • A BREAKFAST SHALL CONTAIN: alternate; or 1/4 cup (volume) or 1/3 ounces(weight), which- ever is less,of cereal;or 1/4 cup of cooked enriched orwhole- • A serving of fluid milk as a beverage or on cereal; or used in grain rice, macaroni, noodles or other pasta products. part for each purpose. AGE 3 UP TO 6: • A serving of vegetable(s) or fruit(s); or full-strength vegetable or fruit juice; or an equivalent quantity of any combination of • Breakfast - 3/4 cup of milk; 12 cup of juice or fruit or these foods. vegetable; 1/2 slice of bread or bread alternate; or 1/3 cup (volume)or 1/2 ounce(weight),whichever is less,of cereal;or • A serving of whole-grain or enriched bread; or an equivalent an equivalent quantity of both bread and cereal. serving of cornbread, biscuits, rolls, muffins, etc., made with whole-grain or enriched meal or flour, or a serving of whole- • Lunch or supper-3/4 cup of milk; 1 1/2 ounces (edible por- grain or enriched or fortified cereal; or a serving of cooked tion as served) of lean meat, poultry or fish; or 1 1/2 ounces whole-grain or enriched pasta or noodle products such as of cheese; or 1 egg;or 3/8 cup of cooked dry beans or peas; macaroni; or cereal grains such as rice, bulgur, or corn grits; or 3 tablespoons of peanut butter, 1/2 cup of vegetables or or an equivalent quantity of any combination of any of these fruits or both consisting of two or more kinds; t/2 slice of foods. bread or bread alternate; or 1/4 cup of cooked enriched or whole-grain rice, macaroni, noodles or other pasta products. BOTH LUNCH AND SUPPER SHALL CONTAIN: • Snack - select two of the following components - 1/2 cup of • A serving of fluid milk as a beverage. milk; 1/2 ounce of meat or meat alternate (which includes 2 ounces or 1/4 cup of yogurt); 1/2 cup of juice; or an equi- • A serving of lean meat, poultry or fish; or cheese; or an egg; valent quantity of fruitor vegetables; 1/2 slice of bread or or cooked dry beans or peas' or nuts or nut butters; or an bread alternate; or 1/3 cup (volume) or 12 ounce (weight), equivalent quantity of any combination of these foods. These whichever is less, of cereal; or 1/4 cup of cooked ennched or foods must be served in a main dish or in a main dish and whole-grain rice, macaroni, noodles, or other pasta products. one other menu item to meet this requirement. Cooked dry beans or dry peas may be used as the meat alternate or as AGE 6 THROUGH 12: part of the vegetable/fruit component, but not as both food components in the same meal. • Breakfast - 1 cup of milk; 1/2 cup of juice or fruit or vege- tables; 1 slice of bread or bread alternate; or 3/4 cup(volume) • A serving of two or more vegetables or fruits; or a com- or 1 ounce(weight),whichever is less, of cereal; or equivalent bination of both. Full-strength vegetable or fruit juice may be quantity of both bread and cereal. counted to meet not more than one-half of this requirement. • Lunch or supper- 1 cup of milk; 2 ounces (edible portion as • A serving of whole-grain or enriched bread; or an equivalent served) of lean meat, poultry or fish; or 2 ounces of cheese; serving of cornbread, biscuits, rolls, muffins, etc., made of or 1 egg; or 1/2 cup of cooked dry beans or peas; or 4 table- whole-grain or enriched meal or flour, or a serving of cooked spoons or peanut butter,3/4 cup of vegetables or fruits or both whole-grain or enriched pasta or noodle products such as consisting of two or more kinds; 1 slice of bread or bread macaroni; or cereal grains such as rice, bulgur, or corn grits; alternate; or 1/2 cup of cooked enriched or whole-grain rice, or an equivalent quantity of any combination of these foods. macaroni, noodles or other pasta products. SNACK SHALL BE SERVED BETWEEN OTHER MEAL TYPES • Snack-select two of the following components-1 cup of milk; AND CONTAIN TWO OF THE FOLLOWING FOUR COM- 1 ounce of meat or meat alternate (which includes 4 ounces PONENTS: or 1/2 cup of yogurt);3/4 cup of juice or an equivalent quantity of fruit or vegetables; 1 slice of bread or bread altemate; or • A serving of fluid milk as a beverage or on cereal; or used in 3/4 cup (volume) or 1 ounce (weight), whichever is less, of part for each purpose. cereal; or 1/2 cup of cooked ennched or whole-grain rice. macaroni, noodles, or other pasta products. • A serving of meat or meat alternate. AGE 12 AND OVER: • A serving of vegetables(s)or fruit(s);or full-strength vegetable or fruit juice; or an equivalent quantity of any combination of • Adult-size portions based on the greater food needs of older these foods. Juice may not be served when milk is served as boys and girls. the only other component INFANT MEAL PATTERNS: • A serving of whole-grain or enriched bread; or an equivalent serving of cornbread biscuits, rolls, muffins, etc., made with • 0 through 3 months: whole-grain or enriched meal or flour, or a serving of whole- grain or enriched or fortified cereal; or a serving of cooked - Breakfast -4-6 fluid ounces of iron-fortified infant formula. whole-grain or enriched pasta or noodle products such as macaroni; or cereal grains such as rice, bulgur or corn guts; - Lunch or supper - 4-6 fluid ounces of iron-fortified infant or an equivalent quantity of any combination of these foods. formula. 2. Except as otherwise provided in this section, the minimum - Snack -4-6 fluid ounces of iron-fortified infant formula. amounts of component foods to serve at meals as set forth above are as follows: • 4 through 7 months: AGE 1 UP TO 3: - Breakfast - 4-8 fluid ounces of iron-fortified infant formula; 0-3 tablespoons of iron-fortified dry infant cereal (optional). • Breakfast - 1/2 cup of milk; 1/4 cup of juice or fruit or vege- tables; 12 slice of bread or bread alternate; or 1/4 cup - Lunch or supper- 4-8 fluid ounces of iron-fortified infant (volume) or 1/3 ounce (weight), whichever is less, of cereal; formula; 0-3 tablespoons of iron-fortified dry infant cereal • or an equivalent quantity of both bread and cereal. (optional); 0-3 tablespoons of fruit or vegetable of appro- pnate consistency or a combination of both(optional). • Lunch or supper- 1/2 cup of milk; 1 ounce (edible portion as served)of lean meat, poultry or fish; or 1 ounce of cheese; or - Snack-4-6 fluid ounces of iron-fortified infant formula. 1 egg; or 1/4 cup of cooked dry beans or peas; or 2 table- Page 4 of 7 940850 • 8 months up to the first birthday - Breakfast -6-8 fluid ounces of o....