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Home My WebLink AboutCOM 0533.103 2000-2002 J~SY ®F h~~ j'~ ~~6i~s Patricia G. Engelhard . Harry Kim ; - Director hfa or d;•8 «o ae~*m• Pamela N. Mizuno ®~.~lp ~r ~~~i ` l Deputy Director DEPARTMENT OF PARIS AND RECREATION 25 Aupuni Street, Room 210 • Hilo, Hawaii 96720-4252 (808) 961-8311 • Fax (808) 961-8411 ' DATE: July 1, 2002 ~ - TO: James Y. Arakaki Council Chair and Council Members VIA: Deanna Sako, Controller FROM: Patricia Engelhard, Directo RE: NOTIFICATION OF GRANT AWARD Compliance with Ordinance No. Section 7(1) 02 -lL Name of Grant Program: Summer Food Service Program Grantor: LJS Department of Agriculture, Food and Nutrition Service County Grantee Department or Agency: Parks and Recreation -Recreation Division Grant No. (IF KNOWN): 1707-8 Amount of Grant: $27,585 Amount of County Match: None County Revenue ~i Expenditure Account Numbers: 3302.76 (Revenue) 010 500 5509.30-341 (Expenditure) Grant Period (Commencement & Completion): June 17, 2002 -July 26, 2002 Purpose of Grant: Summer Fun Meal Program Is final report required by grantor? ~ Yes ®No Notification attached: ®Yes ? No, because C%omrra, N® File No. Ref. ~o:.,~ Rif. U 7 Form NGA 6/O1 s.,®,.~.~ SFSP-25, 3/87, RS 87-1421 ,'`E_-~°~~w STATE OF HAWAII q``,`~;~'~.9- DF.PARTMENi OF EDUCATION N~TlFIC~~I®~ ' OFF!CE. OF BUSINESS SERVICES s: l School Food Services Branch ®~i 1106 Koko Head Avenue ~`''g~:e-~;:a;~`'m Honolulu, Hawaii 96816-3797 (Sumer food ~~r~ic~ ~rograrrn for children) 1. Agreement Number 2. Action Code 3. Fiscal Year 4. Type of Sponsor 5. Type of Program E=ESTABLISH A. School 1. Self-prep ok (New to master file) 8. GOV 2. Vended digit C=CHANGE TO MASTER FILE C. Res. Camp 3. Combination D=DELETE FROM MASTER FILE D. Others Self-Prep & Vended ? ? 6. Name and Address of Service Institutian (Do not exceed maximum line length) 7. Telephone Number 8. Contact Person f; 1: ~ 9. RReals Authorized (Enter 0, 1, or 2 indicating number of 10. Average Daily Number of 11. Days of Operation meal(s) per child to be served each day.) Children Served (estimate) (actual) Breakfast Lunch Supper Supplement June July August . a o a a m m m 12. tlAonths Approved for Operation 13. Number of 14. Administrative 15. Request for Advance Payment o=NO 1=YES Self-Prep Sites Cost Limitations o=NO i=ves June July August Dollars Admin f~1OpeI1'r 16. Advance Authorization for Administrative Cost 17. Advance Authorization for Operating Cost (Whole Dollars Only) (Whole Dollars Only) Firs4 Advance Second Advance First Advance Second Advance Thi?d Advance 18. Number of Sites by Type A. Schools B. Government C. Residential Camps D. Other ti 19. Commenis 20. Dafe of Preparation Signature Tiile M~ont~h Day Year W ~ ~ School Faoc~ ur<rvices Supelvisee DISTRIBUTIONS (~Rir;inlni _ nnG ~+nrtic.,,, , o,.~.._, ~ _ SFSP-1 S~ O F H q Ai'~ 1959. 9, STATE OF HAWAII DEPARTMENT OF EDUCATION AGREEMENT BETWEEN SPONSOR & F~ ~ School Food Services Branch DEPARTMENT OF EDUCATION • 1106 Koko Head Avenue ~~~.___..i:e Honolulu, HI 96816.3797 SLIMMER FOOD SERVICE PROGRAM FOR CHILDREN NAME & MAILING ADDRESS OF SPONSOR (SAME AS ENTERED ON AGREEMENT NUMBER: (FOR DOE USE ONLY) ~ J] 0 APPLICATION FOR PARTICIPATION, SFSP-3. TYPE OR PRINT) ~ County Of HaWali (NO MONIES OR OTHER BENEFITS MAY BE PAID OUT UNDER THIS RECREATION DTVIS ION PROGRAM UNLESS THIS AGREEMENT IS COMPLETED AND FILED AS Department of Parks & Recreation REQUIlZED BY EXISTING PROGRAM REGULATIONS 7 CFR, PART 225) 799 Plllani Street DATES PROGRAM APPROVED TO OPERATE Hilo HI 96720 QOM' 6/6/17/02 TOc 7 26 02 INSTRUCTIONS: (1) SIGNING OF AGREEMENT - AN ORIGINAL AND ONE COPY OF THIS AGREEMENT MUST BE SIGNED AND SUBMITTED WITH THE APPLICATION FOR PARTICIPATION (SFSP-3) TO THE DEPARTMENT OF EDUCATION. (2) COMPLETE SFSP-1 ATTACHMENT A: THE NAME AND LOCATION OF EACH SITE, THE TOTAL NUMBER OF DAYS OF OPERATION OF EACH SITE, THE TYPES OF MEALS TO BE SERVED AT EACH SITE, AND THE ESTIMATED AVERAGE DAILY ATTENDANCE (ADP) AT EACH SITE. DOE WII.L ENTER AN APPROVED OR DISAPPROVED INDICATION, FOR EACH SITE LISTED. (3) DOE WII,L ENTER SPONSOR'S ADMINISTRATIVE COSTS FOR THE SUMMER FOOD SERVICE PROGRAM IN SFSP-1 ATTACHMENT B. (4) A COPY OF THE PROGRAM REGULATIONS IS ATTACHED TO THIS FORM AND BECOMES A PART OF THIS AGREEMENT. (5) A COPY WII.L BE RETURNED TO THE SPONSOR FOR THEIl2 FII.ES WHEN THIS AGREEMENT IS APPROVED. IN ORDER TO CARRY OUT THE PURPOSE OF SECTYON 13 OF THE NATIONAL SCHOOL LUNCH ACT, (42 U.S.C. 1761) AS AMENDED, AND THE REGULATIONS GOVERNYNG THE SUMMER FOOD SERVICE PROGRAM FOR CHILDREN ISSUED THEREUNDER 7 CFR PART 225, .(HEREINAFTER ''FERRED TO AS THE "SUMMER PROGRAM") THE DEPARTMENT OF EDUCATION (fIDREINAFTER REFERRED TO AS "DOE") AND THE SPONSOR ~ LOSE NAME AND ADDRESS APPEAR ABOVE COVENANT AND AGREE AS FOLLOWS: DOE: AGREES TO REIMBURSE THE SPONSOR IN CONNECTION WITH MEALS SERVED IN ACCORDANCE WITH REGULATIONS UNDER THE SUMMER PROGRAM TO APPROVED STIES LLSTED IN ATTACHMENT A DURING THE PERYOD STATED ABOVE. SHALL TERMINATE A SPONSOR'S PARTICIPATION IN THE PROGRAM BY WRITTEN NOTICE WHENEVER TT IS DETERMINED BY DOE THAT THE SPONSOR HAS FAII,ED TO COMPLY WITH THE RULES OF THE PROGRAM. SHALL INFORM THE SPONSOR OF TTS RIGHT TO REQUEST A REVIEW OF DECISIONS MADE BY DOE WHICH AFFECT THE PARTICIPATION OF A SPONSOR IN THE PROGRAM OR THE SPONSOR'S CLAIM FOR REIMBURSEMENT. THE SPONSOR: REPRESENTS AND WARRANTS THAT TT WILL ACCEPT FINAL ADMINISTRATIVE AND FINANCIAL RESPONSIBII,TTY FOR TOTAL PROGRAM OPERATIONS AT ALL STIES LISTED IN ATTACHMENT A. HEREBY AGREES THAT TT WILL COMPLY WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 (P. L. 88-352) AND ALL REQUII2EMENTS IMPOSED BY THE REGULATIONS OF THE DEPARTMENT OF AGRICULTURE (7 CFR PART 15), DEPARTMENT OF JUSTICE (28 CFR PARTS 42 & 50), AND FNS DIItECTIVES OR REGULATIONS LSSUED PURSUANT TO THE ACT OF THE REGULATIONS, TO THE EFFECT THAT, NO PERSON IN THE UNTIED STATES SHALL, ON THE GROUND OF RACE, COLOR, NATIONAL ORIGIN, GENDER, RELIGION, AGE, DISABILITY, POLITICAL BELIEFS, SEXUAL ORIENTATION, AND MARTIAL OR FAMII,Y STATUS (NOT ALL PROHIBITED BASES APPLY TO ALL PROGRAMS), BE EXCLUDED FROM PARTICIPATION IN, BE DENIED THE BENEFITS OF, OR OTHERWISE BE SUBJECT TO DISCRIMINATION UNDER ANY PROGRAM OR ACTIVITY FOR WHICH THE APPLICANT RECEIVED FEDERAL FINANCIAL ASSISTANCE FROM DOE; AND HEREBY GIVES ASSURANCE THAT TT WILL IMMEDIATELY TAKE ANY MEASURES NECESSARY TO EFFECTUATE THIS AGREEMENT. THIS ASSURANCE is GIVEN CONSIDERATION OF AND FOR THE PURPOSE OF OBTAINING ANY AND ALL FEDERAL FINANCIAL ASSISTANCE, GRP.NTS AND LOANS OF FEDERAL FUND, REIMBURSABLE EXPENDITURES, GRANT OR DONATION OF FEDERAL PROPERTY AND INTEREST IN PROPERTY, THE DETAIL 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 SISTANCE EXTENDED TO THE APPLICANT BY DOE. THIS INCLUDES ANY FEDERAL AGREEMENT, ARRANGEMENT, OR OTHER CONTRACT RICH HAS AS ONE IF TTS PURPOSE THE PROVISION OF ASSISTANCE SUCH AS FOOD, CASH ASSISTANCE FOR THE PURCHASE OF FOOD, RENTAL OF FOOD SERVICE EQUIPMENT OR ANY OTHER FINANCIAL ASSISTANCE EXTENDED IN RELIANCE ON THE REPRESENTATIONS AND AGREEMENTS MADE IN THIS ASSURANCE. THIS ASSURANCE IS BINDING ON THE APPLICANT, TTS SUCCESSORS, TRANSFEREES, AND ASSIGNEES AS LONG A5 TT RECEIVES ASSISTANCE OR RETAINS POSSESSION OF ANY ASSISTANCE FROM DOE. THE PERSON OR PERSONS WHOSE SIGNATURES APPEAR BELOW ARE AUTHORIZED TO SIGN THIS ASSURANCE ON THE BEHALF OF THE APPLICANT. _ _ _ SFSP-1 ATTACIiMENT A ~ O F Hq - .