2016 Summer Food Service Program and 2016-2017 National School Lunch Program REGISTRATION

2016 Summer Food Service Program and 2016-2017 National School Lunch Program REGISTRATIO N / RENEWAL

The Florida Department of Agriculture and Consumer Services (FDACS), Division of Food, Nutrition and Wellness requires that vended sponsors of the National School Lunch Program and/or the Summer Food Service Program entering into contracts for the provision of program meals be with a registered food service vendor .

A food service vendor is defined as a commercial enterprise, public or nonprofit private organization or individual that enters into a contract with a school food authority, often in the form of a caterer, restaurant or food service management company. Food service vendors must register or renew annually and be approved by FDACS prior to receiving a contract award. Once registered or renewed, food service vendors will be expected to maintain their vendor file and advise FDACS of any significant business changes. Registered food service vendors may be asked to submit updated information that will be used in determining the food service vendor’s ability to participate in specific procurements and/or programs.

REGISTRATION: Complete the registration form and provide all documentation listed within. Make sure to provide the most recent copies you have on file that have not expired.

RENEWAL: All returning vendors from school year 2015-2016 may renew. Please provide the vendor identification number that starts with 2015***. Only fill in the company name and any new information (i.e., contact info, primary programs, specialty menus and service areas).

Required documentation includes:  Most recent health inspection  Updated food manager certification if expired  Updated business license if expired  Most recent proof of insurance

Vendor training must be completed and passed before being an FDACS-approved vendor. Please go to www.FreshFromFloridaKidsTraining.com to complete our online training course. Food service vendor packets may be submitted to FDACS by fax, certified mail or email. Please choose only one method of submission. Before submitting your completed renewal form, please make a copy and retain it for your own records.

 Fax number: (850) 617-7402

 Certified mail: Florida Department of Agriculture and Consumer Services Division of Food, Nutrition and Wellness (H2) Attn: Procurement 600 South Calhoun Street, Suite 120 Tallahassee, Florida 32399

 Email scanned files to: [email protected] or [email protected] Florida Department of Agriculture and Consumer Services Division of Food, Nutrition and Wellness

FOOD SERVICE VENDOR REGISTRATION / RENEWAL FORM ADAM H. PUTNAM 7 CFR 210.19(a)(5) COMMISSIONER

Please select one:

NEW Food Service Vendor Applicant, or

Food Service Vendor Renewal VIN #:

VENDOR INFORMATION

Company Name:

Doing Business As, if applicable:

Mailing Address Line 1:

Mailing Address Line 2:

City, State, Zip Code:

County:

Regional Address Line 1:

Regional Address Line 2:

City, State, Zip:

County:

Website: List all names/alias es you have used in the past 24 months, if applicable: CONTACT(S) FOR PROCUREMENT NOTICES

This information will be listed publicly on the FDACS Food Service Vendor List. Please provide the information below for one or two representatives to receive procurement notices, solicitations from sponsors, emails from FDACS and annual vendor training opportunities.

Representative 1 Contact Name:

Title:

Telephone Number:

Fax Number:

Email Address:

Representative 2 (Optional) Contact Name:

Title:

Telephone Number:

Fax Number:

Email Address:

AUTHORIZED SIGNATORIES

Please provide a list of individuals that are authorized to enter into contractual agreements.

Name (Last, First) Title CORPORATE PROFILE

Yes No N/A [C1] Is your company incorporated? If yes, the date of incorporation is . [C2] Is your company certified as a Minority-Owned, Woman- Owned, or Veteran-Owned Enterprise? If yes, please submit current certification. [C3] Has your company been terminated for cause in the past 36 months? If yes, please attach written explanation.

Primary Business Function

Please mark the one box that best describes your company.

Caterer Food Service Management Company

Restaurant Other:

Previous Experience

Mark the box next to each United States Department of Agriculture (USDA) program that your company is currently or has provided meals to in the past 36 months. (NSLP) National School Lunch Program (SFSP) Summer Food Service Program (SBP) School Breakfast Program (FFVP) Fresh Fruit and Vegetable Program (SMP) Special Milk Program (ASSP) Afterschool Snack Program

Primary Program(s)

Mark the USDA program that your company has an interest in participating. (NSLP) National School Lunch Program (SFSP) Summer Food Service Program (SBP) School Breakfast Program (FFVP) Fresh Fruit and Vegetable Program (SMP) Special Milk Program (ASSP) Afterschool Snack Program NUTRITION INFORMATION

Minimum Conditions

List any conditions that must be met in order for your company to consider submitting a proposal/bid to a sponsor (i.e. minimum number of meals/day, minimum number of schools, cold meals only, etc.).