-fortified infant formula 6. Substitutions may be made in food listed above in this section or 6.8 fluid ounces of whole milk; 2-4 tablespoons of iron- if individual participating children are unable, because of fortified dry infant cereal; 1-4 tablespoons of fruit or vege- medical or other special dietary needs, to consume such table of appropriate consistency or a combination of both. foods. Such substitutions shall be made only when supported by a statement from a recognized medical authority which - Lunch or supper- 6-8 fluid ounces of iron-fortified infant includes recommended alternate foods. formula or 6-8 fluid ounces whole milk;2-4 tablespoons of iron-fortified dry infant cereal and/or 1-4 tablespoons of RECORDKEEPING REQUIREMENTS (continued from meat, fish, poultry egg yolk or cooked dry beans or peas; page 2) or 1/2-2 ounces weight)of cheese; or 1 ounces(weight or volume) of cottage cheese or cheese food or cheese 12. Daily records of times children are in the center(s)(also known . spread of appropriate consistency; and 1-4 tablespoons of as sign-in/sign-out records). fruit or vegetable of appropriate consistency or a com- bination of both. 13. Special Diet Statements documenting variances from the CACFP meal patterns. - Snack - 2-4 fluid ounces of iron-fortified infant formula, whole fluid milk or full-strength fruit juice; 0-1/2 slice of 14. Food service management company contract or other food crusty enriched or whole-grain bread (optional); or 0-2 service contracts. cracker-type products (optional)made from whole-grain or enriched meal or flour that are suitable for an infant for use 15. All Department of Social Services contract(s) -For Profit Title as a finger food. XX centers only. Breastmilk, provided by the infant's mother, may be served in place 16. Records of payment and billing forms from Department of of infant formula from birth through 11 months of age. However, Social Services-For Profit Title XX centers only. meals containing only breastmilk do not qualify for reimburse- ment Meals containing breastmiik served to infants 4 months of 17. Record of deposit of CACFP reimbursement. age or older may be claimed for reimbursement when the other required meal component or components are supplied by the center. THE STATE AGENCY AND CENTER OR SPONSOR 3. For the purpose of this section, a cup means a standard FURTHER AGREE THAT: measuring cup. Thep center or sponsor shall accept full responsibility for providing • ods 4. To improve the nutrition of participating children additional foods and nrsododoing shall promt storage,provid a writte and use of n resA ponse toyclaiims may be served with each meal. that mishandlings, diversions, and/or losses resulting from improper 5. If emergency conditions prevent an institution normally having use or storage have occurred. a supply of milk from temporarily obtaining delivery thereof, the The center or sponsor shall use USDA commodity foods received State Agency, may approve the service of breakfasts, lunches, under this Agreement solely for the benefit of those persons served or suppers without milk during the emergency period. or assisted by the center or sponsor and shall not otherwise dispose of USDA commodity foods without prior written approval of the State • Agency. TO BE COMPLETED BY THE COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, CHILD AND ADULT CARE FOOD PROGRAM. Center or Sponsor will receive for its child care centers, Head Start centers, outside-school-hours centers, or For Profit Title XX centers: O Regular Donated Commodities -OR- O Cash-in-lieu of Commodities (with bonus commodities) • - Page 5 of 7 • 3400 0 I:), } • :HEDULE B - CACFP Requirements fort s Each institution participating in the Proy i shall serve one or more spoons of p- ..nut butter, 1/4 cup of vegetables or fruits or both of the following types of meals, as provided in its approved consisting of two or more kinds; 1/2 slice of bread or bread application: Breakfast, Lunch, Supper, Snacks served between alternate; or 1/4 cup of cooked enriched or whole-grain rice, such other meals. macaroni, noodles or other pasta products. 1. Except as otherwise provided in this section, and in any • Snack -select two of the following four components -1/2 cup appendix to this part, each meal shall contain, as a minimum, of milk; 1/2 ounce of meat or meat alternate (which includes the food components as follows: 2 ounces or 1/4 cup of yogurt); 1/2 cup of juice or equivalent quantity of fruit or vegetables; 1/2 slice of bread or bread A BREAKFAST SHALL CONTAIN: alternate; or 1/4 cup (volume) or 1/3 ounces (weight), which- ever is less,of cereal;or 1/4 cup of cooked enriched or whole- . • A serving of fluid milk as a beverage or on cereal; or used in grain rice, macaroni, noodles or other pasta products. part for each purpose. AGE 3 UP TO 6: • A serving of vegetable(s) or fruit(s); or full-strength vegetable or fruit juice: or an equivalent quantity of any combination of • Breakfast - 3/4 cup of milk; 1/2 cup of juice or fruit or these foods. vegetable; 1/2 slice of bread or bread alternate; or 1/3 cup (volume)or 1/2 ounce(weight),whichever is less, of cereal;or • A serving of whole-grain or enriched bread; or an equivalent an equivalent quantity of both bread and cereal. serving of cornbread, biscuits, rolls, muffins, etc., made with whole-grain or enriched meal or flour, or a serving of whole- • Lunch or supper- 3/4 cup of milk; 1 1/2 ounces (edible por- grain or enriched or fortified cereal; or a serving of cooked lion as served) of lean meat, poultry or fish; or 1 1/2 ounces whole-grain or enriched pasta or noodle products such as of cheese; or 1 egg; or 3/8 cup of cooked dry beans or peas; macaroni; or cereal grains such as rice, bulgur, or corn grits; or 3 tablespoons of peanut butter, 1/2 cup of vegetables or or an equivalent quantity of any combination of any of these fruits or both consisting of two or more kinds; i/2 slice of foods. bread or bread alternate; or 1/4 cup of cooked enriched or whole-grain rice, macaroni, noodles or other pasta products. BOTH LUNCH AND SUPPER SHALL CONTAIN: • Snack - select two of the following components - 1/2 cup of • A serving of fluid milk as a beverage. milk; 1/2 ounce of meat or meat alternate (which includes 2 ounces or 1/4 cup of yogurt); 1/2 cup of juice; or an equi- • A serving of lean meat, poultry or fish; or cheese; or an egg; valent quantity of fruit or vegetables; 1/2 slice of bread or or cooked dry beans or peas' or nuts or nut butters; or an bread alternate; or 1/3 cup (volume) or 1/2 ounce (weight), equivalent quantity of any combination of these foods. These whichever is less, of cereal; or 1/4 cup of cooked ennched or foods must be served in a main dish or in a main dish and whole-grain rice, macaroni, noodles, or other pasta products. one other menu item to meet this requirement. Cooked dry beans or dry peas may be used as the meat alternate or as AGE 6 THROUGH 12: part of the vegetable/fruit component, but not as both food components in the same meal. • Breakfast - 1 cup of milk; 1/2 cup of juice or fruit or vege- tables; 1 slice of bread or bread alternate; or 3/4 cup(volume) • A serving of two or more vegetables or fruits; or a com- or 1 ounce(weight),whichever is less, of cereal; or equivalent bination of both. Full-strength vegetable or fruit juice may be quantity of both bread and cereal. counted to meet not more than one-half of this requirement. • Lunch or supper- 1 cup of milk; 2 ounces (edible portion as • A serving of whole-grain or enriched bread; or an equivalent served) of lean meat, poultry or fish; or 2 ounces of cheese; serving of cornbread, biscuits, rolls, muffins, etc., made of or 1 egg; or 1/2 cup of cooked dry beans or peas; or 4 table- whole-grain or enriched meal or flour, or a serving of cooked spoons or peanut butter,3/4 cup of vegetables or fruits or both whole-grain or enriched pasta or noodle products such as consisting of two or more kinds; 1 slice of bread or bread macaroni; or cereal grains such as rice, bulgur or com guts; alternate; or 1/2 cup of cooked enriched or whole-grain rice, or an equivalent quantity of any combination of these foods. macaroni, noodles or other pasta products. SNACK SHALL BE SERVED BETWEEN OTHER MEAL TYPES • Snack-select two of the following components-1 cup of milk; AND CONTAIN TWO OF THE FOLLOWING FOUR COM- 1 ounce of meat or meat alternate (which includes 4 ounces PONENTS: or 1/2 cup of yogurt);3/4 cup of juice or an equivalent quantity of fruit or vegetables; 1 slice of bread or bread alternate; or • A serving of fluid milk as a beverage or on cereal; or used in 3/4 cup (volume) or 1 ounce (weight), whichever is less, of part for each purpose. cereal; or 1/2 cup of cooked ennched or whole-grain rice, macaroni, noodles, or other pasta products. • A serving of meat or meat alternate. AGE 12 AND OVER: • A serving of vegetables(s)orfruit(s);or full-strength vegetable or fruit juice; or an equivalent quantity of any combination of • Adult-size portions based on the greater food needs of older these foods. Juice may not be served when milk is served as boys and girls. the only other component INFANT MEAL PATTERNS: • A serving of whole rain or enriched bread; or an equivalent serving of cornbread, biscuits, rolls, muffins, etc., made with • 0 through 3 months: whole-grain or enriched meal or flour, or a serving of whole- grain or enriched or fortified cereal; or a serving of cooked - Breakfast -4-6 fluid ounces of iron-fortified infant formula. whole-grain or enriched pasta or noodle products such as macaroni; or cereal grains such as rice, bulgur or corn guts; - Lunch or supper - 4-6 fluid ounces of iron-fortified infant or an equivalent quantity of any combination of these foods. formula. 2. Except as otherwise provided in this section, the minimum - Snack -4-6 fluid ounces of iron-fortified infant formula. amounts of component foods to serve at meals as set forth above are as follows: • 4 through 7 months: AGE 1 UP TO 3: - Breakfast -4-8 fluid ounces of iron-fortified infant formula; 0-3 tablespoons of iron-fortified dry infant cereal (optional). • Breakfast - 1/2 cup of milk; 1/4 cup of juice or fruit or vege- tables; 1/2 slice of bread or bread alternate; or 1/4 cup - Lunch or supper - 4-8 fluid ounces of iron-fortified infant (volume) or 1/3 ounce (weight) whichever is less, of cereal; formula; 0-3 tablespoons of iron-fortified dry infant cereal or an equivalent quantity of both bread and cereal. (optional); 0-3 tablespoons of fruit or vegetable of appro- pnate consistency or a combination of both (optional). • Lunch or supper- 1/2 cup of milk; 1 ounce(edible portion as served)of lean meat, poultry or fish; or 1 ounce of cheese;or - Snack-4-6 fluid ounces of iron-fortified infant formula. 1 egg; or 1/4 cup of cooked dry beans or peas; or 2 table- • Page 4 of 7 ;r`•., 940850 • 8 months up to the first birthday: -, - Breakfast -6-8 fluid ounces of ire.. :unified infant formula 6. Substitutions max be made in food listed above in this section or 6-8 fluid ounces of whole milk; 2-4 tablespoons of iron- if individual participating children are unable, because of fortified dry infant cereal; 1-4 tablespoons of fruit or vege- medical or other special dietary needs, to consume such table of appropriate consistency or a combination of both. foods. Such substitutions shall be made only when supported Lunch or supper- 6-8 fluid ounces of iron-fortified infant by a statement from a recognized medical authority which formula or 6-8 fluid ounces whole milk;2-4 tablespoons of includes recommended alternate foods. iron-fortified dry infant cereal and/or 1-4 tablespoons of RECORDKEEPING REQUIREMENTS (continued from meat, fish, poultry egg yolk or cooked dry beans or peas; page 2) or 1/2-2 ounces(weight)of cheese; or 1-d ounces(weight or volume) of cottage cheese or cheese food or cheese 12. Daily records of times children are in the center(s)(also known spread of appropriate consistency; and 1.4 tablespoons of as sign-in/sign-out records). fruit or vegetable of appropriate consistency or a com- bination ofboth. 