Florida Department of Agriculture and Consumer Services

[Pages:2]

Florida Department of Agriculture and Consumer Services

Division of Food, Nutrition and Wellness

FOOD SERVICE VENDOR REGISTRATION FORM

|VENDOR REGISTRATION |

|INSTRUCTIONS: Registration forms must be completed and approved by FDACS-FNW in order to bid on solicitations from NSLP and SFSP Sponsors |

|in Florida. |

|COMPANY NAME: | |

| |Vendor Application for Registration |

| |Certification Regarding Lobbying |

| |Disclosure of Lobbying Activities and Instructions (if applicable) |

| |Acknowledgement of Sponsor Responsibilities |

SUBMISSION OF REGISTRATION PACKETS

The registration packet may either be faxed, mailed or scanned and emailed.

• Fax number: 850-617-7402 (Please include a cover sheet)

• Scan or email to: Michael.Ingicco@

• Mail to:

Florida Department of Agriculture & Consumer Services

Division of Food Nutrition & Wellness

Attn: Mike Ingicco

600 South Calhoun St

Tallahassee, FL 32399

Registration packets will be reviewed in the order in which they are received

FOOD SERVICE VENDOR APPLICATION FOR STATE OF FLORIDA REGISTRATION SUMMER 2014 or SCHOOL YEAR 2014-2015

|I. COMPANY IDENTIFICATION |

|1. LEGAL COMPANY NAME AND ADDRESS (Street, City, State, and Zip) |

| |

| |

| |

|Are you a Minority-Owned Enterprise? No___Yes ___ IF YES, include current certification(s) |

|2. VENDOR INFORMATION: Will be listed on registration exactly as it is entered below: |

|a. Vendor Name | |

|b. Contact Person(s) | |

|c. Mailing Address | |

|d. Telephone # | |

|e. Fax # | |

|f. Email | |

|II. CORPORATE PROFILE |

|3. Is Vendor Incorporated? No___Yes ___If YES: Incorporation Date and state |

|4. List all names used by the Vendor in the past 24 months: |

| |

|5. Vendor currently providing / has provided meals to the following programs in the past 3 years? |

|USDA National School Lunch Program: (NSLP) No___Yes ___ |

|USDA Summer Food Service Program: (SFSP) No___Yes ___ |

|USDA School Breakfast Program: (SBP) No___Yes ___ |

|USDA Child and Adult Care Food Program: (CACFP) No___Yes ___ |

|USDA Special Milk Program: (SMP) No___Yes ___ |

|USDA Afterschool Snack Program: (ASP) No___Yes ___ |

|Complete the following. (Attach pages if needed) |

|Program |Sponsor/School |Address |Phone |Year(s) |

| | | | | |

| | | | | |

| | | | | |

|III. PERSONNEL PROFILE |

|6. List name / title of individuals from the company authorized to sign contracts. (Attach pages if needed) |

|NAME |TITLE |

| | |

| | |

| | |

|IV. ADDITIONAL INFORMATION |

|THE FOLLOWING INFORMATION MAY BE USED BY SPONSOR WHEN SOLICITING QUOTES/RFP/BIDS. |

|8. List all Vended Sponsors in Florida with whom your company has a present contract. If not currently providing service in Florida, list three Sponsors |

|with current contracts with your company in other states. (Attach additional pages, if needed) |

|YEAR |SPONSOR NAME |STATE |

| | | |

| | | |

| | | |

|9. List all Sponsors that had consulting contracts with your company in the last 3 years: |

|YEAR |SPONSOR NAME |STATE |

| | | |

| | | |

| | | |

|10. Enter the number of Vendor Contracts awarded and subsequently terminated for cause by a Sponsor in Florida. Please attach a written explanation for each |

|contract terminated |

|Period |No. of Contracts Awarded |No. of Sponsor Terminated contracts* |

|School Yr 2012-13 | | |

|School Yr 2011-12 | | |

|School Yr 2010-11 | | |

|11. LIST MINIMUM CONDITIONS to be met in order for your company to consider submitting a proposal/bid to a Sponsor: (Attach additional pages if needed.) |

|This will be included in the registration list sent to Sponsor upon request. |

|12. LIST ANY SPECIALTY MENU/DIETS YOU PROVIDE. This will be included in the registration list sent to Sponsor upon request. Example: Vegetarian, Organic, |

|Gluten-free, Kosher, Halal |

|V. CERTIFICATION |

|I CERTIFY that the information supplied on this application is true, complete and correct to the best of my knowledge. Any false statement or |

|misrepresentation may be punishable by law. |

| |

|I understand that my company must respond to Sponsor with a proposal or an explanation as to why the Vendor did not submit a proposal for all Sponsor requests.|

|NAME OF AUTHORIZED VENDOR OFFICIAL SUBMITTING REGISTRATION DOCUMENTS |

|(Please Print) ___________TITLE |

|SIGNATURE OF AUTHORIZING OFFICIAL AND DATE: |

| |

| |

|Date: |

|Phone # |Fax # |

|Email |

The Vendor WILL CONSIDER submitting proposals/bids/quotes to Sponsor(s) in the following counties for Summer 2014 and school year 2014-2015 (place an “X” by all that apply):

|____ Alachua |____ Baker |____ Bay |____ Bradford |

|____ Brevard |____ Broward |____ Calhoun |____ Charlotte |

|____ Citrus |____ Clay |____ Collier |____ Columbia |

|____ DeSoto |____ Dixie |____ Duval |____ Escambia |

|____ Flagler |____ Franklin |____ Gadsden |____ Gilchrist |

|____ Glades |____ Gulf |____ Hamilton |____ Hardee |

|____ Hendry |____ Hernando |____ Highlands |____ Hillsborough |

|____ Holmes |____ Indian River |____ Jackson |____ Jefferson |

|____ Lafayette |____ Lake |____ Lee |____ Leon |

|____ Levy |____ Liberty |____ Madison |____ Manatee |

|____ Marion |____ Martin |____ Miami-Dade |____ Monroe |

|____ Nassau |____ Okaloosa |____ Okeechobee |____ Orange |

|____ Osceola |____ Palm Beach |____ Pasco |____ Pinellas |

|____ Polk |____ Putnam |____ Santa Rosa |____ Sarasota |

|____ Seminole |____ Saint Johns |____ Saint Lucie |____ Sumter |

|____ Suwannee |____ Taylor |____ Union |____ Volusia |

|____ Wakulla |____ Walton |____ Washington | |

NONDELEGABLE Sponsor Responsibilities

The Sponsor shall be legally responsible for the conduct of the food service program, and shall supervise and monitor the food service operations to ensure compliance with the rules and regulations of the Florida Department of Agriculture & Consumer Services, Division of Food Nutrition & Wellness (FDACS-FNW) and the United States Department of Agriculture (USDA) regarding the school food service program.

The Vendor acknowledges that the Sponsor is responsible for completing the following duties and that these cannot be delegated to the Vendor:

1. On-site inspections: 7 CFR 210.16(a) (2) (3).

a. Monitor the food service operation through periodic visits to ensure compliance with the approved Vendor contract.

b. Conduct on-site reviews of the lunch counting /claiming system by school. Follow-up on any lunch counts which show counting discrepancies

2. Control and overall financial responsibility of the school food service account. 7 CFR 210.19(a)(2)

3. Advisory board: establish and include parents, staff and students to assist in menu planning. The Vendor must adhere to the cycle for the first 21 days of meal service. Changes thereafter may be made with the approval of the Sponsor. 7 CFR 210.16(b)(1), 7 CFR210.16(a)(8)

4. Health certification: 7 CFR 210.16(a)(7).must be maintained to assure that all state and local regulations are met by the Vendor preparing or serving meals at the Sponsor facilities.

5. Establish all prices: 7 CFR 210.16(a)(4).for food items served under the nonprofit school food service account. (e.g., reimbursable meals, a la carte, and adult meals).

6. Retain signature authority on: (7 CFR 210.9 (a)(b), 210.16(a)(5))

a. Application/agreement to participate in the Child Nutrition Programs including

b. Free and reduced price policy statement; and

c. On-line claim system.

d. Contractual agreements with the school nutrition program i.e., vending meals to other Sponsors, etc. and any commodity processing contracts 7CFR 210.21 &.19(a)(1); 3015; 7CFR250.15(a)

e. Resolution of all program review and audit findings. 7 CFR 210.9(b)(17) and 210.18(k)(1)(2)

7. Submit monthly claim for reimbursement 7 CFR 210.8(a); 7 CFR 210.16(a)(5).

a. FDACS-FNW approves only Sponsor personnel access to the system which also represents secure signature authority for applications and claims.

b. Review to ensure accuracy of lunch counts prior to the claim submission.

c. Edit check worksheets that compare daily lunch counts by eligibility category. Free and reduced-price meals may not be claimed in excess of the number of students approved for such benefits.

8. Free and Reduced Price Meal Process 7 CFR 245.6

a. Develop, distribute and collect parent letter and application for free/reduced price meals & free milk

b. Determination and verification of applications for free/reduced price meals or free milk

c. Conduct any hearings related to such determinations.

9. USDA Foods 7 CFR 210.9(b)(15) (formerly Commodities)

a. Monitor that the max amount are received and used by the Vendor in the Sponsor food service.

b. Monitor that the Vendor credits Sponsor at least annually for all USDA Foods.

10. A la carte food service: 7 CFR 210.16(a)

The Sponsor must also offer free, reduced price and full price reimbursable meals to all eligible children in order to operate an ala carte food service.

I acknowledge that these responsibilities cannot be delegated to the Vendor and must remain the sole responsibility of the Sponsor.

Signature of Vendor Representative Date

Printed Name and Title of Vendor Representative

CERTIFICATION REGARDING LOBBYING

Applicable to Grants, Subgrants, Cooperative Agreements, and Contracts Exceeding $100,000 in Federal Funds

Submission of this certification is a prerequisite for making or entering into this transaction and is imposed by Section 1352, Title 31, U.S. Code. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

The undersigned certifies, to the best of his or her knowledge and belief, that:

No federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of a Federal contract, the making of a Federal grant, the making of a Federal loan, the entering into a cooperative agreement, and the extension, continuation, renewal, amendment, or modification of a Federal contract, grant, loan, or cooperative agreement.

If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of congress, or an employee of a Member of congress in connection with this Federal grant or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying”, in accordance with its instructions.

The undersigned shall require that the language of this certification be included in the award documents for all covered subawards exceeding $100,000 in Federal funds at all appropriate tiers and that all subrecipients shall certify and disclose accordingly.

Vendor

Address of Vendor

City State Zip Code

Name of Submitting Official

Title of Submitting Official

Signature

Date

Check if not applicable to Federal lobbying activities

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ADAM H. PUTNAM

COMMISSIONER

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