"Add-A-site Checklist - Administrative Sponsors (Adding Traditional Child/Adult Facilities)" - Georgia (United States)

Add-A-site Checklist - Administrative Sponsors (Adding Traditional Child/Adult Facilities) is a legal document that was released by the Georgia Department of Early Care and Learning - a government authority operating within Georgia (United States).

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  • Released on September 1, 2016;
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Download "Add-A-site Checklist - Administrative Sponsors (Adding Traditional Child/Adult Facilities)" - Georgia (United States)

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BRIGHT FROM THE START
Add-a-Site Checklist
Georgia Department of Early Care and Learning
Administrative Sponsors
Child and Adult Care Food Program
Adding Traditional
2 Martin Luther King, Jr., SE, Suite 670 East Tower
Atlanta, Georgia 30334
Child/Adult Facilities
(404) 656-5957
Sponsoring Organization’s Name _____________________
CACFP Agreement #_______________
Instructions: Sponsors of Unaffiliated Centers (Administrative Sponsors) should use this checklist as guidance for
completing and submitting all documents that are needed to seek approval to add a new facility to the CACFP. The
new facility’s information must be entered in GA ATLAS in the CACFP site Application section.
The names of new facilities must be entered as both the legal and the “doing business name” as it appears on the
license or other official document. Note: Administrative Sponsors are only allowed to add facilities that are
legally distinct from the sponsor’s organization. The sponsor cannot own (whole or in part) or operate any
facilities that are added to the sponsor’s agreement. Facilities that are owned and/or operated by the
Administrative Sponsor must submit a separate application as an independent center. Contact the Application
Specialist for more information in this area. Complete one checklist for each facility being added. Submit the entire
checklist and all required documentation to the following address:
Bright from the Start: Georgia Dept. of Early Care and Learning
Attn: Business Operations Specialist - CACFP
2 Martin Luther King Jr. Drive, SE, Suite 670 East Tower
Atlanta, GA 30334
Section I. Facility to be Added:
st
In 1
column, list the name of the facility for which an application is being submitted.
In 2nd column, if the facility is currently participating in the CACFP in direct agreement with another sponsor or in
direct agreement with Bright from the Start, input either the sponsor name or Bright from the Start’s Agreement # in
the column. If the facility is a new facility that is not currently participating on the CACFP, leave this column blank.
column, , indicate the date the Principal/Program Contact verified that the center’s Principal or staff
rd
In the 3
performing CACFP duties is not terminated and currently disqualified from participating in the CACFP. Refer to
DECAL’s policy guidance at http://www.decal.ga.gov/documents/attachments/Web-BasedUSDA-NDLInfo.pdf.
In the 4th column, indicate the anticipated date to begin claiming reimbursement for this center under your
sponsorship. Please reference CACFP policy # 8 when determining anticipated effective date to operate. Sign below
the table.
(1) Legal and DBA
(2) Facility Currently
(3) Date Verification
(4) Anticipated Effective
Name
Participating in CACFP
of the NDL
Date to Operate
of Site to Add
(Indicate sponsor name or
Bright from the Start
Agreement #)
______________________________________
___________________________________
Signature and Title of Program Contact
Date
Section II. Forms/Documents due to Bright from the Start:
___ 1. ADD-A-SITE Checklist (Submit checklist with each site application)
Page 1 of 5
Revised 9/2016
BRIGHT FROM THE START
Add-a-Site Checklist
Georgia Department of Early Care and Learning
Administrative Sponsors
Child and Adult Care Food Program
Adding Traditional
2 Martin Luther King, Jr., SE, Suite 670 East Tower
Atlanta, Georgia 30334
Child/Adult Facilities
(404) 656-5957
Sponsoring Organization’s Name _____________________
CACFP Agreement #_______________
Instructions: Sponsors of Unaffiliated Centers (Administrative Sponsors) should use this checklist as guidance for
completing and submitting all documents that are needed to seek approval to add a new facility to the CACFP. The
new facility’s information must be entered in GA ATLAS in the CACFP site Application section.
The names of new facilities must be entered as both the legal and the “doing business name” as it appears on the
license or other official document. Note: Administrative Sponsors are only allowed to add facilities that are
legally distinct from the sponsor’s organization. The sponsor cannot own (whole or in part) or operate any
facilities that are added to the sponsor’s agreement. Facilities that are owned and/or operated by the
Administrative Sponsor must submit a separate application as an independent center. Contact the Application
Specialist for more information in this area. Complete one checklist for each facility being added. Submit the entire
checklist and all required documentation to the following address:
Bright from the Start: Georgia Dept. of Early Care and Learning
Attn: Business Operations Specialist - CACFP
2 Martin Luther King Jr. Drive, SE, Suite 670 East Tower
Atlanta, GA 30334
Section I. Facility to be Added:
st
In 1
column, list the name of the facility for which an application is being submitted.