13. Special Diet Statements documenting variances from the - Snack - 2-4 fluid ounces of iron-fortified infant formula, CACFP meal patterns. whole fluid milk or full-strength fruit juice; 0-1/2 slice of 14. Food service management company contract or other food crusty enriched or whole-grain bread (optional); or 0-2 service contracts cracker-type products(optional)made from whole-grain or es a fieder(Door flour that are suitable for an infant for use 15. All Department of Social Services contract(s) -For Profit Title XX centers only. Breastmilk, provided by the infant's mother, may be served in place 16. Records of payment and billing forms from Department of ices -For Profit Title XX centers onl meals containing only breastmilk do not qualify for reimburse- Y - ment, Meals containing breastmilk served to infants 4 months of 17. Record of deposit of CACFP reimbursement. age or older may be claimed for reimbursement when the other required meal component or components are supplied by the center. THE STATE AGENCY AND CENTER OR SPONSOR 3. For the purpose of this section, a cup means a standard FURTHER AGREE THAT: measuring cup. The center or sponsor shall accept full responsibility for providing 4. To improve the nutrition of participating children additional foods proper accountability, storage, and use of USDA commodity foods may be served with each meal. and in so doing, shall promptly provide a written response to claims that mishandlings, diversions, and/or losses resulting from improper 5. If emergency conditions prevent an institution normally having use or storage have occurred. a supply of milk from temporarily obtaining delivery thereof, the State Agency, may approve the service of breakfasts, lunches, The center or sponsor shall for re USDA commodity foods received or suppers without milk during the emergency period. under r this Agreement solely r or the benefitnshall those erwises served or assisted by the center or sponsor and not otherwise dispose • of USDA commodity foods without prior written approval of the State Agency. TO BE COMPLETED BY THE COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, CHILD AND ADULT CARE FOOD PROGRAM. Center or Sponsor will receive for its child care centers, Head Start centers, outside-school-hours centers, or For Profit Title XX centers: ❑ Regular Donated Commodities -OR- O Cash-in-lieu of Commodities (with bonus commodities) Page 5 of 940850 • SPECIAL PROVISIONS CONTROLLER'S APPROVAL I.This contract shall not be deemed valid until it shall have been approved by the Controller of the State of Colorado or such assistant as he may designate.This provision is applicable to any contact involving the payment of money by the State. FUND AVAILABILITY 2.Financial obligations of the State of Colorado payable after the current fiscal year are contingent upon funds for that purpose being appropriated.budgeted, and otherwise made available. BOND REQUIREMENT 3.If this contract involves the payment of more than fifty thousand dollars for the construction,erection,repair,maintenance,or improvement of any building. rod,bridge,viaduct,tunnel,excavation or other public work for this State,the contractor shall,before entering upon the performance of any such work included in this contract,duly execute and deliver to the State official who will sign the contract,a good and sufficient bond or other acceptable surety to be approved by said official in a penal sum not less than one-half of the total amount payable by the terms of this contract.Such bond shall be duly executed by a qualified corporate surety conditioned upon the faithful performance of the contract and in addition,shall provide that if the contractor or his subcontractors fail to duly pay for any labor,materials.team hire,sustenance,provisions.provendor or other supplies used or consumed by such contractor or his subcontractor in performance of the work contracted to be done or fails to pay any person who supplies rental machinery,tools,or equipment in the prosecution of the work the surety will pay the same in an amount not acceding the sum specified in the bond,together with interest at the rate of eight per cent per annum.Unless such bond is executed-delivered and filed,no claim in favor of the contractor arising under such contract shall be audited,allowed or paid.A certified or cashier's check or a bank money order payable to the Treasurer of the State of Colorado may be accepted in lieu of a bond.This provision is in compliance with CRS 38-26-106. INDEMNIFICATION r. 4.To the extent authorized by law,the contractor shall indemnify,save.and hold harmless the State,its employees and agents,against any and all claims, damages,liability and court awards including costs,expenses,and attorney fees ineuned as a result of any act or omission by the contractor.or its employees, agents,subcontractors,or assignees pursuant to the terms of this contract. DISCRIMINATION•AND AFFIRMATIVE ACTION 5.The contractor agrees to comply with the letter and spirit of the Colorado Antidiscrimination Act of 1957,as amended,and other applicable law respecting discrimination and unfair employment practices(CRS 24-34-402),and as required by Executive Order.Equal Opportunity and Affirmative Action,dated April 16, 1975.Pursuant thereto.the following provisions shall be contained in all State contracts or sub-contracts. During the performance of this contract,the contractor agrees as follows: • (a)The contractor will not discriminate against any employee or applicant for employment because of race,creed,color, national origin.sex, marital status,religion,ancestry,mental or physical handicap,or age.The contractor will take affirmative action to insure that applicants are employed,and that employees are treated during employment,without regard to the above mentioned characteristics.Such action shall include,but not be limited to the follow mg: employment upgrading,demotion,or transfer.recruitment or recruitment advertisings;lay-offs or terminations:rates of pay or other forms of compensation:and selection for training,including apprenticeship.The contractor agrees to post in conspicuous places,available to employees and applicants for employment, notices to be provided by the contracting officer setting forth provisions of this non-discrimination clause. (b):Thecontractor will,in all solicitations or advertisemems for employees placed by or on behalf of the contractor,state that all qualified applicants will receive consideration for employment without regard io rat,creed,color,national origin.sex,marital status,religion;ancestry,mental or physical handicap, • or age. . • (e)The.contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement or other contract or understanding,notice to be provided by,the contracting officer,advising the labor union or workers'representative of the contractor's commitment under the £aecutive Order,Equal Opportunity and Affirmative Actson.dated April 16,1975.and of the roles:regulations;tad relevant Ordaaof the-Govveiaor. (d)The contractor and labor unions will furnish all information and reports required by Executive Order.Equal Opportunity and Affirmative Action of April 16;1975:and by the rules,regulations and Orders of the Governor,or putguanf thereto.and will permit access to hia.books:.seeeds,and accounts by the oontracting agency and the office of the Garner or hiadesigpee for pusposef ofin estigatibn to ascertain-compliance with such roles:regulations