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C Review RFP/Coffee Shop in Lib CITY OF CHANHASSEN 7700 Market Boulevard PO Box 147 Chanhassen,MN55317 Administration Phone: 952.227.11110 fax: 952.227.1110 Building Inspections Phone: 952.227.1180 fax: 952.227.1190 Engineering Phone: 952.227.1160 fax 952.227.1170 Finance Phone 952.227.1140 Fax 952.227.1110 Pari< & Recreation Phone: 952.227.1120 Fax: 952.227.1110 RecrealionCenler 2310 Couller Boulevard Phone: 952.227.1400 fax: 952227.1404 Planning & Natural Resources Phone: 952.227.1130 Fax: 952.227.1110 PublicWorl<s 1591 Park Road Phone 952.227.1300 Fax: 952.227.1310 Senior Center Phone: 952.227.1125 fax: 952.227.1110 - Web Site WWN.ci.chanhassen.mn,us r!" MEMORANDUM TO: Mayor and City Council Todd Gerhardt, City Manage~ . May 8, 2002 FROM: DATE: SUBJ: Draft Copy of Request for Proposal for Coffee Area in New Chanhassen Library I have been approached by the "Friends of the Library" about the idea to create a coffee shop in the new Chanhassen Library. They were requesting a cooperative venture between the City, Friends of the Library, and Dunn Bros. Elliot Park to create a coffee shop in the new library. I appreciate their efforts in researching, designing and reviewing the potential for a coffee shop. However, I still feel that the city must go through a formal request for proposal (RFP) process which the Friends of the Library can respond to and would give the City Council the opportunity to determine the parameters which will measure all potential applicants. I have attached a draft copy of a Request for Proposal, which is very similar to the Carmel Clay Public Library coffee area RFP. I have changed several items in the proposal to conform to our situation. Please review this proposal and be prepared to discuss any changes you would like to make at Monday night's meeting. ATTACHMENT 1. Request for Proposal for coffee area for the new Chanhassen Library. ,¡ ~. The City 01 Chanha"en . A growing community wilh clean lakes. quality schools, a charming downtown, Ihriving businesses. winding lrails, and beautitul parks. A great place to live, work, and play. Q';1 CHANHASSEN PUBLIC LIBRARY COFFEE AREA REQUEST FOR PROPOSALS CHANHASSEN PUBLIC LIBRARY May 2002 PRE·PROPOSAL CONFERENCE Friday, June 14, 2002 2:00 p.m. Chanhassen City Hall 7700 Market Blvd. Chanhassen MN 55317 Closing Date: June 17, 2002 12:00 p.m., (noon) Chanhassen City Hall 7700 Market Blvd. Chanhassen MN 55317 Request For Proposals City of Chanhassen Public Library Coffee Area Table of Contents Section I. General Information Section II, Proposal Review Schedule Section III. Background Section IV. Scope Section V. Administrative Requirements A. Minimum Requirements B. Development Requirements C. Business Terms D. Operating Standards Section VI. Proposal Content and Evaluation Criteria A. Administrative Section B. Program Section Section VII. Technical Assistance/Clarification Section IX. RFP Boilerplate Section X. Attachments E. Supplemental Questionnaire for Proposers F. Coffee Area Floor Plan 2 Request For Proposals City of Chanhassen Public Library Coffee Area SECTION I. GENERAL INFORMATION City of Chanhassen Public Library ("Library") solicits proposals for a vendor to operate a coffee area located in the outer lobby of the new Library building at , Chanhassen, Minnesota. The new Library building currently under construction is scheduled to open in June 2003. The successful Proposer should plan to be fully operational by June 2003. The selected operator will be responsible for the coffee area. Minimum Requirements Certain minimum requirements have been established in order for proposers to be considered for contracts described in this Request for Proposal (RFP): Proposers shall have one or more years of continuous experience within the last five years in the ownership, management, or operation of one of more specialty coffee facilities (carts or bars), Proposers shall submit a proposed rent no lower than 10% of gross monthly receipts or $500 a month, whichever is higher (see Section VI). After the operator is selected, the library reserves the right, in its sole discretion, to agree to a lower monthly rent for the initial 6 months of operation. Proposers not meeting the minimum requirements will result in disqualification of their proposal and will not be considered further. Submission Respondents must submit one original and four complete copies of the proposal to: City of Chanhassen, 7700 Market Blvd, P.O. Box 147, Chanhassen, MN 55317, no later than noon on June 17, 2002. All proposals tha!l.are not received by the deadline will be considered late and will be returned to the Proposer unopened. Proposals shall be submitted at the time and place indicated in the Request for Proposal and shall be submitted in a sealed envelope appropriately marked with the Proposal title and the name and address of the Proposer. Pre-Proposal Conference A pre-proposal conference will be held at the City of Chanhassen, 7700 Market Blvd, Chanhassen, MN 55317, on Monday June 14, at 2:00 p.m., at which time any questions concerning the RFP package will be addressed. A representative of each Proposer's