Food Service Management Contract Form Page 2
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4VENDOR CONTRACT
ADULT CARE FOOD PROGRAM
This is a contract to furnish meals (unitized, if applicable) to be served to adults participating in the Adult Care Food Program (ACFP), a
component of the Child and Adult Care Food Program established by the United States Department of Agriculture (7 CFR, Part 226),
administered by the Florida Department of Elder Affairs. It sets forth the terms and conditions applicable to the proposed procurement. Upon
acceptance, this document and its required attachments shall constitute the contract between the vendor and the institution named herein.
Increases and decreases in the number of meal orders may be made by the institution, as needed, with prior notice of one week.
Please Type or Print Clearly (in Ink)
ACFP Provider: Complete Parts 1, 2, 3 and 6. Vendor: Complete Parts 4 and 5. DOEA/ACFP Representative: Complete Part 7.
1. Contract Issued by:
________________________________________________________
Telephone:
(
) ______________ - _______________
Name of Institution/ACFP Provider
Fax:
(
) ______________ - _______________
Address:
____________________________________________
City/State:
_________________________________Zip________
Email address __________________________________________
CONTRACT OPTIONS
2. ______ Initial Vendor Contract
st
______ 1
year Contract Renewal Option exercised
nd
______ 2
year Contract Renewal Option exercised
The following attachments are required:
A. Debarment & Suspension Certification recently completed and signed by Vendor.
B. Copy of Vendor’s current food-service Inspection Report from licensing agency, with any needed explanations.
C. Vendor’s current license to operate a food-service facility.
D. Current 28-day cycle of menus for each type of meal service vended.
VENDOR INFORMATION
3. Name of Approved Food Service Company
4. Price per Meal (Including Tax)
_____________________________________________________
Breakfast: $ ______________
Address:
____________________________________________
Supplement (Snack) AM: $ ___________ PM: $ ___________
City/State:
_________________________________Zip________
Lunch: $ ______________
Supper: $ ______________
5. Contract Commence Date: _______/_________/________
Contract Expiration Date: _______/_________/________
#_____________
ACCEPTANCE BY INSTITUTION/ACFP PROVIDER
6. Signature: __________________________________________________
Witness: _________________________________________
Board President or Authorized Designee
Printed Name: ______________________________________________
Title:
__________________________________________
(Typed or Printed Clearly)
Date: _______/_________/________
FLORIDA DEPARTMENT OF ELDER AFFAIRS/ACFP APPROVAL
7. Period of Provider Contract: 10/1/_____ - 9/30/______
Approved Date: _____/_____/_____ Denied Date: _____/_____/______
Signature of DOEA/ACFP Representative: _________________________________________________________
Rev.7/28/15
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Parent category: Education