Fruit and Vegetable Incentive Pilot Program

Request for Proposals

Application Form

Store Information (determines eligibility)

  1. Store Name: ______
  2. Store Address: ______
  3. Store Zip Code: ______
  4. Borough: ☐Bronx ☐Brooklyn ☐Manhattan ☐Queens ☐Staten Island
  5. Store Hours: ______
  6. Contact Person Name: ______
  7. Contact Person Title: ______
  8. Contact Person Phone Number: ______
  9. Contact Person Email Address: ______
  10. Store Owner Name(s): ______
  11. What is the store’s approximate size (by square feet)? ______
  12. Is the store authorized to accept SNAP benefits? ☐ Yes ☐ No
  13. What was the store’s approximate SNAP sales total in 2016? ______
  14. Is at least 50% of the store’s retail space for products intended for home preparation (e.g. cereal, soup, produce)? ☐ Yes ☐ No
  15. Does the store sell at least 7 varieties of produce such as: ☐ Yes ☐ No
  16. Fresh fruits and vegetables
  17. Frozen fruits and vegetables without added sugars, fats, oils, or salt
  18. Canned fruits and vegetables without added sugars, fats, oils, or salt
  19. Dried legumes without added sugars, fats, oils, or salt
  20. Does the store sell or market tobacco products? ☐ Yes ☐ No
  21. If the store is awarded the contract, will DOHMH be allowed to briefly survey SNAP customers three times during the first year to evaluate the program? ☐ Yes ☐ No
  22. Are you willing to consider opportunities to procure and sell locally grown produce? ☐ Yes ☐ No

Selection of Fruits and Vegetables (20 points maximum)

  1. How many types of fresh fruits and vegetables does the store sell?

☐1-2☐3-5☐6-9☐10+

  1. How many types of frozen fruits and vegetables without added sugars, fats, oils, or salt does the store sell?

☐1-2☐3-5☐6-9☐10+

  1. How many types of canned fruits and vegetables without added sugars, fats, oils, or salt does the store sell?

☐1-2☐3-5☐6-9☐10+

  1. How many types of dried legumes (e.g. beans, lentils) does the store sell?

☐1-2☐3-5☐6-9☐10+

Tracking, Reporting and Evaluation (35 points maximum)

  1. What is the name of the store’s Point of Sale (POS) system? ______
  2. The purpose of this funding, which comes from the USDA, is to provide financial incentives to SNAP participants for produce. DOHMH is required by the USDA to track spending and the number of people reached. Please complete the table below indicating if your POS system is able to track and report on the following:

POS system can track and report this data / POS system cannot track and report this data / I don’t know
Number of transactions and total dollar amount spent on fruits and vegetables using SNAP per month
Dollar value of incentives issued per month
Dollar value of incentives redeemed per month
Number of SNAP participants that accrued incentives per month
Number of SNAP participants that spent incentives per month
Average incentive value redeemed per recipient weekly, monthly and annually
Transaction history showing items purchased as part of the fruit and vegetable incentive pilot program

Incentive Distribution (35 points maximum)

  1. Does the store have an existing electronic customer loyalty card program? ☐ Yes ☐ No (skip to question 27)
  2. Can the electronic customer loyalty card program be used to distribute and redeem incentives to SNAP customers whenever they purchase fruits and vegetables? ☐ Yes ☐ No

If yes, please briefly describe: ______

  1. Does the store have the capacity to distribute, redeem, and track paper coupons whenever SNAP customers purchase fruits and vegetables? ☐ Yes ☐ No

If yes, please briefly describe: ______

Additional Store Attributes (10 points maximum)

  1. Please indicate the types of alcohol products sold at your store:

☐ Beer

☐ Cider

☐ Wine product (less than 6% alcohol)

☐ Wine

☐ Hard liquor (stores that sell hard liquor are not eligible for the award)

☐ Other Please specify: ______

  1. Does the store accept Women Infants and Children (WIC) checks? ☐ Yes ☐ No
  2. Do you manage or own other food stores? ☐ Yes ☐ No

If yes, please list the address of the other store(s): ______

______

  1. Does the store promote healthy eating in any ways?

☐ Yes - Please briefly describe, including any community organizations your store partners with on programming, marketing or other strategies: ______

☐ No

Certification

I certify that all information provided in this application is correct and accurate to the best of my knowledge.

______

Name (print)SignatureDate

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