firm is 3 Request For Proposals City of Chanhassen Public Library Coffee Area required to attend and sign in. Proposers who do not attend the pre-proposal conference may not submit a proposal. SECTION II: PROPOSAL REVIEW SCHEDULE Activity 1. Request for Proposals Announcement 2. Pre-proposal conference (Library will respond to questions concerning the RFP) 3. Last day to submit questions for clarification 4. Last day to submit proposals by 12:00 p.m. noon 5. Proposal Review Committee decides 6. City Council considers award of bid 7. Contract finalized Date May 14, 2002 June 3, 2002, 3:00 p.m. City of Chanhassen, 7700 Market Blvd, Chanhassen, MN 55317 June 17,2002 June 17, 2002 June 18,2002 June 24, 2002 July 1, 2002 The Library reserves the right to deviate from this schedule. SECTION III: BACKGROUND The Chanhassen Public Library is a major community resource used frequently by many residents. Library statistics consistently show increases each year over the previous year in number of cardholders and library items borrowed. In 2001, with over library cardholders, Chanhassen Public Library loaned to the public more than books and other items. As a result of the increased demand for library services and rapidly rising population, the library will move to a new one-story, 33,000 square foot building on the corner of West 78th street and Kerber Boulevard in early summer of 2003. The City of Chanhassen is faced with a rapidly expanding population and the increased demand for library services. The City of Chanhassen began analyzing the current building's capacity to meet the community's needs in 1998. The result of extensive research and analysis by the City, staff, and library consultants indicated the need for a new library building. Construction for the new building began in May 2002 and the building is scheduled for completion in June of 2003. Coffee Area The coffee area will be located in the southeast corner of the library's outer lobby, just inside what will be the library's primary entrance from the public parking lot. A rectangular alcove of 185 square feet has been set aside for the vendor's operations. Immediately across the corridor there is a customer seating area of 566 square feet, which will seat 17 persons. The operator's area will have a rear preparation/work counter with storage capability above and below. Plumbing and electrical connections, including computer capability, will be provided, A front service counter will be constructed in consultation with the successful operator. 4 Request For Proposals City of Chanhassen Public Library Coffee Area Anticipated Usage of New Building It is anticipated that the new Library, which is eleven times the size of the current one, will bring a significant increase in the number of daily and yearly visitors. It should also be noted that the Library is located in the retail core of downtown Chanhassen. Food and Drink in the Library While consumption of food and beverages is not allowed beyond the outer lobby, staff may consume food and beverages in designated non-public spaces. Staff may transport food and beverages throughout the building, as long as food is in a package and drinks have a lid or cap. Food concessions are becoming more common in libraries throughout the county. Most of these are operated by private-sector vendors who are reaping the rewards of discovering that libraries offer desirable demographics, strong customer loyalty, and high traffic in a unique and distincti ve en vironment. SECTION IV: SCOPE The scope of the required services consists of operating a coffee area located in the Library's outer lobby. The operator will work with the Library's architect to complete the final design of the counter, signage, and lighting. Concept Operate a coffee area of quality craftsmanship and design that is appropriate with the Library's design. The coffee area is to enhance the Library environment and raise revenue for the Library. The coffee area would operate most of the time the Library is open and when it is cost-effective for the operator. Aside from the offerings detailed below, other offerings may be proposed, but are subject to City approval. 1. Location 2. Vending Area: 3. Seating Area 4. Storage 5. Menu Profile 6. Retail 7. Rent Outer Lobby, Chanhassen Public Library 240 square feet 260 square feet, Seating for 17 persons To be determined Espresso drinks, coffee, tea, Italian sodas, bottled water, bottled juices, fresh pastries, garden-fresh salads, delicious sandwiches Whole bean coffee No lower than 10% of monthly gross receipts or $500/month, whichever is higher 5 Request For Proposals City of Chanhassen Public Library Coffee Area SECTION V: ADMINISTRATIVE REQUIREMENTS A. Minimum Requirements Certain minimum requirements have been established in order for proposers to be considered for the contracts described in this Request for Proposal: Proposers shall have one or more years of continuous experience within the last five years in the ownership, management or operation of one or more specialty coffee facilities (carts or bars). Proposers shall submit a proposed rent no lower than 10% of gross monthly receipts or $500 a month, whichever