Healthy Food Access Grant Application

Company*

DBA*

Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Federal Tax ID*

By checking yes, I certify I have no existing or outstanding public health code violations*

By checking yes, I certify that my business is in good standing and current with the state of Michigan and my local municipality in regard to all tax obligations.

Yes

Does your business have a license to sell alcohol products?*

Please provide your MLCC#

By checking yes, I certify that my license is active and in good standing with the MLCC*

Yes

Can your POS system produce or be modified to produce quarterly sales data related to the specific products made available under this grant program?*

YesNoUnsure

Point Of Sale Software Used*

Please check all fields for which grand funds will be used:*

Refrigeration equipment to stock and display of variety of fresh produce, dairy products and unprocessed foodsEquipment for the processing and production of packaged eligible foodsPurchase of start-up inventory of eligible food productsExpansion of a space to add equipment necessary to stock/display eligible food inventoryPoint-of-Sale (POS) software designed to track sales of eligible productsConstruction of community gardens established by federally registered nonprofit organizationsMinor infrastructure improvements necessary to accommodate added equipment/software to fulfill the requirements of the grant. Capital/building improvements are limited to $15,000 of grant award amount and must be matched by recipient each dollar up to the $15,000 maximumMarketing materials, informing consumers of enrollment in grant program providing new or expanded healthy food optionsSocial media and website improvements, informing consumers of enrollment in grant program providing new or expanded healthy food options

Contact Person responsible for grant management*

Email*

Phone*

Total Proposed Budget ($)*

Grant amount requested ($100k MAX)*

Project Description*

Equipment needed to fullfill project*

Infrastructure Modification?*

**If yes, attach plans if modifications are proposed

**If yes, estimated infrastructure modification budget ($)

Owner investment commitment to project ($)*

Will the project require financing?*

YesNo

**If yes, has financing been secured?*

Will the project require:*

**If other, please explain:

If approved; you understand that you will be required to mantain enrollment in the healthy food program for 24 months.

By clicking submit, you affirm that the information provided is accurate and truthful

Healthy Food Access Grant Application

BUSINESS INFORMATION

PERSONAL INFORMATION

PROJECT INFORMATION