Healthy Retail Application_final.pdf

Clackamas County Healthy Retail Grant Notice of Funding Opportunity (NOFO)

Application Questions

BUSINESS INFORMATION

1. Business Name: ___________________________________________________________________

2. EIN or FIN: _________________________________________________________________________

3. Business Mailing Address

a. Address: ___________________________________________________________________

b. City: ________________________________________________________________________

b. State: _______________________________________________________________________

c. Zip Code: ___________________________________________________________________

d. County: _____________________________________________________________________

4. Business Phone: ____________________________________________________________________

5. Business Website: __________________________________________________________________

INDIVIDUAL COMPLETING APPLICATION

1. Name: _____________________________________________________________________________

2. Title: _______________________________________________________________________________

3. Phone: _____________________________________________________________________________

4. Email: ______________________________________________________________________________

5. Preferred Contact Method: __________________________________________________________

BUSINESS OWNER (if different than above)

1. Name: _____________________________________________________________________________

2. Title: _______________________________________________________________________________

3. Phone: _____________________________________________________________________________

4. Email: ______________________________________________________________________________

5. Preferred Contact Method: __________________________________________________________

RESPONSIBLE PROSPER REQUIREMENTS

1. Grantees must be registered to sign agreements with and receive funds from CCPHD. Are you currently registered with the Oregon Secretary of State Business Registry?

Yes No

APPLICANT INSURANCE

Please check if you have the following insurance. Note the insurance below, along with others, may be required if awarded. For additional information on insurance limits and requirements, please see Appendix E of the Notice of Funding Opportunity.

1. Commercial General Liability Insurance

Yes No but will meet insurance requirement prior to Contract execution if awarded.

2. Commercial Automobile Liability Insurance

Yes No but will meet insurance requirement prior to Contract execution if awarded.

3. Professional Liability Insurance

Yes No but will meet insurance requirement prior to Contract execution if awarded.

4. Workers’ Compensation Insurance

Yes No but will meet insurance requirement prior to Contract execution if awarded.

5. Abuse and Molestation Liability Insurance

Yes No but will meet insurance requirement prior to Contract execution if awarded.

6. Cyber Risk Insurance

Yes No but will meet insurance requirement prior to Contract execution if awarded.

APPLICANT INFORMATION: PART I

The next section will ask a series of questions regarding your business.

1. To be eligible for this grant funding opportunity, your business must be in Clackamas County. Is your business in Clackamas County?

Yes No (If selected, you are not eligible for this grant opportunity.)

2. Does the business owner identify as Black, Indigenous or a person of color, LGBTQIA2S+, or as having a disability? Select all that apply:

Black Indigenous Person of Color

LGBTQIA2S+

Has a disability None

3. During your time as owner, has your business been fined for selling tobacco and/or nicotine products to underage persons?

Yes

i. Dates of violation(s)

1. Month ____ Day ____ Year _______

2. Month ____ Day ____ Year _______

3. Month ____ Day ____ Year _______

4. Month ____ Day ____ Year _______

No

4. When does your Tobacco Retail License expire?

Month ____ Day ____ Year _______

5. Please mark which of the following tobacco/nicotine products you carry:

Cigarettes Chew/dip/Snus Cigars/little cigars Vaping products/liquids Loose leaf tobacco Nicotine pouches (like Zyn)

6. Where do you purchase your tobacco/nicotine products for your business?

7. At the time of this application, approximately how much is your tobacco/nicotine inventory worth?

8. Do you have any contracts with the tobacco industry? If so, describe any penalties for terminating the contract(s).

9. Approximately how long will it take to sell down your current inventory of tobacco and nicotine products?

APPLICANT INFORMATION: PART II

1. What type of point-of-sale system do you use? Can it run detailed sales, product and vendor reports?

2. What types of fresh fruits and vegetables do you sell?

3. What types of grocery items do you sell?

4. Do you sell any hot items that are ready to eat? If so, please list them.

5. How long have you operated your current business?

6. What connection(s) does your business have to the surrounding community or neighborhood? Does it play a role beyond offering products for sale?

7. What are your long-term goals for your business?

8. Describe your plan to use this funding to shift your business model away from tobacco/nicotine sales. What new or expanded revenue stream(s) would you pursue?

9. Please describe activities that will be required to implement your plan and estimate the timeframe. This is to help us better understand your proposal. If selected, assistance will be provided to help you create a detailed plan and timeline.

Activities Estimated Timeframe (month/year – month/year)

Who will be involved in the work?

Example: Phase-out sale of tobacco products by selling down current inventory.

8/2024 – 10/2024 Store owner

Example: Develop new business model plan with business advisor.

Meet with local farmers, producers, and distributors. Request bids for repairs to sales floor. Price out new equipment and display stands.

9/2024-12/2024 Business advisor Contractors

Farmers, producers, distributors

Store owner Example: Complete sales floor improvements. Purchase produce cooler and display stands.

1/2025-2/2025 Business advisor Contractors

Farmers, producers, distributors

Store owner Example: Introduce new products on sales floor and promote to customers.

2/2025-3/2025 Store owner

Activities Estimated Timeframe (month/year – month/year)

Who will be involved in the work?

11. How does your plan support a healthy retail-focused business model?

12. How do you plan to market your new business model to your customers and the community?