is higher. (See Section VI). After the operator is selected, the Library reserves the right, in its sole discretion, to agree to a lower monthly rent for the initial 6 months of operation. Proposers not meeting the minimum requirements will result in disqualification of their proposal and will not be considered further. B. Development Requirements The Citv will provide the following: · Floor space for vending and seating as indicated in the Attachment · Tables and chairs for the seating area . Painted gypsum board walls · 12v AC electrical service (4 dedicated 20 AMP circuits) · Hot and cold domestic water service connections · Basic sewer service connections (no grease trap), one floor sink, and one floor drain · Bar or basic design plans for construction of a bar · Wall cabinets, base, and countertops in rear or along side wall · Supply/storage closet along the south (side) wall . Hand and vegetable sinks · Overhead coiling security grill · The operator will work with the construction manager to complete the construction of the coffee area · Construction of coffee area, including plumbing and electric modifications will meet the Minnesota Building Code, and Minnesota Department of Health regulations. Materials and craftsmanship will meet quality standards of project architects, Meyer, Scherer & RockcastIe, Ltd. 6 Request For Proposals City of Chanhassen Public Library Coffee Area The operator will provide the following: · All necessary professional equipment, including installation, to perform the function of the coffee area including, but not limited to, beverage equipment, coolers, dishwashers, and glass display cases · Final utility connections · Additional utility service, professional fees, and installation for such needs beyond that provided by the City · Millwork items beyond the allowance provided by the library · Signage and menu boards Design Specifications The project architects have designed the coffee area (See Attachment 2), which will be used as a guideline for the final design and layout. Design is subject to approval by the City and project architects. In addition, the operator must adhere to these guidelines: · The space available for the coffee area is limited; therefore special attention must be given to the organization of each element. All elements are to be designed as an integral part of the coffee area. · The equipment and its placement are important visual elements of the overall design and appearance of the coffee area. Careful attention is to be given to each piece of equipment and how it is viewed by the public. Wood grain or other simulated material finishes are not permitted on equipment. Natural metal, glass or porcelain finishes are acceptable. All equipment is subject to design review. · Structures such as canopies and sneeze guards are not acceptable. · Neon and exposed fluorescent are not permitted. · Signage/menu boards are subject to approval. Interior signage will be limited to the vending area. No exterior signage will be allowed. · Cabinets and drawers are to be designed to be lockable. An overhead coiling security grill will be provided by the Library to secure the operator's area when not in operation. The City is not responsible for damage, loss, or theft of property in the coffee area. C. Business Terms 1. Rent. Selected operator shall pay a minimum monthly rent of 10% of each month's gross receipts, or $500 monthly, whichever is higher. Actual rent is to be determined by RFP process (see Section VI). Calculation will be based on the first of each month to the last day. Rent begins on the first month the new Library is open to the public. In the case 7 Request For Proposals City of Chanhassen Public Library Coffee Area that the first month of operation is not a full month, rent will be based on sales from the first day to the end of that month or pro-rated on monthly rent, whichever is higher. Operator to make rent payment within 30 days of last day of preceding month, including a statement showing operator's total gross receipts for the preceding month. 2. Late Payment. If operator is delinquent for 30 days or longer in paying to the Library any amounts owed to the Library under the agreement, operator shall pay to the Library 1.5% of rent, accrued monthly until the payment is made in full. 3. Term. The lease begins as soon as the library opens (June 2003). 4. Early Termination. Either party may terminate the lease agreement with a 90-day written notice to the other party. The coffee area millwork, fixtures, built-in equipment, and all improvements automatically become the property of the City of Chanhassen and remain with the coffee area if, for any reason, operator no longer operates the coffee area. In the event of early termination, operator will be compensated for the unamortized capital investment in designated built-in equipment. (Prior to the City signing a lease agreement with a Proposer, the Proposer will be asked to identify from its list of expected capital investment items, those items that will be built-in equipment, and provide a five-year amortization schedule for this built-in equipment. This list of equipment and accompanying amortization schedule are to be mutually agreeable between operator and the City.) Terms for compensation for built-in equipment are to be mutually agreeable between the operator and the City. 5. End of Lease. At the end of the lease, the coffee area and all fixed improvements, millwork, and built-in items remain the property of the City of Chanhassen. 