A Partnership to End Hunger in Our Hometown.

Transcription

1 Partner Agency Information Agency Partner Name: Dba: Physical Address: Mailing Address, if different: A Partnership to End Hunger in Our Hometown. City: Zip Code: County: Phone: Fax: Completed and Current REQUIRED ATTACHMENTS: 501c3: attached? Y N # or Church Supplemental Form? Y N Name of Staff with Food Handlers Certificate: Have you read the Memorandum of Agreement in full and understand its meaning? Y N Contact Information Primary Contact Person(s): Phone for immediate agency contact: for immediate access: Admin Contact: Reporting Contact: Finance Contact: Shoppers (3 max): Primary Website: Distribution: (please include hrs. of service if different: weekly, bi-weekly, or monthly) Sunday: Do you have any requirements for individuals who use your services (i.e. must live in X County or be of a Monday: certain age, picture ID, etc.?) Tuesday: Wednesday: Thursday: Friday: Please list organization s office hours if different from distribution hours: Saturday:

2 Are you on call for appointments outside of distribution hours: Yes No Are your distribution hours posted? Yes No WHERE? Agency Background Type of Agency: Pantry Cooking/ Serving Meals (Rehab, Residential, Youth or Senior Center, etc.) Mobile Pantry/Direct Drop School Pantry Other What date did your organization begin? Do you have multiple locations? If so, list the addresses and define the activity there. Does your agency assist other areas outside of your county? For example, national disasters, third world countries, etc. What documentation does your agency require for food assistance? What are the closest feeding outreaches to your agency? Give name, contact name if you have it, type of distribution and distance in miles from your site. Is your agency inspected by the Dept. of Health, Dept. of Family and Children, APD, or any other organization? If so, please attach a copy of the last inspection and list the date and results of the most recent inspection. BE SURE TO ATTACH YOUR FOOD HANDLERS CERTIFICATE NOW TO THIS APPLICATION. Services and Access What intersection is the closest bus route to your agency? How far in miles is this walk? Do you provide additional information regarding community services to clients? If so, define. Are you already participating in any programs, pick-ups, or events for FNEFL or any other food bank or food distributor? If so, please detail. Please describe the type of services provided by your agency/program. Please include all services, even those that are not food related (prescription assistance, clothes closet, mobile pantry, home delivery, etc.).

3 Please describe the people served by your agency. Include area served (zip code or neighborhood, schools name, etc.) age, income level, veteran s status, physical or mental disabilities, etc. Does your agency provide meals on your premises? YES NO If YES, how often? Daily Weekly Monthly Other Number of people served at each meal: Breakfast Lunch Dinner Snacks Number of staff members served at each meal: Breakfast Lunch Dinner Snacks Does your agency provide home delivered meals? YES NO If yes, how many per week? Where? Does your agency distribute food packages for emergency assistance to the community? YES NO If yes, what s in the food package? What is the average number of individuals your agency serves each month? What is the average number of food packages you distribute each month? How do you determine if your clients lack the necessities of life as a result of poverty or temporary distress? What percentage of your clients is low income? How do you know /determine this? Does your agency provide food to any other agency or organization? YES NO Officers/Authorized Signatures: PLEASE PRINT FULL NAME President/Pastor/Bishop/CEO: Vice-President: Secretary: Treasurer: Authorized Invoice Signer: 1. Phone: 2. Phone:

4 Staff designated to send required QUARTERLY reporting/data : Phone: Funding Do you your require clients to pay for services offered? YES NO If YES, how much and please explain: Is your organization reimbursed by the government for client care services? YES NO Per client reimbursement? Do the people receiving food from your organization contribute any property or service for the food? YES NO If so, explain: Describe your last fund raiser, include the date, how often this occurs (or other events) and approximate funds raised. Are you committed to continue fund raising throughout the growth of your pantry? What do you need to increase your capacity to serve those in need? Food Storage: attach scanned photo s if you can. Is the storage space secured with limited access? YES NO How many people have a key? Is the room temperature controlled year around? YES NO Dry Storage please provide # of shelves(shelves, tables, or pallets) : Do you have any backup storage? If yes, describe. Refrigeration Volume: Type Total Cubic Feet (HxWxD) Type Total Cubic Feet (HxWxD): Freezer Volume: Type Total Cubic Feet (HxWxD) Type Total Cubic Feet (HxWxD) # smoke detectors in building # in pantry? #Fire extinguishers in bldg #pantry What fire suppression or other safety features does your pantry/common space have? Pest Control Service Name: Service Schedule:

5 Should your agency obtain food which is later recalled for health reasons by the FDA, could you trace how that food was used and what individuals received it? YES NO Please explain: Please explain how your food tracking and record keeping works. What kind of food does your agency need most often? Authorized Signature By signing below, you are agreeing to adhere to the policies and guidelines set forth by Feeding Northeast Florida, Inc. Please Print Contact Name: Signature: Date:

6 Feeding Northeast Florida MEMORANDUM OF AGREEMENT This Agreement is made and entered into by Feeding Northeast Florida, Inc. Food Bank of Northeast Florida ( FNEFL- FEEDING NORTHEAST FLORIDA, INC. ), having a place of business at 1116 Edgewood Avenue North, Jacksonville Florida and ( Agency ), having a place of business at this day of, 20. In consideration of the terms hereof, and the delivery of product by FNEFL- FEEDING NORTHEAST FLORIDA, INC. to Agency, the parties agree as follows: 1. Agency represents and warrants that it qualifies as a section 501(c) (3) organization under the Federal Tax Code (26 U.S.C. 501(c) (3). Agency shall have proof of its nonprofit status on file with FNEFL- FEEDING NORTHEAST FLORIDA, INC. prior to joining the Food Bank, shall update it periodically, as required, and shall continue to qualify and maintain its status as a 501(c) (3) organization. In the event agency receives notification that its status as a nonprofit is challenged or revoked and/or it ceases to qualify as a 501(c) (3) organization, Agency shall immediately notify FNEFL- FEEDING NORTHEAST FLORIDA, INC. of such cessation. At the request of FNEFL- FEEDING NORTHEAST FLORIDA, INC., Agency shall also provide a Florida Consumer s Certificate of Exemption, and a copy of Agency s Articles of Incorporation and Bylaws. 2. Agency shall operate year-round food assistance program(s) with a focus on feeding a needy segment of the population, and shall provide FNEFL- FEEDING NORTHEAST FLORIDA, INC. documentation of food distribution for such program(s) for at least 90 days prior to the date shown on application. 3. Agency must have a mission to serving the ill, needy or children. For the purpose of this Agreement, the term needy refers to an individual who lacks the necessities of life, involving physical, mental or emotional well-being, as a result of poverty or temporary financial distress. At a minimum, 50% of the individuals served by Agency s program must, in the opinion of FNEFL- FEEDING NORTHEAST FLORIDA, INC., be proven low-income individuals. 4. Agency preparing meals on-site shall be licensed by the local County Department of Health, or entity responsible for licensure and monitoring, and receive regular health inspections and have a certificate evidencing such license and health inspections on file with FNEFL- FEEDING NORTHEAST FLORIDA, INC. The inspections and certificates will be needed only if it is applicable in the county that the agency is located. Agency shall comply with all FNEFL- FEEDING NORTHEAST FLORIDA, INC. guidelines and recommendations for safe food storage, handling, and facility maintenance. 5. Every agency shall have a staff member who has attended either the Food Manager s Workshop/ Food Handler s Certificate administered by the Department of Business and Professional Regulation, Division of Hotels and Restaurants Hospitality Education Program, or the Safe Food Handling Class offered by FNEFL- FEEDING NORTHEAST FLORIDA, INC or A copy of this certificate will be provided to FNEFL. 6. Agency shall name a Food Program Coordinator and up to three authorized shoppers. The three shoppers shall obtain a badge from the front desk when they have their shopping appointment, and wear it for the entire shopping experience. 7. Agency staff/volunteers must attend New Partner Orientation, Safe Food Handling, and appropriate food bank related workshops and trainings.