and orders.. (e)A labor organization will not exclude any individual otherwise qualified from full membership rights in such labor organization.or expel any such individual from membership in such labor organization or discriminate against any of its members in the full enjoyment of work opportunity because of doe,creed,color. sex,national origin,or ancestry. (f)A labor organization,or the employees or members thereof will not aid,abet,incite,compel or coerce the doing of any act defined in this contract to be discriminatory or obstruct or prevent any person from complying with the provisions of this contract or any order issued thereunder,or attempt,either directly or indirectly,to commit any act defined in thiscontract to be discriminatory. Form 6-AC-028 Revised 1/93 395.53A1.10Z2 page _ of pages 940850 (g)In the event of the contractor's non-compliance with the non-discrimination clauses of this contract or with any of such rules,regulations.or orders, this contract may be canceled- terminated or suspended in whole or in pan and the contractor may be declared ineligible for further State contracts in accordance with procedures.authorized in Executive Order, Equal Opportunity and Affirmative Action of April 16. 1975 and the rules,regulations, or orders promulgated in accordance therewith,and such other sanctions as may be imposed and remedies as may be invoked as provided in Executive Order, Equal Opportunity and Affirmative Action of April 16, 1975. or by rules, regulations.or orders promulgated in accordance therewith,or as otherwise provided by law. (h)The contractor will include the provisions of paragraphs(a)through(h)in every sub-contract and subcontractor purchase order unless exempted by rules-regulations,or orders issued pursuant to Executive Order.Equal Opportunity and Affirmative Action of April 16. 1975.so that such provisions will be binding upon each subcontractor or vendor.The contractor will take such action with respect to any sub-contracting or purchase order as the contracting agency may direct,as a means of enforcing such provisions,including sanctions for non-compliance;provided,however.that in the event the contractor becomes involved in,or is threatened with.litigation,with the subcontractor or vendor as a result of such direction by the contracting agency,the contractor may request the State of Colorado to enter into such litigation to protect the interest of the State of Colorado. COLORADO LABOR PREFERENCE 6a.Provisions of CRS 8-17-101 & 102 for preference of Colorado labor are applicable to this contract if public works within the State are undertaken hereunder and are financed in whole or in part by State funds. b.When a construction contract for a public project is to be awarded to a bidder,a resident bidder shall be allowed a preference against a non-resident bidder from a state or foreign country equal to the preference given or required by the state or foreign country in which the non-resident bidder is a resident.If it is determined by the officer responsible for awarding the bid that compliance with this subsection.06 may cause denial of federal funds which would otherwise be available or would otherwise be inconsistent with requirements of Federal law,this subsection shall be suspended,but only to the extent necessary to prevent denial of the moneys or to eliminate the inconsistency with Federal requirements(CRS 8-19-101 and 102) GENERAL 7.The laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation,execution, and enforcement of this contact.Any provision of this contract whether or not incorporated herein by reference which provides for arbitration by any extra-judicial body or person or which is otherwise in conflict with said laws,rules,and regulations shall be considered null and void.Nothing contained in any provision incorporated herein by reference which purports to negate this or any other special provision in whole or in part shall be valid or enforceable or available in any action at law whether by way of complaint, defence.or otherwise.Any provision rendered null and void by the operation of this provision will not invalidate the remainder of this contract to the extent that the contract is capable of execution. 8.At all times during the performance of this contract,the Contractor shall strictly adhere to all applicable federal and state laws.rules.and regulations that have been or may hereafter be established. 9.The signatories aver that they am familiar with CRS 18.8.301,et.seq.,(Bribery and Corrupt Influences)and CRS 18-8-401.et.seq.,(Abuse of Public Office). and that no violation of such provisions is present. 10.The signatories aver that to their knowledge,no state employee has any personal or beneficial interest whatsoever in the service or property described herein: IN WITNESS WHEREOF,the parties hereto have executed this Contract on the day first above written. Contractor: (Full Legal Name) W.H. Webster STATE OF COLORADO ROY ROMER,GOVERNOR Weld County Board of Commissioners By for q '5 EXECUTIVE DIRECTOR Position(Title) Chair.erson V'r — s..xlJs-'T1 -um. ror dereQ'. r DEPARTMENT HEALTH OF 4 I Attest By Corporate Secretary.or E9 v ent:TowniCity/Coanty rk APPROVALS ATTORNEY GENERAL CONTROLLER By By • Form 6-AC-02C • Revised 1/93 Page _Z which is the last of a_ pages 395.53-01-1030 'See instructions on reverse side. PROGRAM APPROVAL: O4flacn Colorado Department of Puvrtc Health and Environment - Chits ....id Adult Care Food Program Annual Program Renewal Form October 1, 1994 -September 30, 1995 )ear Center CACFP Representatives: This form reflects the most current information the Colorado Department of Public Health and Environment,Child and Adult Care Food Program (CDPHE-CACFP) has on file concerning your center and its participation in the CACFP. Please review the form and verify the accuracy of the information. Make the necessary corrections to anything that is not correct and/or no longer applicable and add anything that is missing. Sign and return the form to the CDPHE-CACFP. If you have any questions, please contact Wanda Unterzuber at 303-692-2346. 1. CENTER/SPONSOR INFORMATION FOR CDH-CACFP USE ONLY Renewal Complete-Postcard Sent O Date: Agreement Number: 65103-05 Federal Tax ID Number: 84-6000813 Renewal Incomplete-Phone Cap El Date: Name and Address:FAMILY EDUC NETWORK OF WELD Person Contacted: COUNTY HEAD START Consultant Approval: 1551 NO 17TH AVE PO BOX 1805 GREELEY CO 80632- County: Weld Authorized Representative:TERE KELLER-AMAY Program Primary Telephone: ( Alternate Telephone: FAX1303)356-3975 Co act: TEREKELLER-AMAYR 3—A3800 MAILING ADDRESS If you would like your reimbursement check mailed to an address different from the above, you must complete a new W-9 form reflecting the new address and submit it to our office. 