6. Utilities. All utilities are paid for by the City of Chanhassen and are included in the rent charged to the operator. Operator is responsible for telephone hook-up, ongoing line, and all other related charges. 7. Insurance. The city will carry building insurance. The operator will carry its own liability insurance. The operator will be responsible for securing and maintaining in full force at least $1 million in liability insurance coverage, with the City of Chanhassen named as additional insured. Operator will also carry their own business personal property insurance covering all equipment and inventory. Operator will also carry workers compensation insurance as required by law. Operator will provide to the City certificates of insurance for all applicable policies. The operator will hold the City harmless for all liability arising from participation in a lease from the City of Chanhassen. The City is not responsible from theft, damage, or loss of property. 8 Request For Proposals City of Chanhassen Public Library Coffee Area 8. Licensing Operator will be responsible for securing and maintaining in full force all licenses required by the Minnesota Department of Health and/or other applicable authorities to operate this coffee area. Operator will also be responsible for the total cost of such licenses and renewals. D. Operating Standards 1. Maintenance Operator is responsible for keeping the coffee area neat, clean, and in good repair. Operator is also responsible for regularly bussing the seating area and immediately cleaning up spills/messes in that area. Operator will ensure that receptacles do not become overfilled during public hours. Operator will not allow boxes, cartons, barrels, or other similar items to remain in view of public areas. 1. Employee Standards Service should be timely, attentive and friendly. Food and beverage orders will be taken promptly and in a friendly and courteous manner. Operator is to recruit, train, supervise, direct, and deploy the optimum number of employees to match the work requirements. Each employee should: (1) be clean, neat, and well groomed; (2) be free from offensive body odor; (3) be professional, courteous, and friendly to the public; (4) not wear excessive amounts of jewelry, perfume, or cologne. 2. Food Quality Operator will make efforts to ensure that only the highest quality of food is sold at the Library, including but not limited to: · Coffee should be ground on demand from whole beans from a quality Toaster, competitive in quality with the best roasters in Minnesota for a balance of flavor, body, aroma, and acidity. Beans for espresso should be appropriate for industry- recognized professional espresso use. Beans should be roasted on demand and valve packaged. Unopened packages should be used within two months. Opened packages should be used within 10 days. · Butter, milk, and milk products shall be USDA Grade "A". · Pastries shall be fresh daily from a quality baker. · Salads shall be made fresh daily from quality ingredients. · Sandwiches shall be made fresh daily from quality products. 3. Non-compliance Failure to comply with any of the Operating Standards can result in a fine of $50/day, if problems are not addressed within seven days of receiving a formal complaint letter from the City. Termination of the lease agreement can result if the problems persist beyond 15 days of written notification. 9 SECTION VI: PROPOSAL CONTENT AND EV ALVA TION CRITERIA Your proposal must be divided into two parts: an Administrative Section and a Program Section. A. Administrative Section A "Supplemental Questionnaire For Proposers" form (Attachment 1) will be completed and signed and included with the proposal. FAILURE TO INCLUDE THIS SIGNED FORM WILL RESULT IN PROPOSAL REJECTION. B. Program Section The City will establish an Evaluation Committee. There will be a two-step evaluation process: (1) Proposers are to answer each item. Items will be scored up to the maximum point value indicated in parentheses. (2) The top three highest scoring proposers will be evaluated further by the panel through site visits to existing operations. Each Evaluation Committee member shall independently assign a score to each criteria during the written evaluation. Designated members of the Evaluation Committee may contact proposers for clarification of proposals; however, no additions, deletions or substitutions may be made to proposals that cannot be termed as clarifications. All such contact shall be documented. Responses should restate the question or use the same sequence of numbers and letters as in the RFP. Scores for the written section and site visit will be combined for a total score. · Responses should restate the question or use the same numbering and lettering sequence as in the RFP. Responses and supporting documentation must be in the same sequence as the RFP. All documents must be included for the proposal to be considered. 