7 8. Agency shall notify FNEFL- FEEDING NORTHEAST FLORIDA, INC. in writing if/when its program changes location, director, contact, shoppers, or type or size of food program. 9. Agency must distribute products for use within FNEFL- FEEDING NORTHEAST FLORIDA, INC. service area, unless otherwise approved by the food bank. 10. Agency shall make every effort to provide assistance in response to requests by FNEFL- FEEDING NORTHEAST FLORIDA, INC. or other cooperative food providers, who may make referrals of needy individuals. Agency shall participate in FNEFL- FEEDING NORTHEAST FLORIDA, INC. referral network, by providing contact information as requested by needy individuals. 11. Agency shall ensure that product storage and handling will conform to state and local regulations and FNEFL- FEEDING NORTHEAST FLORIDA, INC. requirements. 12. Agency agrees that products will not be stored in nor distributed from a private residence. 13. Agency assumes responsibility and shall be accountable for the use of all products after taking possession of such products from FNEFL- FEEDING NORTHEAST FLORIDA, INC. Agency shall ensure that products ordered will not exceed the needs of the program. 14. FNEFL- FEEDING NORTHEAST FLORIDA, INC. reserves the right to limit the amount and type of food the agency may receive. 15. Agency shall not sell, barter, transfer or share donated or Purchase Program products in exchange for money, services or other products. Agency shall not use donated or Purchase product items in any fashion other than to serve Agency s clientele. Agency agrees to adhere to additional donor stipulations. In the event that Agency violates this provision, FNEFL- FEEDING NORTHEAST FLORIDA, INC. may immediately terminate this Agreement without notice and recover possession of any food items or other products in Agency s possession without providing compensation to Agency. Agency shall grant admittance to agents of FNEFL- FEEDING NORTHEAST FLORIDA, INC. for such purpose. 16. Agency shall not give donated or purchased product to staff or volunteers for personal use. Agency must not serve donated products for general congregation use or serve donated products at agency events. 17. Agency agrees that is meets the IRS eligibility requirements for receipt, transfer and use of donated food under section 170 (3). 18. Agency shall not require or request clients to pay, donate or make any contribution of money or services to agency-ever. 19. Agency shall not require clients to participate in counseling, prayer or in a religious service as a prerequisite or in conjunction with food distribution or receiving food. Agency shall not use program to foster or advance religious or political views. 20. Agency shall not discriminate in the provision of services on the basis of race, creed, religion, color, gender, sexual orientation including gender identity, disability, age, ancestry, marital status, veteran status and unfavorable discharge from the military, citizenship, national origin, age, pregnancy, political beliefs, or any other characteristic protected by law.

8 21. Partnership is updated every year. Documentation required for renewal will be mailed to the agency at the beginning of the renewal period. 22. If Agency operates an emergency food pantry or dual program, Agency shall keep accurate product distribution records for three years. Records must be kept on-site and available to food bank agent. A FNEFL Client Sign In Sheet will be provided to you for this purpose. This record will contain the following information: a. Date, Type of Distribution b. name of client c. zip code of residence d. # in household e. Self-reported service to demographic categories such as veteran, senior, individuals with disabilities, etc. 23. If Agency operates a soup kitchen or residential program, Agency shall keep accurate record of menus and number of meals served, for a period of one year. A FNEFL Client Sign In Sheet will be provided to you for this purpose. This record will contain the following information: a. Date, Type of Distribution, Indicator of which meal is being served b. name of client c. zip code of residence d. Self-reported service to demographic categories such as veteran, senior, individuals with disabilities, etc. 24. Dual-program agencies must have separate, labeled/identified food storage for on-site programs and emergency food pantries. 25. Agency shall support the operation of FNEFL- FEEDING NORTHEAST FLORIDA, INC. through active participation in one or all levels such as programs, services or sharing floor via payment of shared maintenance fees, the amount of which will be periodically communicated by FNEFL- FEEDING NORTHEAST FLORIDA, INC. to Agency. 26. Agency status at FNEFL- FEEDING NORTHEAST FLORIDA, INC. will be considered inactive if agency does not participate at any one level for three (3) months or more. Inactive agencies interested in reactivation must reapply to the food bank. 27. FNEFL- FEEDING NORTHEAST FLORIDA, INC. reserves the right to refuse partnership service or food. Food Bank membership will be approved on a probationary basis. 28. In the event of Agency s failure to comply with state and local regulations or with any provision, recommendation or guidelines as outlined in this Agreement, FNEFL- FEEDING NORTHEAST FLORIDA, INC. reserves the right to immediately terminate this Agreement, without notice, and recover possession of food/products in Agency s possession without compensating Agency for the cost or value thereof. Agency shall grant admittance to FNEFL- FEEDING NORTHEAST FLORIDA, INC. agents for such purpose. FNEFL- FEEDING NORTHEAST FLORIDA, INC. reserves the right to terminate its relationship with agency for non-compliance of this Agreement or attachments. 29. This Agreement shall have a term of one year from the earlier of or the date hereof, unless terminated sooner (see above). Agency shall complete a new application and signed Memorandum of Agreement and attend training as deemed necessary by FNEFL- FEEDING NORTHEAST FLORIDA, INC. if the Agreement is to be extended. This Agreement may be terminated at will by FNEFL- FEEDING NORTHEAST FLORIDA, INC. with or without cause upon notice to Agency. Upon such termination, Agency shall remain responsible for any monies owed to FNEFL- FEEDING NORTHEAST FLORIDA, INC. by Agency through the date of termination.