2. LICENSING INFORMATION 507 License Number: N/A License Capacity: WiC License Expiration Date:Varies Timely Renewal: N 3. SCHEDULE I OPERATING INFORMATION Does center care for infants? Age Range of Participants5yrs No Days Open: Mon-₹rrY> Hours: Number of Shifts: 2 + 9 9 Pa 6wkA° 5 rs ,3.} Sat 6:30 -6:00 1 during Migrant Does ce ter ctlr infants Number of Sites Operated: 11 o the CACFP� "5 Oct Nov Dec Jan Feb Mar Apr May Jun Jul fd- Aug Sep ces No. Months Approved for CACFP Participation 1 g g g � g r..^`! 4. FOOD SERVICE INFORMATION If a child is in care for 8 hours or more, does the center Breakfast AM Snack Lunch PM Snack Supper Late Snack claim 4 meals per child per day? Yea No Meals Approved 91 For the period 10/1/94-9/30/95,your c r will r : i e: Meals are: Prepared at the center Prepared off-site z Dist. 6, RE-3 Fir � Cash-In-Lieu of Commodities bt. Vraain5 & Center contracts meal service Yes No Contractors Name: 12 Contract Expiration Date: "t (Retum a copy of the contract covering 10/94.9/95) Is this program a pacing program? Yes LSI No List the staff members that will perform Child and Adult Care Food Program food service functions. Position Name of Person Specific CACFP Food Service Duties 5. FOR PROFIT CENTERS ONLY List the names of the counties your center has Title XX contracts with and the expiration date of the contracts. Retum copies of each contract. County: Expiration Date: County: Expiration Date: County: Expiration Date: County: Expiration Date: I have reviewed this form and certify that the information it contains is correct and accurately reflects the current situation at the Center. • Print \' /� Print \ l • Name:Tit e (..Aer -Ii1vv n.1 Title trt t to l Signature: �---- 4 STD ate: 8/24/94 CDHPE-CACFP-305 (7/94) 940850 CDPHE-CACFP CIVIL RIGHTS COMPLIANCE REVIEW The Colorado Department of Public Health and Environment, Child and Adult Care Food Program is required to conduct a preaward civil rights compliance review of centers or sponsors of centers applying for CACFP participation. Please complete the following information: 1. Write the of each racial/ethnic group in the area your cater is serving. Usually this information can be obtained from the local school district, o Commerce,Census Bureau,or Public Library. If you have more than one center,combine this information for all caters. .05% American Indian or Alaskan Native 71% Hispanic(?orother n of culture or origin Puerto ,regardless of race)Cuban,Central or � 0 Asian or Pacific Islander f Hiic ori 28% White(not of Hispanic origin) .05% Black(not ospangin) 2. 'Count the actual number of children enrolled in your center for each group listed below. Write the number in the space provided. If you have more than one center, combine this information for all centers. 2 American Indian'or Alaskan Native 316 Hispanic(a person of Mexican, Puerto Rican, Cuban, Central or South American. or other Spanish culture or origin, regardless of 0 Asian or Pacific Islander race) 3 Black(not of Hispanic origin) 124 White(not of Hispanic origin) '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/Guardians may be asked to identify the racial/ethnic group of their own child only after it hasten explained,and they as well as we understand 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. 3. The CDPHE-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 and grassroots organizations have an equal opportunity to participate or are informed about changes in the Program? Please check those that apply: X Distribution of brochures of Program information at public locations X Public service announcements in local newspaper,on radio, or on television(circle media type used) _Paid advertisements in local newspapers _ Other. Please explain: Do or will the items you checked above include the following nondiscrimination statement?Yes X 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 m 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 We assure the Colorado Department of Public Health /\and Environment, Child and Adult Care Food Program that at all enrolled participants in regardless and race,l color Food a national origin,age, sex,or handicap,and there pis lno discrimiin Lion mrvthe course of the meals service. char //it/P^ August 24, 1994 Signature o A mistra[or or uthonze epresentative Uate Administrator Signature of the CDPHE-CACFP Title Date q (CDPHE-CACFP 6/94) 9408C50 CDPHE-CACFP CIVIL RIGHTS COMPLIANCE REVIEW / A The Colorado Department of Public Health and Environment, Child and Adult Care Food Program is required to conduct a preaward civil rights compliance review of centers or sponsors of centers applying for CACFP participation. Please complete the following information: 1. Write the of each racial/ethnic group in the area your center is serving. Usually this information can be obtained from the local school district, r o Commerce,Census Bureau,or Public Library. If you have more than one center,combine this information for all centers. American Indian or Alaskan Native 71% Hispanic(a person of Mexican Puerto Rican,Cuban,Central or South 0 S% American,or other Spanish culture or origin,regardless of race) 0 Asian or Pacific Islander 287. White(not of Hispanic origin) .057. Black(not of Hispanic origin) 2. you the actual ctu lnl number mbe of children coine enrolled t iledds din you center n me all rcead group listed below. Write the number in the space provided. If ham re 2 American Indian'or Alaskan Native 11 F Hispanic(a person of Mexican,Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of 0 Asian or Pacific Islander race) 3 Black(not of Hispanic origin) 17 4 White(not of Hispanic origin) '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/Guardians may be asked to identify the racial/ethnic group of their own child only after it has been explained,and they as well as we understand 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. 