1. Describe your experience and background in providing coffee/café operations. (40 points) 2. Provide a concept for operation of a coffee area, including: a) A design drawing of the space for the coffee area, indicating location of equipment, fixtures, finish materials, signage/graphic images and other design elements. Proposers may use the attached floor plan (Attachment 2) as a guide. b) Identification of the equipment to be used, including brand and model. c) List of proposed menu items with prices, including names of providers of food products. d) Hours of operation. e) Staffing (levels, competencies). (30 points) 3. What standards do you have for ensuring a quality-run operation? Please indicate such things as quality and freshness standards for coffee, pastries, and other food products. (35 points) 4. What ideas (promotions, advertising, publicity, special events) do you have for the Library coffee area that would distinguish it from other operations? (20 points) Request For Proposals City of Chanhassen Public Library Coffee Area 5. What is your management philosophy and how does it ensure that the Library coffee area will be staffed with qualified employees? Please include descriptions of any customer service training programs, recruiting techniques, or employee handbooks. (20 points) 6. How do your financial assets allow you to undertake this project? Please provide the following: a. Financial Plan indicating the source of funding to be used for space enhancements and working capital. b. Proforma income statements that provide income and expenses for three years of operation. If in business for only one or two years, submit as applicable. c. Balance sheèt and income statements for the last two fiscal years prepared in accordance with generally accepted accounting principals (GAAP), reflecting the current financial condition of Proposer entity. If in business for only one year, submit as applicable. d. Names, addresses and telephone numbers of at lease three credit references, including at least one banking reference. (20 points) 7. What amount of rent do you propose to pay the Library? Note: the minimum requirement to apply for this RFP is 10% of monthly gross receipts or $500 a month, whichever is higher. Answering this question with the minimum amount is worth 15 points, Each additional percentage is worth 10 points, e.g. 11 % = 20 points, 12% = 30 points. (40 points) 8. What uniquely qualifies you to provide coffee service in this Library? If you have experience providing specialty coffee service within an established business or institution (retail, university, school, hospital, government, other), please provide references. (40 points) SITE EV ALVA TION The top three highest scoring Proposers will be asked to provide hours of operation of current operation(s), During these unannounced site visits, your operation will be evaluated based on the following factors: a) Quality of Products (taste, freshness, temperature) (45 points) b) Customer Service (friendliness, attentiveness, timeliness) (20 points) c) Presentation (cleanliness/appearance of bar, area, packaging) (20 points) d) Staff (appearance, professionalism, knowledge) (15 points) Total Points: 100 Combined Total: 345 11 Request For Proposals City of Chanhassen Public Library Coffee Area SECTION VII: EV ALVA TION PROCEDURES The City will establish an Evaluation Committee. There will be a two-step evaluation process: (1) Proposers are to answer each item. Items will be scored up to the maximum point value indicated in parentheses. (2) The top three highest scoring Proposers will be evaluated further by the panel through site visits to existing operations. Each Evaluation Committee member shall independently assign a score to each criteria during the written evaluation. Designated members of the Evaluation Committee may contact Proposers for clarification of proposals; however, no additions, deletions or substitutions may be made to proposals that cannot be termed as clarifications. All such contact shall be documented. Responses should restate the question or use the same sequence of numbers and letters as in the RFP. Scores for the written section and site visit will be combined for a total score. SECTION VII: TECHINICAL ASSIST ANCE/CLARIFICA TION Any Proposer requiring clarification of the information herein, must submit specific questions in writing to: Todd Gerhardt, City Manager City of Chanhassen 7700 Market Blvd. P.O. Box 147 Chanhassen, MN 55317 Phone: 952-227-1119 Fax: 952-227-1110 Email: tgerhardt@ci.chanhassen.mn.us The deadline for submitting such questions is June 17,2002. If in the City's opinion additional information or interpretation is necessary, such information will be supplied in the form of Addenda that will be mailed to all individuals, firms, etc., having received this Request for Proposal from the City. SECTION IX: RFP BOILERPLATE Cost of Preparation of Response Costs incurred by any agency in the preparation of their response to this Request for Proposal are the responsibility of the responding