"Catering Information Form - Adult Care Food Program (Acfp)" - Florida

Catering Information Form - Adult Care Food Program (Acfp) is a legal document that was released by the Florida Department of Elder Affairs - a government authority operating within Florida.

Form Details:

  • Released on June 1, 2018;
  • The latest edition currently provided by the Florida Department of Elder Affairs;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

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Download "Catering Information Form - Adult Care Food Program (Acfp)" - Florida

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Catering Information Form
Adult Care Food Program (ACFP)
Please complete and attach copies of current license(s), and food service inspection report(s) and food
service management certification(s). Submit to the Department of Elder Affairs Nutrition Program 4040
Esplanade Way Tallahassee, Florida 32399 or email to:
barberg@elderaffairs.org
To be completed by the Caterer:
Name of Catering Company, including DBA:
License Number and Regulatory Agency:
Physical Address:
Mailing Address, if Different:
Owner/President:
Phone Number:
E-mail:
Contact Person’s Name/Title
(that will appear
on the ACFP Catering List):
Phone Number:
E-mail:
Counties to be Served by Main Catering Site:
List the kitchen that will produce and deliver
meals. If you own/operate more than one
kitchen, a separate Catering Information
Form must be completed for each kitchen
providing meals. Contracts must specify
Kitchen Facility Name:
which kitchen meals will come from.
Physical Address:
Contact Name and Phone Number:
License Number and Regulatory Agency:
Counties to be served:
1
Updated 06/2018
Catering Information Form
Adult Care Food Program (ACFP)
Please complete and attach copies of current license(s), and food service inspection report(s) and food
service management certification(s). Submit to the Department of Elder Affairs Nutrition Program 4040
Esplanade Way Tallahassee, Florida 32399 or email to:
barberg@elderaffairs.org
To be completed by the Caterer:
Name of Catering Company, including DBA:
License Number and Regulatory Agency:
Physical Address:
Mailing Address, if Different:
Owner/President:
Phone Number:
E-mail:
Contact Person’s Name/Title
(that will appear
on the ACFP Catering List):
Phone Number:
E-mail:
Counties to be Served by Main Catering Site:
List the kitchen that will produce and deliver
meals. If you own/operate more than one
kitchen, a separate Catering Information
Form must be completed for each kitchen
providing meals. Contracts must specify
Kitchen Facility Name:
which kitchen meals will come from.
Physical Address:
Contact Name and Phone Number:
License Number and Regulatory Agency:
Counties to be served:
1
Updated 06/2018
Caterer information Form
Please initial, acknowledging the requirements to be an approved caterer for the ACFP:
I am aware that if I am accepted on the ACFP catering list, my kitchen will be reported to
the Department of Business and Professional Regulations as serving elders, which are a high-
risk population. I am aware that my license will need to reflect such information, and it will be
categorized as a “Risk Level 3.”
I am aware no food service entity will be allowed on the ACFP catering list that has had a
“temporary closure” or “administrative complaint” within 12 months of completing this
application.
I am aware no food service entity will be allowed on the ACFP catering list that does not
have at least 3 sanitation inspections and/or has not been open for business at least 6 months.
I am aware, once on the list, an accumulation of 10 high priority violations in a 12-month
period (July 1 - June 30), an Administrative Complaint, and/or closure (temporary or permanent)
issued by the Department of Business and Professional Regulations will result in immediate removal
from the ACFP catering list, and subsequent immediate termination of any contracts with ACFP
providers.
____I am aware ACFP contracts must specify kitchen location and food can only come from the
designated kitchen. Subcontracting and/or using any kitchen (whether approved or unapproved)
without notifying DOEA in writing will result in immediate removal from the approved ACFP
catering list for 12 months and subsequent termination of contracts with any and all ACFP
providers.
Signature of Authorized Caterer Representative
Date
Title
2
Updated 06/2018
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