3. The CDPHE-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 and 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 X Public service announcements in local newspaper, on radio, or on television(circle media type used) _Paid advertisements in local newspapers Other. Please explain: Do or will the items you checked above include the following nondiscrimination statement?Yes X 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. My 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 S. Have you ever been found to be in noncompliance of the Civil Rights laws by any federal agency? Yes No If yes, please explain the Child andeAdult Colorado eDFood programatbthe center(and )described n the application forms are Food ed the sani�meals at no senaratencharvr� regardless or race, color, national origin, age, sex, or handicap, and there is no discrimination in the course of the meal service. 11�� J/ r�, _ ,,-J August 24, 1994 Signature o ilmmistrator or u ionize presentative Date Administrator Signature of the CDPHE-CACFP Title Date (CDPHE-CACFP 6/94) 940850 0 C = I V. C T G u L U — J r. _ _ L v U C — _ C.: ^— - _ C 'el: ^ Cr Ca — C- L ^ G C. >•• \ _ _ Co L _ r .. ". _ U E L .. C ` _ c . — C C C C .. r. C = c" s C F _ _ - _ c: : _ _ C - _ L — C - G _ -CC_ _. _ Ct< Is � ` _'. 3 _ > y 3 U C CC) C L. U — Z Y c E < _ _ .= — . C G :J - u T -•.••• L - C - .. - L — - 3 L: C C — C L - I-• ". I Cs L -. '7L C. L G Z L. ` . _ 7. ` — a— U _ C) >. 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Center/Sponsoring Weld County Division of Human Services Organization: Family Educational Network of Weld Count VAgreement Number: 65103-05 1 Address: P.O. Box 1805 1551 North 17th Avenue 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 Services 5. What federal funds does your organization receive other than CACFP? (Examples: National School Lunch Program,Title XX) Head Start - Region VIII $ 1,400,000.00 Head Start - Region XII $ 1,300,000.00 6. What is the total annual budget for the organization identified in Question#4? (include all federal,state,and"other" funds) $ 6 nnn non nn 7. When does your organizations's fiscal year begin and end? January 1st through December31 8. Does your organization have fiscal year end schedules(financial statements)? Yes X No 9. Does you organization have computerized records? Yes X No Questionnaire prepared by: Marilyn Carlino Date: August 25, 1994 Title: Fiscal Officer Phone Number: (303 ) 353-3800 (CDPHE-CACFP 8/94:Fatms\AuditQue.PM5) fail tiara • SPECIAL PROVISIONS CONTROLLER'S APPROVAL I.This contract shall not be deemed valid until it shall have been approved by the Controller of the State of Colorado or such assistant as he may designate.This provision is applicable to any contract involving the payment of money by the State. FUND AVAILABILITY 2.Financial obligations of the State of Colorado payable after the current fiscal year are contingent upon funds for that purpose being appropriated,budgeted. and otherwise made available. ' BOND REQUIREMENT 3.If this contract involves the payment of more than fifty thousand dollars for the construction,erection,repair,maintenance,or improvement of any building, read-bridge,viaduct.tunnel,excavation or other public work for this State,the contractor shall,before entering upon the performance of any such work included in this contract,duly execute and deliver to the State official who will sign the contract.a good and sufficient bond or other acceptable surety to be approved by said official in a penil sum not less than one-half of the total amount payable by the terms of this contract.Such bond shall be duly executed by a qualified corporate surety conditioned upon the faithful performance of the contract and in addition,shall provide that if the contractor or his subcontractors fail to duly pay for any labor,materials,team hire,sustenance,provisions.provendor or other supplies used or consumed by such contractor or his subcontractor in performance of the work contracted to be done or fails to pay any person who supplies rental machinery,tools,or equipment in the prosecution of the work the.surety will pay the same in an amount not exceeding the sum specified in the bond,together with interest at the rate of eight per cent per annum.Unless such bond is executed.delivered and filed,no claim in favor of the contractor arising under such contract shall be audited,allowed or paid.A certified or cashier's check or a bank money order payable to the Treasurer of the State of Colorado may be accepted in lieu of a bond.This provision is in compliance with CRS 38-26-106. INDEMNIFICATION 4.To the extent authorized by law,the contractor shall indemnify, and hold harmless the State, its employees and agents,against any and all claims. damages,liability and court awards including costs,expenses,and attorney fees incurred as a result of any act or omission by the contractor.or its employees, agents,subcontractors,or assignees pursuant to the terms of this contract. DISCRIMINATION•AND AFFIRMATIVE ACTION 5.The contractor agrees to comply with the letter and spirit of the Colorado Antidiscrimination Act of 1957. as amended,and other applicable law respecting discrimination and unfair employment practices(CRS 24-344021,and as required by Executive Order.Equal Opportunity and Affirmative Action,dated April 16, 1975.Pursuant thereto.the following provision shall be contained in all State contracts or sub-contracts. During the performance of this contract,the contractor agrees as follows: • (a)The contractor will not discriminate against any employee or applicant for employment because of race,creed,color, national origin, sex, marital status, religion,artcesary,mental or physical handicap,or age.The contractor will take affirmative action to insure that applicants are employed,and that employees am treated dining employment,without regard to the above mentioned characteristics.Such action shall Slttde,but not be limited to the following: employment upgrading,demotion.or transfer,nxruirment or recruitment advertisings:lay-offs or terminations:rates of pay or other forms of compensation:and selection far training, including apprenticeship.The contractor agrees to post in conspicuous places,available to employees and applicants for employment. notices to be provided by the contracting offerer setting forth provisions of this non-discrimination clause. (b)Thecontractor will io all solicitations or advertisements for employees placed by or on behalf of the contractor,state that all qualified applicants gill receive consideration for employment without regard io taen creed,color,national origin,sex.marital status,religion,ancestry,mental or physical handicap. or age. • _ (e)The.contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement or other contract or understanding,notice to be provided by the contracting officer,advising the labor union or workers'representative of the contractor's commitment under the Executive order.Equal Opportunity and Affirmative Action,dated April 16,1975,and of the rules.regulations.and releva it Ordersof the•Govemor:. • (d)the contractor and labor unions will furnish all information and reports required by Executive Order,Equal Opportunity and Affirmative Action of April 16..1975;and by the rules,regulations and Orden of the Governor,or pursuant thereto,and will permit access to his.books..records,and accounts by the Contracting agency and the office of the Governor or hi•designee for purposes of investigation to ascertain compliance with such mica.