In 2nd column, if the facility is currently participating in the CACFP in direct agreement with another sponsor or in
direct agreement with Bright from the Start, input either the sponsor name or Bright from the Start’s Agreement # in
the column. If the facility is a new facility that is not currently participating on the CACFP, leave this column blank.
column, , indicate the date the Principal/Program Contact verified that the center’s Principal or staff
rd
In the 3
performing CACFP duties is not terminated and currently disqualified from participating in the CACFP. Refer to
DECAL’s policy guidance at http://www.decal.ga.gov/documents/attachments/Web-BasedUSDA-NDLInfo.pdf.
In the 4th column, indicate the anticipated date to begin claiming reimbursement for this center under your
sponsorship. Please reference CACFP policy # 8 when determining anticipated effective date to operate. Sign below
the table.
(1) Legal and DBA
(2) Facility Currently
(3) Date Verification
(4) Anticipated Effective
Name
Participating in CACFP
of the NDL
Date to Operate
of Site to Add
(Indicate sponsor name or
Bright from the Start
Agreement #)
______________________________________
___________________________________
Signature and Title of Program Contact
Date
Section II. Forms/Documents due to Bright from the Start:
___ 1. ADD-A-SITE Checklist (Submit checklist with each site application)
Page 1 of 5
Revised 9/2016
___ 2. Termination Letter from previous sponsor or Voluntary Closure Form for centers under direct agreement with
Bright from the Start (only applicable to those facilities currently participating on the CACFP)
Copy of original IRS letter assigning Federal Employer Identification Number (FEIN) to the entities’ legal
_ __3.
business name.
___ 4.
Most current registration filed with the Secretary of State, indicating corporation officers.
Deed or lease of center with legal name of business or owner’s name referenced in the document
___ 5.
(Government, Military, or BOEs exempt).
___ 6. Center Site Application (One per Site) The center must complete the site application and the principal of
the site must sign. The sponsor must enter the site information in GA ATLAS, and submit a copy of
the site application with the package.
a. ___ If charging a separate fee for meals, the center is considered a pricing center. If a pricing
center, the site must complete and submit a Written Free and Reduced Price Policy Statement (See
site pricing information in the Add-a-Site instruction booklet for more information or refer to 7
CFR 226.23(c) to review what must be included in the policy statement.)
Food Service Section of the Site Application - All organizations that contract out with another entity to
prepare and deliver meals must submit one of the following:
a. ___ Agreement to Furnish Food Service for Sites using a School Food Authority (Not applicable
to sites that prepare their own meals or have a central kitchen for sites owned by same legal
entity)
b. ___ Procurement Documents for sites that intend to contract with a vendor (Not applicable to
sites that prepare their own meals, have a central kitchen for sites owned by same legal entity, or use a
School Food Authority) Include Procurement Checklist, Agreement to Furnish Foods/Contract, and
Small Purchase Document.
c. ___Certificate of Incorporation for Vendor and/or Food Service Management Companies that are
corporations.
Use Procurement Manual found on the Bright from the Start website at
http://www.decal.ga.gov/Nutrition/HandbooksInstructions.aspx.
___ 7. Budget for Sponsored Center (Note: Not applicable for School Food Authority if the budget has been waived
via submission and approval of the waiver request form.)
___ 8. Roster of Food Program Participants (Form 7 or Form 8) – Adult Care Center or Child Care Center Roster of
Food Program Participants
a. ___ At Risk After School Program Roster of Food Program Participants (If applicable, a separate
roster must be created solely for the children in this program).
___ 9. Media Release for site(s) added (use correct release depending on pricing/non-pricing programs)
___ 10. Completed pre-operational visit monitoring form conducted with new site(s) (Note: Not applicable for School
Food Authorities adding schools that already participate in the National School Lunch Program.)
Section III. Forms/Documents regarding legal entity: Corporations, LLC, and Partnership ONLY: If the site is
incorporated, a limited liability, or partnership, check the appropriate item and send in requested information. (Based
on the answer in item C-6 of the site application. (Government, Military, or BOE’s/SFA’s exempt)
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Revised 9/2016
___ 1. Copy of Certificate of Incorporation for Incorporated centers
___ 2. Copy of Certificate of Organization for Limited Liability Companies
___ 3. Copy of Certificate of Limited Partnership for partnerships
___4. Copy of Articles of Incorporation Incorporated centers
___ 5. Copy of Articles of Organization for Limited Liability Companies
Section IV. CHILD CARE FACILITIES ONLY
Forms/Documents to determine eligibility for all Child Care Programs: To qualify for the CACFP, the child care
center must meet one of the following conditions. Place a check beside the eligibility method being used to qualify the
program and submit any documents requested under the applicable item. Item 3 can only be used after determining the
child care center does not qualify under Item 2, Title XX/Pre-K Cat 1.
1. ___ Non-Profit child care centers (check one of the three items below and submit documents)
a. ___ If the center has received official notice of nonprofit status, submit a copy of the 501 (C) 3
documentation on IRS letterhead (excludes government entities, SFA’s/BOE’s)
i. ___ If a church which has tax-exempt status under the umbrella of the national church
affiliation, submit the list attached to the IRS letter which contains the church’s name, or
submit a letter from the chief financial officer, or comparable person verifying that the
subordinate church is included in the tax-exempt status of the national organization along with
item a above.
b. ___If a church or the parent organization has not filed for tax-exempt status with the IRS, submit the
Tax Exempt Status Certification for Churches form with section 2 completed and signed by the
financial officer of the organization.