~P:'e X959. \9~ STATE OF HAWAII ".'i DEPARTMENT OF EDUCATION SUMMER FOOD SERVICE PROGRAM g~ ! School Food Services Branch s``~ _ 1106 Koko Head Avenue woe Honoiuln, Hl 96816-3797 SITE INFORMATION SI-IFFY ~6 _e.pp. POG9' County of Hawaii-Department of Parks SPONSOR NAME: & Recreation -Recreation Divisio AGREEMENT NUMBER: ~ _ ~,r INSTRUCTIONS: COMPLETE EVERYTHING IN BLACK INK. LIST SITES CONSECUTIVELY. IF MORE SPACES FOR SPfES ARE NEEDED, PLEASE DUPLICATE THIS PAGE. SHOW ONLY THE TOTAL NUMBER OF DAYS FOOD WILL BE SERVED. DO NOT INCLUDE HOLIDAYS (JULY 4) OR WEEKENDS, UNLESS FOOD IS ACTUALLY SERVED. CAP'S WILL BE COMPLETED BY THE DEPARTMENT OF EDUCATION. *CAMPS MUST LIST EACH SESSION SEPARATELY. *ALL NEW SITES MUST ALSO COMPLETE A SITE INFORMATION FORM (SFSP-4). *ACCORDING TO REGULATIONS, SPONSOR MUST VISTT ALL NEW SITES BEFORE THE SITES ARE LISTED BELOW. *ADP =AVERAGE DAILY PARTICIPATION AT THE MEAL SERVICE. IF THE SITE PARTICIPATED LAST YEAR, USE THE ACTUAL ADP FROM LAST YEAR'S DAILY SITE RECORDS {NOT WHAT WAS ON LAST YEAR'S APPLICATION) OR CURRENT ENROLLMENT. CAMPS SHOULD REPORT HERE THE NUMBER OF ELIGIBLE CHII.DREN ONLY. *IF ANY OF THE FOLLOWING SITES HAS DISABLED ADULTS YOU MUST CONTACT THE DEPARTMENT OF EDUCATION IMMEDIATELY. FOR DOE USE ONLY DATES OF EXACT' NAME, ADDRESS & OPERATION TOTAL MEAL TIMES ~ SITE PHONE NUMBER OF STIES, BEGIN END NO OF CAP CAP NO. NAME OF SITE SUPERVISOR MO/DAY MO/DAY DAYS MEAL ADP FROM TO 1 2 Yano Memorial Ha11 BRx 82-6156 Mamalahoa Hwy 6/17/02 7/26/02 29 LUNCH 8O 10:30 11:30 1 Capt. Cook, HI 96704 SNACK am am PHONE: DINNER Hale Halawai BRx 75-5760 Alii Dr. LUNCH 2 Kailua-Kona, HI 96740 sxacx 40 " " PHONE: 808 327-3565/ rshall T hara DINNER Kekuaokalani Gym/Park BRx 75-5500 Kuakini "~"Y ~ ~ ~ ~ ~ ~ LUNCH ~ ~ ~ ~ 3 Kailua-Kona HI 96745 SNACK 140 PxoNE: (808 j 327-3553/ ictor Mc aniel DINNER Waimea Co unity Cente 65-1260 K waiahae Rd. " " " BRx ~ " " i'! LUNCH 4 Kamuela, I 96743 SNACK PxoNE: (g 587-3014/De n Go a DINNER Kam Par /Kohala 54-3853 Akoni-Pule Hwy " LUNCH 60 " S Kohala, HI 96715 sNACx PHONE:(g08) 889-6506/Ch is Cackl y DINNER Waiakea`Uk~Gym BRx 1200 Aini a Dr . " " " LUNCH ~ ~ " ' 6 Hilo, 720 SNACK PHONE: 08) 59-9474/Da re11 Y moto DINNER Andred~ Gy /Waiakeawa a Schoo BRx 33 W. Ka ilani St. f I 7 Hilo, HI 6720 sNACx ~ ~0 PHONE: (8 8) 59-9047/R den Cho DINNER SFSP-1 ATTACHMENT A (continued, FOR DOE USE ONLY DATES OF EXACT NAME, ADDRESS & OPERATION TOTAL MEAL TIMES SITE PHONE NUMBER OF STIES, BEGIN END NO OF CAP CA.P NO. NAME OF STIE SUPERVISOR MO/DAY MO/DAY DAYS MEAL ADP FROM TO I 2 BRK LUNCH SNACK PHONE: DINNER BRK LUNCH SNACK PHONE: DINNER BRK LUNCH SNACK PHONE: DINNER BRK LUNCH SNACK PHONE: DINNER BRK LUNCH SNACK PHONE: DINNER BRK I LUNCH SNACK PHONE: DINNER BRK LUNCH SNACK PHONE:" DINNER BRK LUNCH SNACK PHONE: DINNER BRK LUNCH SNACK PHONE: DINNER BRK LUNCH SNACK PHONE: DINNER BRK LUNCH SNACK PHONE: DINNER BRK LUNCH SNACK PHONE: DINNER BRK LUNCH SNACK PHONE: DINNER . SFSP-1 ATTACHMENT S O F Iy ~P/'~ ~9 59 ; ;STATE OF HAWAII ` DEPARTMENT OF EDUCATION ADMINISTRATIVE COSTS APPROVAL FORM School Food Services Branch FOR SUMMER PROGRAM z~; ~ i~ 1106 Koko Head Avenue ~Y fp~;.h° xonol~lu, HI 9681b3797 (To be completed by the Department of Education) Pursuant to this Agreement Number ~ y~ f is authorized $ fir' for administrative costs. Schedule of negotiated and approved administrative costs: Administrative Salaries (including monitors and clerical salaries) Transportation Telephone Rental of Office Space Office Supplies (including postage) Office Equipment Rental Audit Fees Legal Fees Utilities REIMBURSEMENT WILL NOT EX E Office Buildlri Maintenance MEALS TAMES RATES. Your Pual reimbuesemen4 g may be less fhon 449is DOE a roved amount. Use Allowance (depreciation) Other TOTAL OF ADMINISTRATIVE COSTS vZ.2 SFSP-3 1/02 STATE OF HAWAII 1. AGREEMENT NUMBER _ DEPARTMENT OF EDUCATION ~ ~ ~ .7 - SCHOOL FOOD SERVICES BRANCH 2. NAME & MAILING ADDRESS OF APPLICANT/SPONSOR SPONSOR APPLICATION FOR PARTICIPATION County of Hawaii, Department of Perks & SUMMER FOOD SERVICE PROGRAM Recreation-Recreation Division INSTRUCTIONS: Complete two copies of this application. Submit applications 799 Piilani Street, Hilo, HI 96720 with an original form SFSP-4 (Site Information Sheet) for each site and for each TELEPHONE NUMBER ( ) (808) 961-8740 eXt 23 session (if more than one is offered) where the program will be administered by the T~'PE OF APPLICANT applicant. If more space is needed, continue on a plain sheet of paper numbering each item. Type or print clearly all infom~ation. C { (1) PUBLI,. C° PRNATZ~ i`;ONPR~3''1I' .>k;!'I00'~ ~I1013 NOTE FOR SPONSORS WHO OPERATED THE SFSP LAST YEAR: The State agency may designate sponsors which have operated some or all of the same sites in i (2}PUBLIC OR NON1'RC:i^ } ls~(Y?s'3'~".l~~`sI13FN'"#~,i bQ~lvifv.c>; the SFSP in the rior ear with no si ificant deficiencies or o erational roblems as f s; ~"~,1f .:.:.:::::.::;.;:.:.;:~:~:;:~;:.;:.:::s:.::~;::~:;;:;:~;::.::;;:~:.; ors to omit certa•n i f w h e s ons ~ n ormation from S on r "Ex erienced "and allo t es so P P P i ?l-~1d:OLI: u'G~ ~h13c1'~d -~::€~~€a'~<~.`:€',':`>'4:?~:€:`.ii'£A?'f~`€'^3t'dY:~€'c'.'::t'.?3 and Site application forms if the information has not changed from the previous YaA I ;f i7.Ifz1 ~f:?#.'1`;'~.'iPf"P~£ `'w`'. ear. If the State a enc has desi ated ou as an "Ex enenced" s onsor ou ma ~ `•`~~~>~~~~#z'<~% Y g Y !;n Y P P . Y Y . i the haded blocks on the S onsor A lication and on Site :::>:<:>:>::>s>s:z <:>::>:~::::;:::»;::;:<~:>::::>:>:~»>;:::>:<'~::::~:~:<:»:;~:~>~<•:;<s:~s::;:<::>::> omit the ueshons n s " P PP (4~ 5 I ~ ~ i f34.?4 '~Ia1+I3f €€~IS,I.a €'4::~~€:><~s:'1"~3t:'st:£:viu~~~€~~#1 ee for sites which ou o erated last ear if the answers to these ; -TKl .:.::v.:,::::. Information Sh is y p y >.:».:ri.>~ ear. Y u u t il in a last o m s f e a co lete Site t" av not Chan ed s c ues ions h e Y mp g 9 ' which ou will o erate thi ea . n new site s r Info ati n heet for a rrrr o S n;.. Y P Y Y ,s 1 ~ ~7 ter;~;i~~t~,~.~`~'~:~at~##~~<~~€t1`~:~~d~~.~Y4€'~'~:.;:.;:.:;;;~ . f. bI?J.V A 3n"."4~^II 7~S:Tf~~.t L~'.v,~CS$f:i~j~:Y~bi~:~L'.f;K,~:k:+f.~.t'.S,'.Z.~. "~~:l~st ~i~',?~£t}~2•: Y::::~ h; <j. Jiiii i t~S IZTj.I~''E° ~ icy t' `c < ~ ~2ft'i~ ~ a~ x.3.,''"3 ~43~~A'~'~~'~~£~.~ 't~3s`'S?i:i`';`':(>:.~,*`, ~ ::-:j?'(.~L..' : 2::; ~ ;:;n., .},,'h~::..<:}••:'i.<Ei :{'~'i #-}•'~'`}~`(~n$'>'~?!q''~':~~":•'.'•:~~y.`.%;S":Ei:'~i~i~: ..:::L.;,~ ! ~~W,.•vY"f.2.;~;,~., 4J,.•.2; S.W~w, ~~~`b5,4,~1: X11'k•?~^~,.~,"~:ifi?SS.~.>rl:.fi.{3 ~ ~~~.'•::k::~.ii:pii:?$ ~~J?iJi:''{.i:~iiiJi' ;i'Y Y~ i'YiiF':i::iibi:!'Ci:Ciii:4ii:^ii:•i:•iii:•i'?:vii:4:?:•i:•i:C::•i:•'r:•ii:Mi::ii::. ~.i•: x:::::;n h_~.: + :::~.2a.~.:.~:~3:#~ (~~:33::::`i::t~~:`::<::~::ir:::::;?:~rri:%:::•'::;i::::•'.t:'~:~::::is~:%~:~'r~i::~:%::is~`:~:~:::::~i:::~:~:~i`~:~:<3 ~k.: l,. r :::::>:as: ..s.........:. 3. INTENDED DATES OF FOOD SERVICE PROGRAM OPERATION <:;:I.::.::.~:::::.~.~ .:::::::::.::.:•::::::::::::::::.~.:.;~~:::::::.::::.::.::::.:::a:•::•::•:::;::s:~;.:::.:::.::.;;::s.;•;;:;.:;:::.::.::.:::.;.:::::::.: ND E BEGIN 02 . 06 18 '7 26 02 / / ERATION F OP OF DAYS O TOTAL NUMBER 29 ~ 4. NAME & TITLE OF AUTHORIZED SPONSOR REPRESENTATIVE WHO . WILL SIGN THE AGREEMENT, . RM F P- d Director Patricia En elhar g P k & Recreation f ar s 6. INDICATE OTHER PROGRAMS IN WHICH THE APPLICANT PARTICIPATES ~C~CNONE ~ ~ CHILD & ADULT CARE FOOD PROGRAM ~ ~ NATIONAL SCHOOL LUNCH PROGRAM ~ ~ SCHOOL BREAKFAST PROGRAM ~ ~ FOOD DISTRIBUTION PROGRAM ~ ~ SPECIAL MILK PROGRAM NOTE: Sites may not participate in the SFSP and SMP simultaneously 7. HAS THE APPLICANT PARTICIPATED IN THE SUMMER FOOD SERVICE PROGRAM IN PRIOR YEARS?}~~ YES ~ NO If `des", has the State agency designated you as an "Experienced" sponsor? (If you are unsure, please contact your State agency.) ~~YES ~~NO If "yes", you may omit shaded questions on Sponsor Application and on the Site Inforrrration Sheets for sites which you operated last year if the responses to the questions have not changed since last year. If "no", state the agreement number, year, and State in which the applicant participated for the most recent period of participation and complete all sections of the Sponsor Application for Participation and the Site Information Sheet(s) for each site you plan to operate. 8A. DOES THE APPLICA2v''F PROVIDE AN;ONGOING, FEAR-ROUNb SERVICE TO TIE COMIviUNIT~' ~A ~VC~rI r KAY>s I'~;~'By 5[mi1v1FF? ~OOI7 SERVICE PROGRAl'!1~ ; YF~ ~~4N(s > If "yes", ~escr!be the nature is, the serytce, the Aare ti was mstttuted, : tld t;,~ average number of pzici a,ic3 voiuntan hprtt~,s:~€##~t~ <#3 3"fCs##t~s .1`#-(~m~.~~fi. appi,catror_ i ii.Y:ru'u.;.;:.i:.i gB. tNAS,TrIr RPr.'I,rCAN"~ EVF.R `•."E1Zh4TNATEI?n121)f:TER1~1INFs13 `1'O HAVE BEEN SE}Z;<')USL~ DLk''_~ t1~~ 1 I ~~,#:i3('~.~~s..:<:t~3€~€ s~~~~'9I~ ti! „Y~f~;;,i? .FOOD SERVI~'T':pROG12At t'~?? ,~i~°Y t`H1LI31VTii1?:ITI/JN P}?O ,-~.+.Y" : ~ : ~ ~ vF, x ..~~s .iC.Nr, `Yc~" i)iea~e cxpla,ri PeIOW. PAGE 1 OF 5 SFSP-3 1 /02 RURAL NON-RURAL 9. 1lOW ~~~ILL MEALS $E PRO"4'IDED TO SITES? ~ NO. OF SITES SEKVED j ~ A: SELF PREPARATION ON SITr: 1 ~ ~ B. SPONSOfi PREPARATION AT CEN I:rtA3_. NO. OF SITES SERVED KITCHEN FAC~i,~T'~` ADDRESS{ES; i I C: SPONSOR PREPARATION r1T A NO. OF SITES SERVED SCHCOLFOOT):SER>'IC FAL;ILiY ~JAivlEfSl AND P DL)RFSS(ESj ~,j;D: AGRF.F,MEN T WTTY SGNOOt. FCjC~p AU, I~O~I'1~ NO. OF SITES SERVED ~C rI(~:11 ~A)ris~`I~) iNF? >~1~L?#tkb~(~~~ COMPANY NAME(S) AND ADDRESS(ES) ~'C:7~:iwi iti'L:J:i : iiii?iiT ..fi., :i:i4?%:: ii:::::i::::f'Y:ii:?::ii i::i:::y': ':::iii::i? ` ;::ii:::::::::::::::: <.::.::.:.r.::::::::. jC~{E. CONTRACT WITH FOOD SERVICE MGMT ~ NO. OF SITES SERVED RURAL NON-RURAL COMPANY 3 X IF YOU AREA IF YOU HAVE BEEN NEW SPONSOR DESIGNATED AS AN OR HAVE NOT EXPERIENCED BEEN SPONSOR: If a contract DESIGNATED AS will exceed $10,000, AN EXPERIENCED attach a bid schedule. SPONSOR: If a Sponsors must also Contract will exceed submit a summary $10,000, attach a of meal service and copy schedule of bid dates of IFB if changing and a copy of IFB method of procuring meals. COMPANY NAME(S) AND ADDRESS(ES) HCEOC-Hawaii County Economic Opportunity Coundil 47 Rainbow Drive Hilo, HI 96720 ~ ~ F. OTHER 10. FOR THE GEOGRAPHIC AREA SERVED BY YOUR SPONSOR PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE POPULATION TO BE SERVED, AND DESCRIBE EFFORTS TO (1) ASSURE THAT MINORITY POPULATIONS HAVE EQUAL OPPORTUNITY TO PARTICIPATE AND (2) CONTACT MINORITY AND GRASSROOTS ORGANIZATIONS ABOUT THE OPPORTUNITY TO PARTICIPATE IN THE PROGRAM. 