S-10000-00007929 Att C - Applicant Questionnaire and Service Selection~1.pdf

RFA # S-10000-00007929 – On-Call Feeding and Bottled Water Delivery Service Attachment C (Agency Internal #5700)

ATTACHMENT C

APPLICANT QUESTIONNAIRE AND SERVICES SELECTION

Submit this completed form with your Application Packet

1. Applicant’s Point of Contact for Price Agreement Negotiations:

Name

Title

Phone

Email

2. Applicant’s Business Name:

Name of Business

Physical Address of Business Location

City, State, Zip

Note: If Applicant has more than one restaurant, food truck, etc. location they want to be considered for Price Agreement award, Applicant must list their additional business type and location information on a separate piece of paper and attach it to this Attachment C.

3. Applicant Business Type:

Please select the type of business entity that most closely describes your current business structure. (Check all that apply, for “Other:” please write in your business type)

• Restaurant ____

• Caterer ____

• Food Truck ____

• Food Retailer ____

• Food Distributor ____

• Water Distributor ____

• Food Wholesaler ____

• Other: _________________________________________________________

4. Applicant Supply Chain:

During a declared emergency/disaster or extreme weather incident supply chains may become impacted. Agency needs to understand your current supply chain and resources used in obtaining the food and water you provide through your business . Please describe your supply chain and resource you use (e.g., purchase from retail stores, wholesale, local farms, connections to USDA, etc.):

5. Applicant Service Selection:

Please select which On-Call Feeding and Bottled Water Services you want to provide:

a. Feeding Service: (Applicants may select one or more option)

• Large Scale Meal Preparation YES NO Preparation and delivery of a large quantity of individually prepared meals off site at Applicant’s place of business, at least two of which must be warm. Number of meals Agency requests will depend on the need, but an example of a possible large scale meal request might include providing 3 meals a day to 500 Agency Clients across multiple different location sites, total of 1500 meals per day.

Applicant must have the necessary facility to prepare and transport up to 1,500 meals per day or more.

• Small Scale Meal Preparation YES NO Preparation and delivery of a small quantity of individually prepared meals off site at Applicant’s place of business, at least two of which must be warm. Number of meals Agency requests will depend on the need, but an example of a possible small scale meal request might include providing 3 meals a day to 100 Agency Clients across multiple different location sites, total of 300 meals per day.

• Onsite Meal Preparation YES NO Meals prepared onsite by the Applicant, such as mobile food trucks, catering services where meals are warmed and provided onsite, or utilizing an onsite facility kitchen to prepare and serve the meals. An example of a request may be providing breakfast, lunch, and dinner at a site that lodges 100 Agency Clients. Number of meals Agency requests will depend on the need, but an example of a possible request might include providing 300 onsite meals per day.

• Food Box Preparation and Delivery YES NO Preparation and delivery of food boxes containing the equivalent of 21 meals (approximately 25 pounds) for each household. Number of meals Agency requests will depend on the need, but an example of a possible request might include providing 200 food boxes per day across multiple different location sites.

• Meal Cards / Vouchers Service YES NO Coordination of a system where Applicant issues a reloadable meal card or voucher, initial issued card or voucher will be pre-loaded with funds, to Agency Clients for their use a at restaurants, grocery stores, or farmers markets to obtain meals and food.

b. Bottled Water Service: YES NO

Provide and deliver bulk quantities of bottled water, typically pallets of bottled water cases will be ordered by Agency. The quantities of bottled water requested by Agency will depend on the need, but an example of a possible request might include a one-time delivery of a truckload of pallets to a warehouse or staging site, or a regularly scheduled delivery of a smaller quantity of cases to a sheltering site for a period of time.

6. Service Area:

a. Applicant, please list the Oregon County or Counties you wish to provide Services in:

Note: If Applicant wants to provide Services in all Oregon Counties, write “All.”

b. If Applicant selected an individual Oregon County or Counties to provide services in, will Applicant only provide Services within a certain radius from their place of business? YES NO N/A

If yes, what is the radius in miles that Applicant will provide Services:_______________

7. Food Handlers Card:

Does the Applicant’s staff who will be doing the preparing, handling, and delivery of Meals and Food Boxes have a valid Food Handlers Card? YES NO N/A Note: If applicant only selected to provide Bottled Water and/or Meal Cards/Vouchers, please mark N/A.

8. Applicant Service Rates.

Applicants provide your current Service rate or rates below for the Services you are applying to provide. Service rate or rates provided must be all inclusive, to included, but not limited to, travel costs, such as fuel and delivery charges, and meal packaging containers.

Is Applicant willing to negotiate with Agency the Service rate or rates provided below?

YES NO

Feeding Service (Prepared Meals):

Cost per individual Meal: $_______________ Children Under 12

$_______________ Adults and Children Over 12

Feeding Service (Food Boxes):

Cost per Food Box: $_______________ Infants (birth to 4 years)

Note: Applicant, if you do not provide or want to provide food boxes for infants write in “N/A” on the rate line above.

$_______________ Children (Under 12)

$________________ Children (12 and over)/Adults

Meal Cards/Vouchers:

If Applicable, provide any administrative fee or percentage to load funding on Meal Cards/Vouchers:

Bottled Water:

Cost per case (16.9 Fl. Oz): $_______________

Cost per pallet (16.9 Fl. Oz): $_______________ How many cases in a pallet: _________

Note: If Applicant offers water container sizes larger than 16.9 Fl. Oz, provide those additional sizes and costs on a separate sheet of paper and attach to this Attachment C.

Applicant Signature: _____________________________ Date: ___________________________

Printed Name: _________________________________ Title: ___________________________