9 30. In the event of litigation between Agency and FNEFL- FEEDING NORTHEAST FLORIDA, INC., and/or Feeding America, Original Donor, the parties agree that the state and federal courts located in DUVAL County, Florida shall be the exclusive venue for any action. However, if such do not have subject matter jurisdiction over such cause of action, then action may be brought in any court in the State of Florida where in subject matter jurisdiction properly lies. The substantially prevailing party in such litigation shall be entitled to collect and recover from the party not substantially prevailing all costs of such action or proceeding incurred by such substantially prevailing party, including, but not limited to, reasonable attorney, paralegal and expert fees and costs through all levels and nature of proceedings, including appeals. LIABILITY RELEASE AND INDEMNIFICATION (agency name) hereby: 1. Accepts the food as is. No representations or warranties, express or implied, are made by Feeding Northeast Florida, Inc., Feeding America and the original Donor regarding the food s fitness for human consumption. 2. Agrees to store and inspect food soon after receipt, as is practical, and to determine whether the food is fit for human consumption. If not, the agency will immediately advise the food bank. 3. Agrees to store all acceptable food in the manner as is appropriate given the nature of the various food products. 4. Releases FNEFL- FEEDING NORTHEAST FLORIDA, INC., Feeding America, and all Donors from any liability resulting from the condition of the donated food. The agency further agrees to indemnify, defend and hold FNEFL- FEEDING NORTHEAST FLORIDA, INC. Feeding America and original Donor free and harmless from and against all and any liabilities, damages, losses, claims, causes of action, suits at law or in equity or any obligation whatsoever and all costs and expenses including attorney s fees arising out of or attributed to any action of the agency in connection with the agency s storage and/or use, including distribution of donated food. 5. Acknowledges that the food is donated to further charitable (non-commercial) purposes and, therefore, the agency agrees not to sell, trade, share, barter or offer to sell the food or exchange it for services. 6. Agrees to assume any and all responsibility for food product liability relating to any act or failure to act by the agency associated with distribution, storage, preparation, or service of the food after the agency assumes possession of the food. 7. The agency agrees to notify the FNEFL- FEEDING NORTHEAST FLORIDA, INC whenever it receives notice of any claim liability with respect to the food received from the FNEFL- FEEDING NORTHEAST FLORIDA, INC. CODE OF ETHICS

10 All organizations or individuals acting for or with Feeding Northeast Florida, Inc. Food Bank are expected to: Represent accurately, honestly and completely Feeding Northeast Florida, Inc.'s and Feeding America s mission and activities to the larger community. Conduct all Feeding Northeast Florida, Inc. business in accordance with applicable laws, rules and regulations. Perform all duties with honesty, transparency and integrity. Treat all people with respect and dignity without regard to race, national or ethnic origin, citizenship, color, religion, sex, sexual orientation, income source, age, or mental or physical ability. Treat all those who access services with the utmost dignity and respect, including preserving the confidentiality and personal information of those served. Refrain from obtaining any improper personal benefit because of their employment or association with Feeding Northeast Florida, Inc. Exercise independent judgment free from any improper outside influence. Ensure that contributions are used in accordance with donors intentions. Acquire and share food in a spirit of cooperation with other food banks and food programs. Implement best practices in the proper and safe storage and handling of food and only distribute products that are safe to consume. Promptly report any improper discriminatory behavior, sexual harassment, illegal activities or other violations of this Code. The undersigned hereby affirm that they are authorized agents of the applicant organization, and their legal signatures do bind the applicant organization to the terms, conditions, and limitations of the application agreement. I declare under the penalty of perjury that the foregoing is true and correct. Name of Partner Agency: Date By Signature of Highest Organization Authority Date Printed Name and Signature of Food Program Contact Person and their Contact Thank you for your Commitment and Dedication to the Mission of Ending Hunger in Our Hometown! This agency is accepted/ renewed as a partner of Feeding Northeast Florida, Inc. pursuant to the above-stated terms and conditions. Partner Agency Code/Reference# Signature of Authorized Representative for FNEFL- FEEDING NORTHEAST FLORIDA, INC. Date: