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HomeMy WebLinkAbout2017-479-E Finance - Farmer Foodshare - Outside Agency Performance Agreement DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2017, ("Effective Date") by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and Farmer Foodshare, a not-for-profit corporation, located at 902 North Mangum Street, Durham,NC 27701 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Farmer Foodshare agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30, 2018. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 6250 b. All funds appropriated shall be used for purposes described in Exhibit B. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of 1562.5. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Farmer Foodshare) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 - June 30. Reports are due on January 12, April 13, and July 13 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services,upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default"), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance,incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement,in whole or in part and/or require the Provider to repay the funds within ten(10)business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Farmer Foodshare) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement,insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury,including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance,including hired and non-owned vehicles,if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A - Statutory State NC& Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Farmer Foodshare) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender,national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.75 per hour. To the extent possible, Orange County recommends that Farmer Foodshare provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Farmer Foodshare) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 County: Finance &Administrative Services Provider: Farmer Foodshare Orange County 902 North Mangum Street Post Office Box 8181 Durham,NC 27701 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable,it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. 18. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 19. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. Fo it AiriotZulf of the Provider aiIAd I 9/1/2017 AE195B3E83BE435... Date (Farmer Foodshare) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 rFora 1 cdi*of Orange County Government botA Ural, AOW %U"S 9/5/2017 9€ — 94eE477... Bonnie Hammersley, County Manager Date (Farmer Foodshare) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FY 2017-2018 Outside Agency Funding Application HUMAN SERVICES • ORANGE COUNTY • TOWN OF CARRBORO • TOWN OF CHAPEL HILL Orange County (OC) Town of Carrboro (CA) Town of Chapel Hill (CH) 200 S. Cameron Street 301 W. Main Street 405 Martin Luther King, Jr. Blvd. Hillsborough, NC 27278 Carrboro, NC 27510 Chapel Hill, NC 27514 044N 0 loo o...rmffcom.orI * II� toe e 0,41 s'ss.41 ( Page 1 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Program Information a. ❑ Human Services Needs Priority b. ❑ Type of Program A separate Section 3 is c. ❑ Agency Collaboration required for each d. ❑ Summary of Program program. e. ❑ Description of Identified Need f. ❑ Description of Population to be Served g. ❑ Program Staffing, Capacity, & Expertise h. ❑ Program Implementation Timeline i. ❑ Value of Investment j. ❑ Impact of Reduced/No Allocation k. ❑ Other Pertinent Information I. ❑ Target Population/Beneficiary Chart m. ❑ Work Statement n. ❑ Program Budget, Detail, & Cost per Individual 4. Attachments a. ❑ Audit: Organizations receiving $300,000 or more in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ❑ NC Solicitation License d. ❑ IRS Federal Tax-Exemption Letter e. ❑ Certificate of Insurance f. ❑ List of Board of Directors g. ❑ Solid Waste Program Fee (SWPF) Verification Page 3 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Farmer Foodshare Applicant Organization's Physical Address: 902 N. Mangum St, Durham, NC 27701 Applicant Organization's Mailing Address: P.O. Box 2873, Chapel Hill, NC 27515 Applicant Organization's Web Address: www.farmerfoodshare.orq Executive Director: Gini Bell Telephone Number: 919.360.6358 E-Mail: giniAfarmerfoodshare.or Tax ID Number: b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrbor Chapel Oran a Total o Count Donation Station Program- Farmers Market $5,000 $5,000 $10,000 $20,000 based program that supports local Orange County farmers and organizations working to increase access to fresh food to community members in needs. Totals $5,000 $5,000 $10,000 1 $20,000 