-regulations and orders. (e)A labor organization will not exclude any individual otherwise qualified from full membership rights in such labor organization,or expel any such individual from membership in such labor organization or discriminate against any of its members in the full enjoyment of work opportunity because of rite,creed,color. sex,national origin,or ancestry. • (f)A labor organization,or the employees or members thereof will not aid,abet,incite,compel or coerce the doing of any act defined in this contract to be discriminatory or obstruct or prevent any person from complying with the provisions of this contract or any order issued thereunder,or attempt,either directly or indirectly,to commit any act defined in this contract to be discriminatory. Fenn 6-AC-028 Revised 1/93 39553-01.1022 page_( of _Z pages 940850 (g)In the event of the contractor's non-compliance with the non-discrimination clauses of this contract or with any of such rules,regulations.or orders, this contract may be canceled, terminated or suspended in whole or in pan and the contractor may be declared ineligible for further State contracts in accordance with procedures. authorized in Executive Order, Equal Opportunity and Affirmative Action of April 16. 1975 and the rules. regulations.or orders promulgated in accordance therewith,and such other sanctions as may be imposed and remedies as may be invoked as provided in Executive Order. Equal Opportunity and Affirmative Action of April 16. 1975. or by rules,regulations.or orders promulgated in accordance therewith, or as otherwise provided by law. (h)The contractor will include the provisions of paragraphs(a)through(h)in every sub-contract and subcontractor purchase order unless exempted by rules,regulations,or orders issued pursuant to Executive Order,Equal Opportunity and Affirmative Action of April 16. 1975.so that such provisions will be binding upon each subcontractor or vendor.The contractor will take such action with respect to any sub-contracting or purchase order as the contracting agency may direct,as a means of enforcing such provisions.including sanctions for non-compliance:provided,however,that in the event the contractor becomes involved in.or is threatened with.litigation,with the subcontractor or vendor as a result of such direction by the contracting agency,the contractor may request the State of Colorado to enter into such litigation to protect the interest of the State of Colorado. COLORADO LABOR PREFERENCE 6a.Provisions of CR5 8-17-101 At 102 for preference of Colorado labor are applicable to this contract if public works within the State are undertaken hereunder and arc financed in whole or in pan by State funds. b.When a construction contract fora public project is to be awarded to a bidder,a resident bidder shall be allowed a preference against a non-resident bidder from a state or foreign country equal to the preference given or required by the state or foreign country in which the non-resident bidder is a resident.If it is determined by the officer responsible for awarding the bid that compliance with this subsection.06 may cause denial of federal funds which would otherwise be available or would otherwise be inconsistent with requirements of Federal law,this subsection shall be suspended,but only to the extent necessary to prevent denial of the moneys or to eliminate the inconsistency with Federal requirements(CRS 8.19-101 and 102) GENERAL 7. The laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation.execution, and enforcement of this contract.Any provision of this contract whether or not incorporated herein by reference which provides for arbitration by any extra-judicial body or person or which is otherwise in conflict with said laws,rules,and regulations shall be considered null and void.Nothing contained in any provision incorporated herein by reference which purports to negate this or any other special provision in whole or in pan shall be valid orenforceable or available in any action at law whether by way of complaint, defence,or otherwise.Any provision rendered null and void by the operation of this provision will not invalidate the remainder of this contract to the extent that the contract is capable of execution. 8.At all times during the performance of this contract,the Contractor shall strictly adhere to all applicable federal and state laws,rides,and regulations that have been or may hereafter be established. 9.The signatories aver that they are familiar with CR5 18.8-301.et.seq..(Bribery and Corrupt Influences)and CRS 18-8.401,et,seq.,(Abuse of Public Office). and that no violation of such provisions is present. 10.The signatories aver that to their knowledge,no state employee has any personal or beneficial interest whatsoever in the service or property described herein: IN WITNESS WHEREOF,the parties hereto have executed this Contract on the day first above written. Contractor: • (Full Legal Name) W H WPhgt Pr fhairpergnn STATE OF COLORADO ROY ROMER,GOVERNOR Board of Con ry ommiq nnerc By for Q J /�4 '5 EXECUTIVE DIRECTOR Position(Title) Chairperson Soon yweer�e Faar/ DEPARTMENT If Corporation:) �A./Vjlrr'�II(AA{/// OF HEALTH Attest(Sea • By Corporate Seeman.or Equivalent.TowMtry/Coony Clerk APPROVALS ATTORNEY GENERAL CONTROLLER - By By • Fenn 6-AC-02C Revised I/93 Page which is the last of_Z pages .395-53-0 030 'Sin instructions on reverse side. PROGRAM APPROVAL: 940851 mEmoRAnDum Whit Board of County Commissioners To W. H. Webster, Chairperson Date September 12 1994 COLORADO From Walter J. Speckman, Executive Director, Human Services Subject: Agreement between FENWC & Colorado Department of Health, Child and Adult 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 cal Tere Keller-Amaya at 353-3800. 1 940850 r1 Hello