"Farmers' Market Application and Information Form - Louisiana Farmers' Market Nutrition Program" - Louisiana

Farmers' Market Application and Information Form - Louisiana Farmers' Market Nutrition Program is a legal document that was released by the Louisiana Department of Agriculture & Forestry - a government authority operating within Louisiana.

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FMNP Market # _________
(Office Use Only)
2022
Louisiana Farmers’ Market Nutrition Program
Farmers’ Market Application and Information Form
The information below must be provided for the Farmers’ Market to participate in the Farmers’ Market Nutrition Program. Information
provided will determine eligibility to participate in the program and will also be used in promoting the market by the Louisiana
Department of Agriculture & Forestry as one supporting the Farmers’ Market Nutrition Program. The Farmers’ Market Nutrition
Program (FMNP) refers throughout the document to compliance with both the Senior Farmers’ Market Nutrition Program (Senior
FMNP) and WIC Farmers’ Market Nutrition Program (WIC FMNP) unless specifically stipulated as Senior FMNP or WIC FMNP.
1.
Name of Farmers’ Market: ______________________________________________________________________________________________
2.
Market Location/Schedule of Operation:
a.
Location #1: __________________________________________________________________________________________________
Schedule: _____________________________________________________________________________________________________
(Months Open/Days of Week/Hours of Operation)
b.
Location #2: __________________________________________________________________________________________________
Schedule: _____________________________________________________________________________________________________
(Months Open/Days of Week/Hours of Operation)
c.
Location #3: __________________________________________________________________________________________________
Schedule: _____________________________________________________________________________________________________
(Months Open/Days of Week/Hours of Operation)
3.
Mailing Address: _______________________________________________________________________________________________________
(Street or P.O. Box)
______________________________________________________________________, LA ___________________________________________
(City)
(Zip)
4.
Person to Represent the Market: __________________________________________________________________________________________
Mailing Address (If different from Above): __________________________________________________________________________________
(Street or P.O. Box)
______________________________________________________________________, LA ____________________________________________
(City)
(Zip)
Phone #: ________________________ Fax #: _____________________ Email: ____________________________________________________
Website: ______________________________________________________________________________________________________________
5.
Approximate Number of Farmers Who Sell at the Market During an Average Week: ___________________________
Approximate Number of Other Vendors Who Sell at the Market During an Average Week: ______________________
6.
Do you currently provide nutrition education at your market site(s)? Yes __________ No __________
If so, who is providing the nutrition education, how often and in what manner?
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
7.
Does your market have an incentive program for Farmers’ Market Nutrition Program benefits card shoppers such as “Market
Match” that gives them additional funds to use at the market if they use all of their benefits?
Yes __________ No _________
If so, please explain how this program works.
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
FMNP Market # _________
(Office Use Only)
2022
Louisiana Farmers’ Market Nutrition Program
Farmers’ Market Application and Information Form
The information below must be provided for the Farmers’ Market to participate in the Farmers’ Market Nutrition Program. Information
provided will determine eligibility to participate in the program and will also be used in promoting the market by the Louisiana
Department of Agriculture & Forestry as one supporting the Farmers’ Market Nutrition Program. The Farmers’ Market Nutrition
Program (FMNP) refers throughout the document to compliance with both the Senior Farmers’ Market Nutrition Program (Senior
FMNP) and WIC Farmers’ Market Nutrition Program (WIC FMNP) unless specifically stipulated as Senior FMNP or WIC FMNP.
1.
Name of Farmers’ Market: ______________________________________________________________________________________________
2.
Market Location/Schedule of Operation:
a.
Location #1: __________________________________________________________________________________________________
Schedule: _____________________________________________________________________________________________________
(Months Open/Days of Week/Hours of Operation)
b.
Location #2: __________________________________________________________________________________________________
Schedule: _____________________________________________________________________________________________________
(Months Open/Days of Week/Hours of Operation)
c.
Location #3: __________________________________________________________________________________________________
Schedule: _____________________________________________________________________________________________________
(Months Open/Days of Week/Hours of Operation)
3.
Mailing Address: _______________________________________________________________________________________________________
(Street or P.O. Box)
______________________________________________________________________, LA ___________________________________________
(City)
(Zip)
4.
Person to Represent the Market: __________________________________________________________________________________________
Mailing Address (If different from Above): __________________________________________________________________________________
(Street or P.O. Box)
______________________________________________________________________, LA ____________________________________________
(City)
(Zip)
Phone #: ________________________ Fax #: _____________________ Email: ____________________________________________________
Website: ______________________________________________________________________________________________________________
5.
Approximate Number of Farmers Who Sell at the Market During an Average Week: ___________________________
Approximate Number of Other Vendors Who Sell at the Market During an Average Week: ______________________
6.
Do you currently provide nutrition education at your market site(s)? Yes __________ No __________
If so, who is providing the nutrition education, how often and in what manner?
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
7.
Does your market have an incentive program for Farmers’ Market Nutrition Program benefits card shoppers such as “Market
Match” that gives them additional funds to use at the market if they use all of their benefits?
Yes __________ No _________
If so, please explain how this program works.
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
8.
Does your market have a current list of rules and regulations governing participation and conduct in the market?
Yes _______ No _______
If so, please attach a current list of your market rules and regulations.
9.
Upon signature of the Market Representative, you agree to abide by the following conditions to receive authorization by the Louisiana
Department of Agriculture & Forestry to participate in the Farmers’ Market Nutrition Program:
a.
Cooperate with the Louisiana Department of Agriculture & Forestry, local agencies and local farmers in promoting the
Farmers’ Market Nutrition Program as an approved farmers’ market program in your market.
b.
Recommend to the department those farmers who sell at the market who are eligible to be certified. Likewise, do not recommend
farmers or any other vendor who do not meet the eligibility standards to participate in the program.
c.
Assist in monitoring the FMNP participating farmers to ensure compliance with program rules as specified in the FMNP Farmer
Participation Agreement signed by participating farmers. At a minimum, monitor rules for posting Vendor Display Signs and
Produce Price Signs, and make sure that farmers are extending the same courtesies to benefits card recipients as they do to other
customers, including produce quality and price, and make sure participating farmers abide by the USDA nondiscrimination
policy prohibiting discrimination on the bases of race, color, national origin, sex, age, disability, reprisal or retaliation for
protected activities.
d.
Assist benefits card recipients in identifying certified farmers and buying produce with their benefits cards, and monitor the use
of benefits cards to ensure compliance with the FMNP rules.
IN WITNESS WHEREOF, the following parties agree to accept the “Farmers’ Market Application and Information Form” as correct to its content
and agree to fully support and cooperate with the other party in the Louisiana Farmers’ Market Nutrition Program at this market.
_____________________________________________
__________________________________________
(Market Representative Signature)
(Date)
_____________________________________________
__________________________________________
(LDAF Representative or Designee Signature)
(Date)
_____________________________________________
__________________________________________
(LDAF FMNP Director Signature)
(Date)
Louisiana Department of Agriculture & Forestry
Delivery Address
Michelle Estay, FMNP Director
47076 N. Morrison Blvd.
47076 N. Morrison Blvd.
Hammond, LA 70401-7308
Hammond, LA 70401-7308
Tel: (985) 345-9483
Fax: (225) 237-5630
Email: fmnp@ldaf.la.gov
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies,
offices, and employees, and institutions
participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or
reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American
Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have
speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made
available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination
Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html,
and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the
information requested in the form. To request a copy of the complaint form, call (866) 632-9992.
Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture (USDA)
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.
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