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: (ice- � L ' „ E I ;'cutive Director Date Signature. c 41' " 1 /3/// it — Board Ch erson r" Date Page 4 Of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ © a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ © b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ © c) Current beneficiaries of the program for which funds are being requested? ❑ © d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. / 07- Signature: EOcutive Director Date Signature: _L/ Board Cha rerson Date Page s of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): 7 years in operation, Sept./ 2010 b) Agency's Purpose/Mission (no more than a few sentences): Farmer Foodshare connects people who grow food with people who need food in ways that are economically sustainable and socially just. We believe that everyone has a right to healthy, fresh food, and that farmers deserve to make a fair wage — a system where everyone wins. c) Types of Services the Agency Provides (bullet format): • Hunger and malnutrition relief. • Access to fresh, healthy food for members in this community in need who would often receive filling, but less healthy highly processed, shelf-stable food. • Support the local farm economy for small farmers at a fair price • Provide reliable markets for local farmers • Connects local agencies with local farmers • Empower recipients to make healthier food decisions d) Agency's History with Providing These Services: Since our inception, we have collaborated with farmers, community members, and local hunger-relief agencies. We partner with all of these groups in order to build a healthy, sustainable food system in Orange County. These community partnerships are essential to the successful performance of Farmer Foodshare operations and execution of its mission.We believe that change happens through relationship building and community engagement! e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director?Are there new initiatives?) • We have a new Director of Development and Community Outreach. • We have a new Community Foodshare initiative • The POP Market program is now known as the Wholesale Market program. • The Donation Station program continues to fortify the health of Orange County residents; particularly people facing diet or nutrition-related diseases, such as obesity, diabetes and heart disease. In order to expand this program, we are piloting a Community Foodshare Site Project. f) Schedule of Positions (For Entire Agency) • Full Time Equivalent (FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. Page 6 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 .� # of FTE - Full-Time Paid Positions: 5 # of FTE - Paid Part-Time Positions: 1.25 # of Volunteers: 230 # of FTE -Volunteers:10,000 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) YES If yes, is this agency an Oran se Count, Living We e Certified Em er? No If no, please explain. We hold a Living Wage Certification from Durham County because our office is physically located in Durham County. h) Agency Budget i. Is your agency currently receiving and/or requesting other (non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) No If yes, please list below: Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY16- I FY17-18 Source 17 Request Award Donation Station Program 7 $2,500 $10,000 Orange County Donation Station Program $2,500 $5,000 Chapel Hill Donations Station Program $2,000 $5,000 Carrboro Total _.... ._ $7,000 I $20,000 Total Funding *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it Page 7 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Agency Budget Attached** iii. Does your agency budget show a Surplus or Deficit? Balanced Is there a significant change?Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. iv.. What is your agency's fiscal year? January 1, 2017 through December 31, 2017 (Example: July 1, 2016 through June 30, 2017) Page 8 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Donation Station Program Program Primary Contact and Title: Katy Phillips, Telephone Number: 19.381.06 '1 E-Mail: katvCc�farmerfoodshare.orq a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apt to this _._.___.._..._ m_.._._.._.__......�._. Public Housing Program Category )(out Adult Elder! Disabled Neighborhoods/Resident Affordable Housing Affordable 6���.�._.-....m... ........ Healthcare Education Family Resources Jobs/Jobs Training Food X X x X X Transportation Other: Please specify c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. Donation Stations operate and collect fresh, healthy food each week at each of the following Orange County Farmers Markets: Carrboro, Page 9 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Chapel Hill, • Eno River, • Hillsborough Donation Stations provide fresh, healthy food to the following fifteen agencies: • Camp Chestnut Ridge, • CASA, • Central Elementary School families in dire need (as identified by the school social worker), • Chapel of the Cross, • Chapel Hill Day Care Center, • Child Care Services Association of Chapel Hill (Weekly food orders for the kids meals), • Club Nova (51 weeks of Chapel Hill Farmers Market food weekly) • Friends of the DSS, • Inter-Faith Food Council for Social Services (52 weeks of food for IFC, fridge, holiday meal drives), • Meals on Wheels of Chapel Hill, • PORCH, • TABLE (52 weeks of food for TABLE, fridge), • Read2Me, • Refugee Community Partnership, • Residential Services, Inc. As an expansion of the Donation Station Program, Farmer Foodshare would like to pilot a Community Foodshare Site Project which will deliver community supported agriculture (CSA) priced shares to the following partner agency in Orange County: • Refugee Community Partnership Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? Both the Donation Station program and pilot Community Foodshare site project address the Human Services Priority Area #3: Improving the health and nutrition of needy residents. The Donation Station program meets this aim by collecting fresh, local food gleaned from farmers at farmers markets and/or purchased from those farmers with funds donated by market shoppers. Each farmers market is paired with a recipient agency of their choice. Oftentimes, agencies are chosen by the market because the recipient agency serves the most urgent hunger needs of the lowest Page 10 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION income or disadvantaged populations in the immediate community. The fresh food is delivered the day it is donated. The Donation Station Program and Community Foodshare Site Projects are based on requests from the participants of our partner organizations themselves. These "mobile farmers markets"will increase fresh food access for food-insecure families in their communities. The project is intended to foster community engagement around food by sharing practical cooking and nutrition education through a peer-to-peer community health training program with a long-standing partner organization and recipient of fresh food from the Donation Station program. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Fluman Services Needs Assessment, Orange e p t OC Goals and Priorities, own of Chapel 1-hil Council Goals, C nnbo o Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. The Donation Station programs and Community Foodshare Site Project provide fresh, healthy food to Chapel Hill residents who cannot afford or who do not have access to nutritious food. This program is designed to meet this significant human need identified by community stakeholders in the Chapel Hill Human Services Needs Assessment. The Donation Station Program and Community Foodshare Site Project invest in the Orange County economy by making fresh food purchases from local farmers present at farmers markets. This program, as well as the Community Foodshare Site Project, are committed to building a healthy, sustainable food system by creating partnerships between farmers and recipient agencies specifically outlined in Goal 3 of the Orange County BOCC Goals and Priorities. Our organization also adheres to the values outline in OC BOCC Goals and Priorities: Farmer Foodshare works to support local farmers, while creating community through the practice of healthy eating. The Donation Station program and Community Foodshare Site Project provide an additional revenue stream to maintain ethnic and economic diversity as outlined in the Town of Carrboro's Board Priority A. We support small farmers at our flagship Donation Station like Transplanting Traditions, a farming community aimed at assisting the large Burmese refugee population. Our pilot site for the Community Foodshare Project, Refugee Community Partnership, is a place that emphasizes how culinary traditions are a powerful way to celebrate and preserve cultural heritage and identity. The Donation Station program and Community Foodshare Site Project also enhance and sustain quality of life/place issues for everyone as outlined in the Town of Carrboro's Board Priority E. Farmer Foodshare has spent time cultivating relationships with partner agencies through Page 11 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION shared meals, cooking demonstrations, and gatherings.Through our years of partnership, we have learned that participants want a more sustainable way to contribute to and make decisions about their own health. They have specifically requested access to more fresh produce on a regular basis. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Farmer Foodshare partners with agencies that serve populations in need: children, the elderly, individuals with disabilities or who are food insecure. Agencies are selected in conjunction with the Farmers Market in Orange County with a focus on urgent hunger and persistent need. Diverse groups are intentionally chosen. We work with a range of agencies across the county, which distribute the fresh food we connect them with to a diverse demographic. We intentionally partner with agencies that support the most urgent hunger and lowest income populations. We annually verify the demographics our partner agencies serve, and work to ensure that the voices of our clients are heard and represented in our program planning. We are a community owned and operated group — and we believe that is the key to our continued presence in the Orange County,Chapel Hill and Carrboro community. When sourcing food from local farmers, we are also intentionally diverse. We work with farmers who have been left out of"the system", specifically with USDA defined "Limited Resource, Socially Disadvantaged and Beginning"farmers. These are farmers that are not eligible for traditional farm support and subsidies, yet who produce an enormous amount of healthy food in our communities. We believe that it is important to help both local farmers, as well as individuals and agencies that do not have access to resources. We believe that if we can introduce these groups to one another—the farmers, the agencies, and the individual recipients, that the Orange County network of community services and relationships will be strengthened. So far, we have seen this to be the case— where farmers who formerly knew nothing about hunger in our county, suddenly began growing food to donate. Other farmers provide special items at a deep discount, because they know it will go to help feed the children at TABLE, or the mentally ill adults at Club Nova. And most partner agencies that want to buy additional fresh food begin to buy from local farmers and keep their dollars in the county. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Donation Stations are run by volunteers under the supervision of our Director of Community Partnership, Katy Phillips. She cultivates and coordinates efforts of our partner agencies and volunteers in retrieving collected donations and sharing it with recipients. Katy has a strong background in education, has five years of non-profit management experience and is a farmer herself. e 12 of DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Farmer Foodshare recognizes the significant value and resource that volunteers and interns bring to the organization. Their work directly increases Farmer Foodshare's ability to empower communities to feed themselves sustainably. Volunteers participate in all aspects of the organization from staffing Farmers Market Donation Stations to helping with food deliveries; from speaking on behalf of Farmer Foodshare to hosting community meals. The effectiveness as volunteers is dependent on support and resources offered and so all volunteers attend an orientation, position specific training, the opportunity to shadow lead volunteers, and a volunteer handbook. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. The Donation Station program operates on a consistent, weekly basis- subject to the specific farmers market's hours. The pilot Community Foodshare Site Project will operate through the summer and fall harvest (June to October). i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) Funding from Orange County, the Town of Chapel Hill and the Town of Carrboro would enable Farmer Foodshare to expand the reach of its Donation Station and the Community Foodshare Site Project in this community. These programs make it possible for us to provide more fresh food to individuals at risk for malnutrition, and support more small- to mid-sized farmers in earning a healthy living. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Reduced funding will reduce our ability to re-invest in the local economy and support a growing desire for access to fresh food from our recipient agencies. Aside from providing nutritious food, we believe working to create a positive culture around food will create a community of health. Through the Donation Station and Community Foodshare Site Project we endeavor to continue support and meet the needs of the populations we serve. We request these funds in order to keep pace with the growing demand from our community partners in Orange County, and the Towns of Chapel Hill and Carrboro. Reduced funding will affect our potential to meet the growing demands or our partners in this community. k) Include any other pertinent information. Farmer Foodshare works collaboratively in all our efforts to end hunger and food insecurity. By working with agencies within the community to distribute fresh produce to their networks of individual in need, we are able to support and enhance existing efforts, while keeping overhead costs low. Additionally, we have regular dialogue with our partners to provide support like recipes and fresh food safety information and help in sourcing the right kinds of produce in the right amounts. When requested, we connect with our partner agencies to provide cooking demonstrations and provide volunteers to help with food prep and packing. Additional Program information I) Target Population Page 13 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projecte 2015-16 2016-17 d 2017-18 Gender Male 2,800 3,000 3,500 Female 5,100 5,300 5,500 9,000 (Focuse d on Orange 7900 8,300 County. (Focused (Focused More on Orange on Orange focused County. County. with More More increase focused focused d with with educatio increased increased nal educational educationa services services I services and and more and more more food food food Total servings) servings) servings) Ethnicity 3,318 3,486 3,780 African-American (42%) (42%) (42%) 213 (2.7%) 224 (2.7%) 243 American Indian or Alaska Native (2.7%) Asian 237 (3%) 249 (3%) 270 (3%) 1,580 1,660 1,800 Caucasian (20%) (20%) (20%) Native Hawaiian or other Pacific Islander 79(20%)o_..........__... .. _ � ( ... . ° 83 83 (1%) 90 (1%) 181.7 190.9 207 Other: specify (2.3%) (2.3%) (2.3%) 5,608 (more 5,893 6,390 focused on (more (more Orange focused on focused County) Orange on Total County) Orange Page 14 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION County) 2,292 .........�....... 2,407_...._...._............._2;610...... Of the above, how many Hispanic/Latino (29%) (29%) (29%) Of the above, how many non-Hispanic/Latino Total 7,900 8,300 9,000 Age 0-5 years 958 1006 1,089 6-18 years 1561 1640 1,800 19-50 years 3423 3596 3,870 51+ years 1,198 1,260 2,241 Total 7,900 8,300 9,000 Geographic Location Alamance County '. ........__...X............................................X www _.�mw .��Xm_ �._ Chatham County X X x Durham County X X x Wake County X X x Orange County Breakdown Chapel Hill Public Housing X X x Town of Chapel Hill (Non-Public Housing) X X x Town of Carrboro X X..�..i._...___ x_..._._... Town of Hillsborough X L_......._.._........_. _.._...,.. ..._.......�.._._ ....._.__...X City of Mebane (Orange County) X X x Orange County (Outside Municipalities) I X X x p,, ,p ir Total l ° l � r ps rt on iiiuir t uu uu° s°tiiu���� . for pr re be m., .IIIl liii.liiisiiii°°ies i Illh Vii liii net dela Mat has Illh :,e nslllh s red % liiitim .. Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART G l to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) Page 15 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program: Donation Station Program 1. Program Activity Donation Station Program Name Program Goal Ensure that fresh produce is regularly urchased from local farmers and collected to donate to recipient agencies. We aim to feed 9,000 people, support 200 local farmers and collect 20,000 pounds of food. 1 Community Food Share site set up in Orange and serving 75 community members fresh food and education around fresh food. Performance Measures Number of people fed, number of farmers supported, and pounds of food collected. Pilot Community Foodshare site will run through scheduled time (June-October) and serve 75 individuals with fresh food. Previous Year Program 7,900 people fed, 150 number of farmers supported and Results 16,000 pounds of food collected. Current Year a ._...__...._.�........�. .��.... �__.........� ......_.....__...� .....____.... .................................................................................................. a_ Estimated 8,300 people fed, 200 number of farmers supported and Results 20,000 pounds of food collected. Next Year Projected 9,000 people fed, 200 number of farmers supported and Results 20,000 pounds of food distributed. As part of the pilot CFS project, we aim to set up 1 new site in Orange County where 225 individuals have access to fresh food purchasing through Wholesale Market, are provided education, and can host community meals/gatherings with community members. n) Program Budget- hull for Dummtahon Math m111111H l m mlmfim m:iiu 1. Submit your program budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Page 16 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: 2. Program Budget Detail—Provide description of"other" budget items, not defined. Donation Station Program PROGRAM EXPENSES FY15-16 1 FY16-17 FY 17-18 Compensation $ 48,000 $ 55,959'$ 61,568 Rent & Utilities $ 5,000 $ 5,000 $ 5,960 Supplies & Equipment $ 7,500 $ 8,630 $ 10,285 Travel & Training $ 5,500 $ 6,310 $ 7,420 3. This program budget represents what percent of the agency budget? 11.7 % for the Donation Station Program. 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. n tioa Station Munn 2 r5- Estimated 2 1 ,,i Projected i 200( Total Cost of Program $66,000 $75,899 $85,233 Total # of Individuals 7,900 8,300 9,000 Cost Per Individual $8.30 $9.14 $9.40 Page 17 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Farmer Foodshare Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $52,733 $72,000 $ 80,450 12% Agency Generated Revenue (fees) $152,000 $315,000 $ 443,452 41% Local Government Grants: Human Services-Town of Carrboro $1,500 $2,000 $ 5,000 150% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $2,500 $2,500 $ 5,000 100% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $5,000 $2,500 $ 10,000 300% Other- Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $- $20,000 $ - $ (1.00) State Government $25,000 $- $ - #VALUE! Federal Government (CDBG/HOME/etc.) $9,000 $106,000 $ 74,530.00 $ (0.30) Private Foundation Grants $332,281 $217,875 $217,112.00 $ (0.00) Other Revenue $ - $ - $ 163,426 0 In kind donations $ 113,426 Corporate donaitons $ 50,000 Total Agency Revenue $ 581,251 $ 746,217 $ 998,970 34% AGENCY EXPENSES Compensation $215,814 $324,930 $ 355,745 9% Rent& Utilities $17,063 $25,290 $ 30,474 20% Supplies & Equipment $20,530 $53,150 $ 63,235 19% Travel & Training $14,500 $27,595 $ 52,806 91% Other Expenses: $313,344 $315,252 $ 496,710 58% Cost of Goods Sold $ 472,774 Contractor Fees $ 15,750 Retained for Future Projects $ 8,186 Total Agency Expenses $ 581,251 $ 746,217 $ 998,970 34% SURPLUS/(DEFICIT) FOR PERIOD: $ - I $ - I $ - I 0 FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Section III. Program Information Program Budget Worksheet AGENCY NAME: Farmer Foodshare Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 21,000 $ 25,399 $ 42,033 65% Program Generated Revenue(fees) $ - $ - $ 500 0 Local Government Grants: Orange County $ 5,000 $ 5,000 $ 10,000 100% Town of Chapel Hill $ 2,500 $ 2,500 $ 5,000 100% Town of Carrboro $ 1,500 $ 2,500 $ 5,000 100% Other Local: 0 Other Local: 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way 0 State Government 0 Federal Government 0 Other Grants: Private Foundation $ 26,000 $ 30,000 $ 11,000 -63% Other Grants: 0 Miscellaneous/Other Revenue $ 10,000 $ 10,500 $ 11,700 11% Please list 3 largest Miscellanous sources: sponsorships and business support $ - $ 10,000 $ 10,500 $ 11,700 $ - Total Program Revenue $ 66,000 $ 75,899 $ 85,233 12% PROGRAM EXPENSES Compensation $ 48,000 $ 55,959 $ 61,568 10% Rent& Utilities $ 5,000 $ 5,000 $ 5,960 19% Supplies & Equipment $ 7,500 $ 8,630 $ 10,285 19% Travel &Training $ 5,500 $ 6,310 $ 7,420 18% Other Expenses: $ - $ - 0 Please list 3 largest"Other Expenses": $ $ $ - Total Program Expenses $ 66,000 $ 75,899 $ 85,233 12% DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION SURPLUS/(DEFICIT) FOR PERIOD: $ - I $ - I $ - I 0% DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2015, for calendar year agencies, and FY 2015-16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit/report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2014 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS'tta ie uidq, for more details. For Form 990-N (e-postcard)filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its 'roqu °qtly I ed Questions Guide PDF about exemptions. If exempt per N.C.G.S. § 131 F-3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax-Exern tion Letter A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: if Approved for :Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 — June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. Page 18 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Limits for Coverage Compensation' A - Statutory State Limits for Coverage A - Limits for Coverage A - NC, for each Statutory State NC, for I Statutory State NC, for employee each employee I each employee Limits for Coverage Limits for Coverage B - Limits for Coverage B - B - Employers Employers Liability of: Employers Liability of: Liability of: $100,000 Each Occurrence $500,000 each $1 million Each $100,000 BID for each accident, $500,000 Occurrence employee BID for each employee $1,000,000 BID2 $500,000 BID limit $500,000 for BID limit limit Commercial $100,000 Property General Liability Damage Liability $1 million Each $1,000,000 Bodily $1 million Each Occurrence Occurrence Injury and Property $2 million Aggregate $2 million Aggregate Damage Limit Automobile Not Applicable $1 million Each Occurrence $500,000 Each Liability Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence _uu.... �. ....i $2 million Aggregate 1. Visit the NC Industrial Commission's weOsite for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts websiage for more information about the County's risk assessment procedures. f) List of Board of Directors Provide the following information about each board of director's member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. g) Solid Waste Prenram Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either Page 19 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION a.) proof of payment of the agency's FY 2016-17 Solid Waste Program Fee, OR b.) a statement on agency letterhead indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. Page 20 of 20 DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 EXHIBIT `B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Farmer Foodshare Program Name: Donation Station Funding Award: $6,250 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel support for managing the Donation Stations in Orange County,including the training $5,750 and management of volunteers Supplies for Donation Stations $500 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Each week that farmers markets operate, utilize volunteers to ensure that fresh produce is regularly purchased and collected from local farmers to donate to local agencies • Each week, ensure that agencies have access to healthy, local food for their clients • Increase capacity of Agency to handle fresh produce and recipients to use produce Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Amount of donations collected/spent with farmers at Orange County farmers markets,generating $15,000 fresh food to donate to local agencies. Number of meals supplemented with fresh food amassed at Orange County Donation Stations 100,000 (using a serving size of 1/4 lb of fresh food per serving.) Number of education events requested by and held at recipient agencies to teach recipients how to 15 prepare and store fresh food. ---DocuSigned by: Executive Director 9/1/2017 A Ei9,71874 Certified by: Title: Director of Development Date: 08.07.2017 (Provider's Signa e) DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 ATTACHMENT "A" Orange County Certifications—FY 2017-18 Outside Agency Performance Agreement Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title,residential address;phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DocuSigned by: 9/1/2017 Certified by. AE195B3E83BE435__ Title; Executive Di rector Date. (Provider's Signature) (Farmer Foodshare) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:8A1AB1BF-ACDB-42A1-A3DE-9E9549E569B4 FARME-3 n2n'L0 coRO CERTIFICATE OF LIABILITY INSURANCE OATE(MM/DD/YYYY) 08!10/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 910-673-4771 ACT Alex Maiolo Lee-Moore Insurance Agency Inc PHONE 910-673771 FAX P.O.Box 667 (NC,No,Est): A/C,No): West End,NC 27376 ADDRESS:leemooremsurance @gmail.com Alex Maiolo INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:AUTO-OWNERS INS.COMPANY 18988 INSURED Farmer Foodshare INSURER B;AON Association Services I Gini Bell 902 N Mangum St _INSURER C: Durham,NC 27701 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP ... 01.1, LIMITS LTR TYPE OF INSURANCE INS() WVD POLICY NUMBER li IMM/DDIYYYYf �/DD/YYYYI�i A X COMMERCIAL GENERAL LIABILITY $ 2,000,000 EACH OCCURRENCE - CLAIMS-MADE OCCUR X 35269000 06/15/2017 06115/2018 MEMISES(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY �$ 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER G ENERAL AGGREGATE $ 2,000,000 PRO-RO- LOC PRODUCTS PRO- $ 2,000,000 OTHER $ COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) _ $ _.._ X ANY AUTO 5126900000 06/15/2017 06/15/2018 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED P�7OPERTYpAMAGE AUTOS ONLY _.... ..I AUTOS ONLY ( er accdent) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ A WORKERS COMPENSATION X STATUTE _ . __ ERH- ANDEMPLOYERS'LIABILITY Y/N 35278607 05/29/2017 05/29/2018 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A --- _-- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500'000 If yes,describe under 100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B D&O Liability NFP0128555-00 06/15/2017 06/15/2017 DOLT 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Orange County,its officers,official agents,and employees are listed as additional insured on General Liability policy. CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN �] ty ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management 200 S Cameron St AUTHORIZED REPRESENTATIVE Hillsborough,NC 27278 rip • AI ACORD 25(2016/03) ©1988-2015 ACORD CORPORATIO . All rights reserved. The ACORD name and logo are registered marks of ACORD •