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* 1. Legal Business Name

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* 2. Business Address

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* 3. City

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* 4. Zip Code

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* 5. Business Phone Number

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* 6. Phone Number for Coordinating Delivery

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* 7. First Name

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* 8. Last Name

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* 9. Title

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* 10. Phone Number

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* 11. Email

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* 12. Are you corporate owned?

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* 13. Do you have a valid permit from San Mateo County Environmental Health to operate?

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* 14. How many meals can you prepare for breakfast?

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* 15. How many meals can you prepare for lunch?

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* 16. How many meals can you prepare for dinner?

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* 17. Which days of the week can you prepare meals? (Check all that apply)

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* 18. What time of day can meals be picked up from your restaurant? (Check all that apply)

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* 19. What communities can you deliver to? (Check all that apply)

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* 20. Delivery drivers need to complete a background check as part of this program. If you have your own delivery drivers, do you screen your employees?

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* 21. Do you have a relationship(s) with a food delivery service that completes background checks?

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* 22. Are you able to follow the nutrition guidelines for this program (no sugary drinks-100% juice allowed, low sodium and one fruit/vegetable with each lunch/dinner entree)?

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* 23. What else should we know about your restaurant's ability to serve meals to seniors?

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