HomeMy WebLinkAbout1986-148
1
RESOLUTION NO. 86-148
2 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
PREPARATION AND EXECUTION OF AN APPLICATION, AGREEMENT AND
3 LIABILITY RELEASE FOR SAN BERNARDINO COUNTY COMMUNITY SERVICES
FOOD DISTRIBUTION PROGRAM.
4
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF
5 SAN BERNARDINO AS FOLLOWS:
6 SECTION 1. The Director of Parks, Recreation and Community
7 Services is hereby authorized and directed to prepare, execute
8 and submit an application, agreement and liability release for San
9 Bernardino County Community Services Food Distribution Program, a
10 copy of which documents are attached hereto, marked Exhibit "A"
11 and incorporated herein by reference.
12 I HEREBY CERTIFY that the foregoing resolution was duly
13 adopted by the Mayor and Common Council of the City of San
14 Bernardino at a reou1ar meeting thereof, held on
15 the 21st day of April , 1986, by the following vote,
16 to wit:
17
18
19
20
21
22
23
24 of
AYES:
Council Members
Estrada Reilly, H~rn~n~~~,
Marks. Ouiel. Frazjer Strickl~r
NAYS:
None
ABSENT:
None
~P~~~/
/' City Clerk
The foregoing resolution
day
/;L" --
,.2 ~/cjL
~pr i 1
, 1986.
;:1
7-
Sari Bernardino
25
26 Approved as to form:
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28 CIty Attorney
Ct)~:.:~.:~IT.~. S~~::==::=S D:::?;.?::,:-::=:rl'
c)~ .3~.!': 5E?~:~?DI:~;J ':c)C:~7Y
:O'JD DISTRISC':'IOl; PR0:;~.:
AD:.:::::;IST?.ATI\'E: Or-FICES , \'7;'.?'=:P-OUSi.::
636 E':"ST '-!II..::' STP.E::T 1743 !-1I?.o \-;J-,y
.s.Z\:'; E::::?.:J;;RDn;O, Cp.. 92415 FCALTC, CA 92376
(71~\ 383-2521 or 382-2796 (714) 829-7475 or 829-7476
APPLICATIOl.;
!.!E!1BER AGENCY IN=OFJ.:ATION SHEET
v'
_. .~gen::;y
Pho., '2
.:.. Address
Zip
_. Director
4. Contact Person
_. NUIilier of Paid Staff
6. Nurrber of Volunteer Staff
7. Agency Status Identification:
A. Private Non-Profit
B. Public Non-Profit
C. Profit Inc.
Inc.
Inc.
D. Other
(Specify)
8. Tax Exempt #
9. Liability Insurance (carrier)
10. Parent Organization
11. Days and Hours of Operation
FOO~ PROG?~1 (S) SERVICES:
12. Does your organization provide meals on your premises? Yes No
If yes, how often? Daily_____Weekly_____Month1y_____Other
Number of people served? Breakfast Lunch Dinner
13. Does your organization distribute emergency food boxes? Yes No
.,
14. How many families do you distribute food to? Weekly
Monthly
15. Specific geographic area served:
.<
16. Other services provided:
17. Who is eligible for your service?
18. Current sources of food obtained for your program{s).
(designate %)
_____%Direct food purchases
%Retail Store Don2.f:ions
-----%Food Drive Donations
%USDA Commodities
%Other (specify)
100 %TOTAL
STORAGE FACILI~IES:
19. Does your agency have storage facilities?
(Please give dimensions) Refrigerated
Frozen
Dry
FOOD PICK UP:
20. Do you have transporatation to the foodbank? (Describe)
~l. Hm" often co you prefer to piCk up food? Daily_weeklY~10nthly
22. Persons authorized to pick up food:
1)
2)
23. Where and to whom should CSD FDP reports and forms be sent. Name
Address:
Zip
(Continue on page two)
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:.:~::3.s?. F.G:S!-JCY AG?.E::::::.ENT =OF-1.:
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J-"..;e:lcy
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':'he above nar:\sd Age"cy agrees to and will comply ",ith the following crit:.eria of a
:.je"ber Agen:::::' :::or par-:icipati:::':i i!i Co::unur:i::y Services Departme"t Fooi Distribut:ion
?rog!.-am.
1. ~ust be a" establishei Agency and approved by the Community Services
Department =ood nistri~~tio:i Program.
2. Must be an Agency tjat serves low-inco~e, needy individuals/households
residing within San Eernardino County (in accordance wit:.h eligibility
guidelines provided). (Exhibit E)
3. Nust ~rovide food to its clients consistent with funding source
guidelines.
4. !1ust not o=fer for sale, charge for meals, transfer nor barter or
hoard food supplied by Community Services Department =ood Distribution
Program in exchange for money, other properties or services.
5. ~lust have adequate refrigeration and storage space to insure the
wholesomeness of the food until used and/or distributed.
6. Must provide transportation to pick up food at Community Servies Depart-
ment Food Distribution Program Warehouse, except when delivery is provided.
7. Must be licensed by the State and/or City as a food service establishemnt
according to the service it provides. (where applicable)
8. Must provide required reports.
(Exhibits A & B)
9. Must secure and maintain complete eligibility records on clients served
for the purpose of documentation and recall. Information will be disclosed
to Community Services Department Food Distribution Program by the member
Agency. Confidentiality will be maintafhed by Community Services Department
Food Distribution Progran. (Exhibit C)
;;,. -_/
10. Must provide names, addresses and telephone n~ers of all volunteers
utilized with food programs within Agency. (Exhibit D)
11. Must be agreeable to monitoring by the Community Services Department
Food Distribution Program personnel or a panel of the Advisory Committee.
12. Must be a non-profit organization. COpy OF 501 (C) (3) TAX EXEHPT
STATUS WITH THE INTERNAL REVENUE SERVICE OR OTHER APPLICABLE DOCUHEIH
MUST BE ATTACHED.
WE, THE UNDERSIGNED REPRESENTATIVES OF THE APPLYING AGENCY, ACKNOtfLEDGE THAT WE'VE READ
THE AFOREMENTIONED CONDITIONS AND UNDERSTAND THAT THEY HAVE BEEN INCOR?ORATED INTO
THIS APPLICATION. VIOLATION OF ANY OF THESE CONDITIONS MAY BE CAUSE FOR I~~DIATE
TERMINATION OR SUSPENSION FROM PARTICIPATION IN THE COMMUNITY SERVICES DEPART~lENT
FOOD DISTRIBUTION PROG~l. SHOULD SUSPENSION OCCUR, PARTICIPATION WILL NOT RESU~lE
UNTIL SUCH TIME AS VIOLATION(S) IS CORRECTED.
SIGNED: AUTHORIZED REPRESENTATIVE
CSD FOOD PROGRAI-1 (S) M.'l\.NAGER
Signature
Signature
Title
Date
Date Approved
RVH/fa
Revised 10/85
?a::2
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~'.::::'~E.K AGENCY LI.;;'BILITY FELEAS::::
T~s uudersig~2~ a~thorized Agert 0:
Warne of Agency)
hereby warra~~s that duri~s active me~~ership assorted foods will Le received
fro~ the Co~~~~ity Services Departme~t ?ood Distribution Program. Said agent
f~rt~er warra~ts that the a~ove described food will be duly inspected upon
delivery and fou:1:: fit for hurra~ consumption.
It is further agreed betvleen the Co~~unity Services Deparment Feod Distribution
Program and .
That:
(Name of Age~cy)
1. The Food is accepted "as is".
2. Community Services Department Food Distribution Program and the original
donor expressly disclaim any implied warranties of merchantability or
fitness for a particular use.
3. There have ~een ~o express warranties in relation to this gift of
food.
4. Said Agency releases both the original donor and Community Services
Department Food Distribution Program from any liability resulting
from the condition of the donated food and further agrees to indemnify
and hold Community Services Department Food Distribution Program and
the original donor free and harmless against all and any liabilities,
damages, losses, claims, causes of action and suits or law or in
equity or any obligation whatsoever arising out of or attributed to
any action of said Agency or any personnel employed by said Agency
in connection with its storage and use of the donated food.
5. Must not offer for sale, charge for meals, transfer nor barter or hoard
the food supplied by Community Services Vepartment Food Distribution
Program in exchange for money, other properies or services.
~--
SIGNED: AUTHORIZED REPRESENTATIVE
CSD FOOD PROGRAM(S) MANAGER
Signature
Signature
Title
Date
Date Approved
RVH/fa
Revised 10/85
COMMUNITY SERVICES.DEPARTMENT
SAN BERNARDINO COUNTY FOOD DISTRIBUTION PROGRAM
1985
INCOME ELIGIBILITY GUIDELINES
GROSS INCOME MUST NOT EXCEED THE FOllOWING:
INCOl1E MUST BE VERIFIED - EXHIBIT C
EXHIBIT E
NUMBER IN GROSS MONTHLY
HOUSEHOLD INCOME
1 656.25
2 881.25
3 1,106.25
4 1,331.25
5 1,556.25
6 1,781.25
7 .....:.-.. 2,006.25
a 2,231.25
9 2,381.25
10 2,531.25
GROSS YEARLY
INCOME
7,875.
10,575.
13,275.
15,975.
18,675.
21,375.
24,075.
26,775.
28,575.
30,375.
FOR FAMILY UNITS WITH MORE THAN 10 MEMBERS ADD $2,610. {YEARLY} OR $218.
(MONTHLY) FOR EACH ADDITIONAL MEMBER.
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_.~~-------~
COMMUNITY SERVICES DEPARTMENT FOOD DISTRIBUTION PROGRAM
SUB-AGENCIES MONTHLY PERPETUAL INVENTORY
. AGENCY NAr~E
WEEK OF
YEAR
F 0 0 D
PRO D U C T S
DATE ACTIVITY 1. 2. 3. 4. 5. 6. 7. 8.
RECEIVED
DISTRIBUTED
BALANCE
DESCRIBE PLANS TO DISTRIBUTE OR STORE BALANCE:
r
~JEEK OF
DATE ACTIVITY
RECEIVED
BALANCE
DESCRIBE PLANS TO DISTRIBUTE OR STORE BALANCE:
WEEK OF
DATE ACTIVITY
RECEIVED . ~.
BALANCE
DESCRIBE PLANS TO DISTRIBUTE OR STORE BALANCE:
'" ~
WEEK OF
DATE ACTIVITY
RECEIVED
BALANCE
DESCRIBE PLANS TO DISTRIBUTE OR STORE BALANCE:
AUTHORIZED SIGNATURE
DATE.
RVH/fa
EXHIBIT A
Revised 10/85
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'C9mmunity Services Department
~ n
..~! COUNTY OF SAN SERNARDlN .
r:::;.~~ HUMAN RESOURCES AGEN~: :
~ ~... ItI_aDl...o'
~?~~~~~~~~T~~~"WAX~~'t~Y~~~:~;~" ..~,~r~~~~~~
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\!'11!'!:..~/ U71LlTY ASSIST,:. '.<.:E
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EMERGENCY SERViCES
383-7328
FOOD DISTRIBUTION
383-2521
WEATHERIZATION
383-3202
NUTRITION FOR SENIORS
383-3527
TRANSPORTATION
383.3728
GRASSRCOTS WOMEN
363- 3894
DISABLED SERVICES
383-2456
T.T.Y.
8ea.8476
:ood Dist~ibution Program
ON-SITE FEEDING PROGRAMS
DAILY SIGN-IN SHEET
AGENCY:
ADDRESS
INCOME ELIGIBILITY GUIDELINES
Number Gross Gross
In Household r~onthly Income Yearly Income
1 656.25 7,875.
2 881.25 10,575.
3 1,106.25 13,275.
4 1,331.25 15,975.
5 1,556.25 18,675.
6 1,781.25 21,375.
7 2,006.25 24,075.
8 2,231.25 26,775.
9 2,381.25 28,575.
10 2,531.25 30,373.
CLIENT ELIGIBILITY CERTIFICATION
By my signature below, I certify under penalty of perjury that my household Gross
Monthly Income does not exceed the above amounts indicated for the number of in-
dividuals residing within my household.
1
1
1
1
1
1
lqna ure Adults Children Total Number Served
1.
2.
3.
4.
5.
6.
7.
8. ,
9.
o.
1.
.2.
,3.
4.
:>.
Number Served
S' t
TOTAL SERVED
RVH/fa
EXHIBIT C
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Revised 10/85
AdminIstrative Office
~;1~) 383-3=23
686 East Mill Stree!
San 5err.arolno. CA 924'5-061'
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Agency
?hone
Address
Zip
Director
Contact Person
AGENCY VOL~~ITEERS
Name
Name
Add~ess
Address
Zip
Zip
Phone
Phone
Name
Address
Name
Address
Phone
Phone
Name
Address
Name
Address
Phone
Phone
Name
Address
Name
Address
(
Phone
Phone
---~---------------~-----~------~---~-------------------------~--~---~---------------
Name
Address
Name
Address
Phone
Phone
Name
Name
Address
Address
Phone
Phone
-----------------------------------------------------------------------~-------------
PLEASE USE ADDITIONAL SHEETS, !? REQUI?~D.
RVH/fa
Revised 10/85