agency and will not be reimbursed by the City. Proposals are Public Records All information submitted by Proposers shall be public record and subject to disclosure pursuant to applicable Minnesota law, except such portions of the proposals for which Proposer requests exemption from disclosure consistent with Minnesota law. All requests shall be in writing, 12 Request For Proposals City of Chanhassen Public Library Coffee Area noting specifically which portion of the proposal the Proposer requests exception from disclosure. Proposer shall not copyright, or cause to be copyrighted, any portion of said document submitted to the City as a .result of this Request for Proposal. Cancellation The City reserves the right to cancel award of the contract any time before execution of the contract by both parties if cancellation is deemed to be in the City's best interest. In no event shall the City have any liability for the cancellation of award. The Proposer assumes the sole risk and responsibility for all expenses connected with the preparation of its proposal. Rejection of Proposals The City reserves the right to reject any or all responses to this Request for Proposal. Assignment Neither the resultant contract nor any of the requirements, rights, or privileges demanded by it may be sold, assigned, contracted, or transferred by the Contractor without the express written consent of the City. Collusion A Proposer, submitting a proposal, hereby certifies that no officer, agent, or employee of the City has a pecuniary interest in this proposal; that the proposal is made in good faith without fraud, collusion, or connection of any kind with any other Proposer; the Proposer is competing solely in its own behalf without connection with, or obligation to, any undisclosed person or firm. Disputes In case of any doubt or differences of opinion as to the items or service to be furnished hereunder, or the interpretation of the provisions of the RFP, the decision of the City shall be final and binding upon all parties. Clarification of Responses The City or its agent reserves the right to obtain clarification of any point in a firm's proposal or to obtain additional information necessary to properly evaluate a particular proposal. Failure of a Proposer to respond to such request for additional information or clarification could result in rejection of that firm's response or responses. 13 Request For Proposals City of Chanhassen Public Library Coffee Area SECTION X: ATTACHMENTS SUPPLEMENTAL QUESTIONNAIRE FOR PROPOSERS Attachment 1 Please complete and submit with other required information and other related materials you wish to provide the City of Chanhassen. A.ORGANIZATIONIDENTIFICATION: Organization Name: Address: Telephone: Fax: Federal ill #: Ownership (check one): 0 Corporation 0 Partnership 0 Individual List Parent Company (if applicable): Year business established: IF A CORPORATION, PLEASE ANSWER THE FOLLOWING: List State of Incorporation: List Resident Agent for Service of Process in Minnesota: List (or attach a list) or principal shareholders (those owning 5% or more of the corporation's stock): List (or attach a list) of all officers and directors of the corporation: 14 Request For Proposals City of Chanhassen Public Library Coffee Area IF A PARTNERSHIP, PLEASE ANSWER THE FOLLOWING: List (or attach a list) of the general or limited partners, and, if applicable, officers: Current number of employees: D Full-time D Part-time D Total Name and address of current liability insurer: Are you or your business currently involved in any lawsuits? (check one) 0 Yes 0 No If yes, list caption and cause number for all lawsuits for which you are involved: Are you and your business current in meeting all state, federal, local, sales, and payroll taxes? (check one) 0 Yes 0 No If no, please explain: B. CURRENT COFFEE OPERATIONS: List locations of your specialty coffee operations under your ownership: Address: Years in Operation (under your ownership) Address: Years in Operation (under your ownership) Address: Years in Operation (under your ownership) Address: Years in Operation (under your ownership) C. EXPECTED CAPITAL INVESTMENT: 15 Request For Proposals City of Chanhassen Public Library Coffee Area Please list (or attach) an itemization of your expected capital investment for the Library coffee area listing each item (including equipment listed in the Program Section of your RFP) and the anticipated dollar amount of each item. Amount Item Description (please list below) D. ASSURANCES: The Proposer hereby certifies that Proposer: 1. Has the authority and/or responsibility to submit a proposal and to represent their organization in all phases of this RFP process. 2. The information provided is true and accurate to the best of their knowledge. 3. Understands any false statement may disqualify this proposal from further consideration or be cause for contract termination. 4. Agrees to notify the City Manager for the City of Chanhassen within 30 days of any change in the above information. AGENCY DIRECTOR (Name): Type or Print AGENCY DIRECTOR (Signature): DATE: FAILURE TO SIGN AND SUBMIT THIS FORM SHALL BE CAUSE FOR REJECTION 16