2. ___ For-Profit child care centers qualifying by 25% of the enrolled children or licensed capacity (whichever is
less) receiving compensation under Title XX and/or Georgia Pre-K Category 1
a. ___ Submit copies of DFCS forms 69, 77 that are signed by the DCFS representative, or Maximus
report for Title XX children
3. ___ For-Profit child care centers qualifying by 25% of the enrolled children or licensed capacity (whichever is
less) being eligible for Free and/or Reduced price meals based on the income stated on the Income Eligibility
Statements
a. ___ Obtain complete Income Eligibility Statements for all children. Indicate each child’s eligibility on
the Roster of Food Program Participants submitted with the application. Do Not Submit the IES
forms.
Licensure/Alternate Approval Verification for all Child Care Centers: Place a check beside the item that applies
to each site for which you are making an application and submit the documents indicated under the item checked if
requested to do so. Refer to the section on licensing in the new application instruction booklet if you have questions
concerning licensure or exemptions from licensure.
1. ___ If licensed by Bright From the Start, Georgia Department of Early Care and Learning check here and
submit copy of license (or approval to operate if new and no license has been received)
a. ___ Submit copy of most recent Inspection Report (within past 12 months)
2. ___ If licensed by the Department of Defense, check here and submit Certificate to Operate a Child
Development Program
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Revised 9/2016
a. ___ Submit copy of most recent Installation Child Care Evaluation Team Assessment
3. ___If approved by the U.S. Department of Health and Human Services to operate a Head Start program,
submit the following:
a. ___Head Start Performance Standard Review (Triennial or 360 degree assessment) (Provide a copy of
the cover letter from the center’s most recent review)
4. ___If approved by any other Federal, State, or local entity, submit the current approval documentation from
the governing Federal, State, or Local authority.
5. ___Alternate Licensure and Child Care Standards. If the center is not approved by a Federal or local authority,
and the center is exempt from licensure in the State of Georgia, the center must meet CACFP Child Care
Standards to qualify for the program. Georgia law requires all child care programs to be licensed or exempt.
a. ___Alternate Licensure Self-Certification form
b. ___Exemption Letter from Child Care Licensing
c. ___Child Care Standard Form
d. ___ Copy of Certificate of Occupancy
e. ___ Copy of a current health/sanitation permit or satisfactory report of inspection and fire inspection
conducted by the local environmental health agency within the past 12 months.
Section V. ADULT CARE FACILITIES ONLY
Forms/Documents to determine eligibility for Adult Care Programs: Submit any documents requested under each
section below.
Profit versus Non-profit: Place a check beside the eligibility method you are using to qualify for the program
1.
___ Non-Profit adult care centers
a. ___Submit copy of 501 (C) 3 documentation with IRS letterhead.
b. ___If a church which has tax-exempt status under the umbrella of the national church affiliation,
submit the list attached to the IRS letter which contains the church’s name, or submit a letter from the
chief financial officer, or comparable person verifying that that subordinate church is included in the
tax-exempt status of the national organization along with item a. above.
c. ___If a church or the parent organization has not filed for tax-exempt status with the IRS, submit the
Tax Exempt Status Certification for Churches form with section 2 completed and signed by the
financial officer of the organization.
2.
___ For-Profit adult centers qualifying by 25% of the enrolled adults or licensed capacity (whichever is less)
receiving compensation under Title XIX
a. ___Submit Title XIX documentation (list from the Department of Medical assistance of those
participants receiving Medicaid funding).
Licensure/Approval: Adult centers must have approval from a Federal, State, or Local authority and must
demonstrate they have met written standards of criteria. Refer to CACFP policy 33.
1.
___ Submit a copy of the current valid license, or current approval documentation current approval
documentation from a governing Federal, State, or Local authority (This documentation may be in the form
of certification, review instrument, or approval letter. If the review instrument is not submitted, attach the
written standards or criteria on which the center is evaluated). Note: As of January 7, 2015, State law
requires adult day care centers which provide adult care services to be licensed and/or approved to
operate by the Georgia Department of Community Health. Refer to Bright from the Start Policy 33-
Revision Effective Date 9/1/2015) for more information.
Page 4 of 5
Revised 9/2016
Note: Approval dates are not based on the receipt of the application in the office, but on accurate completion of the
application. Please see Bright from the Start Policy CACFP/00-8.
In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this
institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, and reprisal
or retaliation for prior civil rights activity. (Not all prohibited bases apply to all programs.)
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 responsible State or local Agency that administers
the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal
Relay Service at (800) 877-8339. Additionally, program information is available in languages other than English.
To file a complaint alleging discrimination, complete the USDA Program Discrimination Complaint Form, AD-3027,
found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or 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: mail: U.S. Department of
Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C.
20250-9410 fax: (202) 690-7442; or email: program.intake@usda.gov.
This institution is an equal opportunity provider.
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Revised 9/2016
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