Specialty Menu

Mark the box next to each specialty or diet menu that your company can provide. Please mark all that apply.

V Vegetarian H Halal

VG Vegan L Latin

F Gluten-Free N All Natural

DF Dairy-Free R Renal

PF Peanut-Free K Kosher

PKF Pork-Free P Puree

CF Casein-Free ORG Organic

SF Salt-Free SS Shelf-Stable

ALG Special Allergy DIAB Diabetic

LS Low-Sodium Other SERVICE AREA(S)

Mark the box next to each Florida county or counties that your company is able and willing to contract for food services.

Alachua Franklin Lee Pinellas

Baker Gadsden Leon Polk

Bay Gilchrist Levy Putnam

Bradford Glades Liberty Santa Rosa

Brevard Gulf Madison Sarasota

Broward Hamilton Manatee Seminole

Calhoun Hardee Marion St. Johns

Charlotte Hendry Martin St. Lucie

Citrus Hernando Miami-Dade Sumter

Clay Highlands Monroe Suwannee

Collier Hillsborough Nassau Taylor

Columbia Holmes Okaloosa Union

DeSoto Indian River Okeechobee Volusia

Dixie Jackson Orange Wakulla

Duval Jefferson Osceola Walton

Escambia Lafayette Palm Beach Washington

Flagler Lake Pasco REQUIRED DOCUMENTATION

Please submit the following documents:

 A copy of the two (2) most recent health inspections for your facility. o (Only applicable if meals are prepared in a facility not controlled by a sponsor, i.e., catering kitchen, restaurant, etc.)  A food manager certification for each facility where program meals are prepared. o (Only applicable if meals are prepared in a facility controlled by a sponsor, i.e., school, summer camp, church, etc.)  Business license  Proof of insurance  Certificate Regarding Lobbying  Disclosure of Lobbying Activities  Minority-MBE, Woman-WBE, or Veteran-VBE Owned Business Certification (if applicable)  Written explanation for termination (if applicable)

CERTIFICATION

I certify that the information submitted on this application for registration is true and correct and that the company is aware that misrepresentation may result in prosecution under applicable state and federal statutes.

SIGNATURE OF AUTHORIZED OFFICIAL Date

PRINT NAME Date Florida Department of Agriculture and Consumer Services Division of Administration CERTIFICATION REGARDING LOBBYING; DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS ADAM H. PUTNAM COMMISSIONER FOR EXPENDITURE OF FEDERAL FUNDS

LOBBYING

As required by 7 CFR Part 3018, for persons entering into a contract, grant or cooperative agreement over $100,000 involving the expenditure of Federal funds, the undersigned certifies for itself and its principals that:

(a) 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 making of any Federal grant, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal grant or cooperative agreement;

(b) If any funds other than Federal appropriated funds have been paid or wm 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; and

(c) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subgrants, contracts under grants and cooperative agreements, and subcontracts) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. 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.

PRINTED NAME/TITLE OF REPRESENTATIVE CONTRACT I PURCHASE ORDER NUMBER

SIGNATURE OF REPRESENTATIVE I DATE

DEBARMENT, SUSPENSION AND OTHER RESPONSI BILITY MATTERS

As required by 7 CFR Part 3017, for persons entering into a contract, grant or cooperative agreement over $25,000 involving the expenditure of Federal funds, the undersigned certifies for itself and its principals that:

(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

(b) Have not within a three-year period preceding this application been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

(c) Are not presently indicted tor or otherwise criminally or civilly charged by a Government entity (Federal, State, or local) with commission of any offenses enumerated in paragraph (b) of this certification; and

(d) Have not within a three-year period preceding this application had one or more public transaction (Federal, State, or local) terminated for cause or default; and

Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this application. CONTRACT I PURCHASE P S ORDER NUMBER R I N E T E N D

N T A M E A / T TI I T L V E

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