11. INDICATE TOTAL AVERAGE DAILY PARTICIPATION OF ELIGIBLE CHILDREN TO BE SERVED BY MEAL TYPE AT ALL SITES LISTED ON FORM(S) SFSP-4, SITE INFORMATION SHEET(S). (FOR CAMPS, LIST ONLY THE ESTIMATED TOTAL AVERAGE DAILY PARTICIPATION OF ELIGIBLE CHILDREN FOR EACH SESSION IN WHICH REIMBURSEMENT FOR MEALS WILL BE CLAIMED UNDER SFSP. BREAKFAST AM SUPPLEMENT LUNCH PM SUPPLEMENT SUPPER (A) (B) (C) (D) (E) 600 PAGE 2 OF 5 SFSP-3 1/02 12. START UP AND ADVANCE PAYMENTS None A. DOES THE APPLICANT REQUEST B. DOES THE APPLICANT REQUEST C. DOES THE APPLICANT REQUEST ADVANCE PAYMENTS START-UP PAYMENTS ADVANCE PAYMENTS FOR FOR ADMINISTRATIVE COSTS? OPERATIONAL COSTS? YES NO YES NO YES NO i 3. LIST THE SPONSOR-LEVEL PERSONNEL WHO WILL BE RESPONSIBLE FOR ADMINISTERING THE SUMMER FOOD SERVICE PROGRAM TITLE OF POSITION NO. HOURS SALARY PER NO. TOTAL SOURCE OF NAME OF SA PER HOUR OF SALARY FUNDS ADMINISTRATIVE APPROVED DAY (VOLUNTEER- DAYS FOR PERSONNEL AMOUNT ON USE "V") PROGRAM SFSP ADMINISTRATOR Arlene Mi ake 1 1.5 29:12 29 1266.72 USDA Y SFSP-DIRECTOR OR COORDINATOR 3 1.5 23.25 29 3Q34.13 orge Ikeda, am rkowsk' Den is Mats d~ SFSP-ASSISTANT DIR./ 7 1.5 16.54 29 5036.43 " See back COORDINATOR BKEEPER/ ACCOUNTANT ~r CLERICAL STAFF 1 1.5 11.30 29 491.55 " In the prose s of hirir Secreta MONITORS (not less than one er 20 sites 30 1.5 8.93 29 11653.65 " 'r " OTHERS TOTAL ADMINISTRATIVE 43 22,103.6 SALARIES 14. DID ANY OF THE PERSONNEL NAMED IN ITEM 13 WORK FOR ANOTHER SUMMER FOOD SERVICE PROGRAM SPONSOR OR A FOOD SERVICE MANAGEMENT COMPANY? ~ ~ YES * ~ NO (If yes, give name of person, name and address of sponsor or food service management company and dates of employment there) _ 15. OPERATIONAL AND ADMINISTRATIVE BUDGET A. ESTIMATED OPERATIONAL COST (FOOD SERVICE) B. ESTIMATED ADMINISTRATIVE COSTS SPONSOR SA APPROVED SPONSOR SA APPROVED AMOUNT AMOUNT AMOUNT AMOUNT TOTAL ADMINISTRATIVE FOOD SALARIES (See 13 above) ~U,5~2 r ~ . ~b $22,103.6 "~2~.~-G% SITE RENT OF OFFICE SPACE (Attach contract) UTILITIES KITCHEN OFFICE SUPPLIES LABOR AUDIT FEES Attach letter TRANSPORTATION RENTAL (ADMINISTRATIVE NON-FOOD SUPPLIES AND MONITORS) RE! t~'I~~i~T 9LL NOT EX EE® EUGI®LE TELEPHONE AA UTILITIES rovo arnourt4. POSTAGE KITCHEN OR TRUCK RENTAL LEGAL FEES (Attach contract) USE ALLOWANCE EQUIPMENT RENTAL OFFICE BLDG. MAINTENANCE (Attach contract of included in Rental A Bement OTHER S eci OTHER S ecif SUB-TOTAL f,~ ~ C.' % ~ "7'~(~ ~ , ~ (J INDIRECT COST (Rate) (Attach copy of co izant a ens 's a royal SUBTOTAL 22 ,103.6 ,~~c,.~ . ~ PAGE 3 OF 5 SFSP-3 (1/02 16. SHOW PROJECTED INCOME FROM ALL SOURCES OTHER THAN USDA THAT WILL BE USED TO HELP FINANCE THE SFSP (Attach additional sheets if necessa INCOME SOURCE INCOME AMOUNT DESCRIBE THE COSTS FOR WHICH THIS INCOME WILL BE USED None $ $ $ $ $ 17. TRAINING SESSIONS Trainin is mandato for all s onsor and site ersonnel A. NAME(S) OF PERSON(S) RESPONSIBLE FOR CONDUCTING TRAINING B. NAME(S) OF PERSON(S) RESPONSIBLE FOR CONDUCTING TRAINING SESSIONS FOR SPONSOR PERSONNEL SESSIONS FOR SITE PERSONNEL Sue DeCoite Sue DeCoite C. DATES OF TRAINING SESSIONS Attach summa of trainin ro ms, includin to ics to be covered SPONSOR PERSONNEL TRAINING SITE PERSONNEL TRAINING May 17, 2002 May 17, 2002 18. THE FOLLOWING ITEMS MUST BE ATTACHED FOR APPLICATION APPROVAL: CHECK EACH ITEM INCLUDED IN THIS APPLICATION (For items not checked, please provide an explanation.) ~ ~ A. THE SCHEDULE FOR MAKING PRE-OPERATIONAL VISITS ~ ~ E. DESCRIPTION OF PROCEDURES FOR COLLECTING TO SITES (INCLUDE THE NUMBER OF SPONSOR PERSONNEL INFORMATION ON THE DAILY NUMBER OF MEALS AND NUMBER OF SITES THAT WILL BE VISITED PER WEEK) SERVED TO CHILDREN, THE DAILY NUMBER OF HOURS WORKED BY SITE PERSONNEL (IF LABOR COSTS ~ ~ B. THE SCHEDULE FOR VISYTING ALL SITES LISTED ON THE WILL BE CLAIMED). PERSONNEL (IF LABOR COST WILL SITE INFORMATION SHEETS (FORM SFSP-4) DURING THE BE CLAIMED), INCLUDING BOTH THE FREQUENCY FIRST WEEK OF OPERATION AND FOR REVIEWING ALL OF INFORMATION COLLECTINN, THE METHOD USED SITES DURING THE FIRST FOUR WEEKS OF OPERATION TO COLLECT INFORMATION FROM SITES. IF FORM (INCLUDE THE NUMBER OF SPONSOR PERSONNEL AND FOR MEAL COUNTS IS AVAILABLE, ATTACH COPY. NUMBER OF SITES THAT WILL BE VISITED AND REVIEWED.) ~ ~ F. A DESCRIPTION OF THE METHOD USED TO SECURE ~ ~ C. A COPY OF THE FREE MEAL POLICY STATEMENT CORRECTIVE ACTION IF PROBLEMS ARE OBSERVED AT A SITE, INCLUDING PLANS FOR FOLLOW-UP ~ ~ D. A COPY OF THE PUBLIC ANNOUNCEMENT ON NON- AND EXPLANATION OF WHEN A SITE WOULD BE DISCRIMINATION WITH A DESCRIPTION OF WHEN, HOW, CLOSED. AND TO WHOM THE ANNOUNCEMENT WILL BE ISSUED. ~ ~ G. A COPY OF THE PROPOSED LETTER TO LOCAL HEALTH DEPARTMENT PROVIDING NOTIFICATION OF INTENTION TO OPERATE A FOOD SERVICE AT THE SITES LISTED ON ATTACHED SITE SHEETS (Give specific dates and times of operation for each site Z 19. MANAGEMENT PLAN: IDENTIFY BYNAME AND TITLE THE PERSON(S): A. AUTHORIZED TO APPROVE PURCHASES OR RENTALS (Specify dollar limitation, as applicable) $ -ArLP_np Mi yakP - Ranraa t; nn Arl ,~yT~S ~,~~D~ B. AUTHORIZED OAP OVE THE NUMBER OF HOURS OF REGULAR AND OVERTIME PAY FOR EMPLOYEES AY~lene Miyake. Recreation Administrator C. SPONSIBL FOR EIVING PARTICIPATION AND COST DATA, AND FOR PREPARING CLAIMS FOR REIMBURSEMENT ~onette ~yo,~ccount Clerk D. RESPONSIBLE FOR SCHEDULING AND SUPERVISING MONITORS, REVIEWING SITE REPORTS OF DEFICIENCIES, RESTRICTING OR TERMINATING FOOD SERVICE IF NECESSARY, AND EFFECTING CORRECTIVE ACTION Arlene Mi_vakP_ Recraaati~n Administrator E. RES ONSIBLE OR COORDINATING WITH OFFICIALS TO WHOM SITE SUPERVISORS REPORT, IF APPLICABLE Arlene Miyake, Recreation Administrator PAGE 4 OF 5 SFSP-3 (1/02} WARNING STATEMENT OF CRIMINAL PROVISIONS AND PENALTIES a. ESTABLISHED IN Section 13 (o) of the National School Lunch Act (42 U.S.C. 1761(0)). Whoever, in connection with any application, procurement, recordkeeping entry, claim for reimbursement, or other document or statement made in connection with the Program, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing the same to contain any false, fictitious, or fraudulent statement or entry, or whoever, in connection with the Program, knowingly makes an opportunity for any person to defraud the United States, or does or omits to do any act with intent to enable any person to defraud the United States, shall be fined not more than $25,000 or imprisoned not more than five years, or both. (B) Whoever being a partner, officer, director, or managing agency connected in any capacity with any partnership, association, corporation, business, or organization, either public or private, that receives benefits under the Program, knowingly or willfully embezzles, misapplies, steals, or obtains by fraud, false statement, or forgery any benefits provided by this Program, or any money, funds, assets, or property derived from benefits provided by this Program, shall be fined not more than $25,000 or imprisoned for not more than five years, or both (but, if the benefits, money, funds, assets, or property involved is not over $200, then the penalty shall be a fine of not more than $1,000 or imprisonmen4 for not more than one yeaz, or both.) (C) If two or more persons conspire or collude to accomplish any act described in paragraphs (a)(5)(i)(A) and (B) of Section 225.6 and one or more of such persons do an act to effect the object of the conspiracy or collusion, each shall be fined not more than $25,000 or imprisoned for not more than five years, or both. TERMINATION PROCEDURES As established by Section 225.11 (c) of the SFSP regulations. ' 1. The State agency shall terminate the Program agreement with any sponsor which it determines to be seriously deficient. However, the State agency shall afford a sponsor a reasonable opportunity to correct problems before terminating the sponsor for being seriously deficient. 2. The State agency may approve the application of a sponsor which has been disapproved or terminated in prior years in accordance with this paragraph if the sponsor demonstrates to the satisfaction of the State agency that the sponsor has taken appropriate corrective actions to prevent recurrence of the deficiencies. Serious deficiencies which are grounds for disapproval of applications and for tem-mination include, but are not limited to, any of the following: a) Noncompliance with the applicable bid procedures and contract requirements of Federal Child Nutrition Program regulations. b) The submission of false information to the State agency. c) Failure to return to the State agency any start-up or advance or reimbursement payments; d) Noncompliance with civil rights laws and regulations e) Program violations at a significant proportion of the sponsor's sites. Such violations include, but are not limited 4o the following: 1) Noncompliance with the meal service time restrictions set forth in Section 225.15(c) 2) Failure to maintain adequate records 3) Failure to adjust meal orders to conform to variations in the number of participating children 4) The simultaneous service of more than one meal to any child 5) The claiming of Program payments for meals not served to participating children 6) Service of significant number of meals which did not include required quantities of all meal components 7) Excessive instances of off-site meal consumption 8) Continued use of food service management companies that are in violation of health codes f) Failure to take corrective action on Program violations cited in an audit or review or after being determined seriously deficient; and g) Any imminent threat to the health, and safety of participating children. NOTE: Sponsors or sites which have been terminated in accordance with the provisions above shall be allowed to appeal in accordance with Section 225.13. I certify that the information on this application and the attached Forms SFSP-4, Site Information Sheet, is true to the best of my knowledge, that reimbursements will be claimed only for meals served to eligible children at approved food service sites, and that these sites have been visited and have the capability and facilities for the meal service planned for the number of children anticipated to be served. I understand that this information is being given in connection with the receipt of Federal funds, and that deliberate misrepresentation may subject me to prosecution under applicable State and Federal criminal statutes. The program must be made available to all eligible children regardless of age, sex, disability, race, color, or national origin. If government sponsor, I certify that the program is directly operated at all sites. DATE NAME & TITLE OF AUTHORIZED SPONSOR SIGNAT>~R~ OF AUTHORIZED SPONSOR REPRSENTATIVE REPRESENTATIVE (Print or type) / PAGE 5 OF 5