Matters ▸ Attachment
INTF5264P01223127055 CITY OF SOMERVILLE — File 23-1127
7KH&RPPRQZHDOWKRI0DVVDFKXVHWWV
([HFXWLYH2IILFHRI+HDOWKDQG+XPDQ6HUYLFHV
'HSDUWPHQWRI3XEOLF+HDOWK
:DVKLQJWRQ6WUHHW%RVWRQ0$
$WWQ
5(&RQWUDFW
/LVWHGEHORZLVWKHFRQWUDFWEXGJHWHGIXQGLQJDPRXQWV
,I\RXKDYHTXHVWLRQVDERXW\RXUaward SOHDVHFRQWDFW\RXUSURJUDPPDQDJHU
0$85$7+($/(<
*RYHUQRU
.,0%(5/(<'5,6&2//
/LHXWHQDQW*RYHUQRU
.$7+/((1(:$/6+
6HFUHWDU\
52%(57*2/'67(,10'3K'
&RPPLVVLRQHU
7HO
ZZZPDVVJRYGSK
06/20/2023
CITY OF SOMERVILLE
93 HIGHLAND AVE
SOMERVILLE, MA 02143
Kelley Hiland
INTF5264P01223127055
This letter is to inform you that the Massachusetts Department of Public Health, Bureau of Infectious Disease &
Laboratory Sciences is amending your contract as indicated below:
Future Years
Current Year
Previous Years
The contract will be in effect through 06/30/2024 with options for renewal in accordance with RFR# 223127 -
Local health support for COVID-19 case investigation and contact tracing through 06/30/2027. The effective
start date of the contract amendment shall be the anticipated start date specified in the Standard Contract Form or
a later date the Standard Contract Form has been executed by an authorized signatory of the Department of
Public Health.
Kevin Cranston at
kevin.cranston@mass.gov.
The contract total maximum obligation is $900,000.00.
Amendment Reason: Renewal
07/01/2023
07/01/2022
09/16/2021
06/30/2024
06/30/2023
06/30/2022
$300,000.00
$300,000.00
$300,000.00
x
STANDARD CONTRACT FORM
7KLVIRUPPXVWEHVLJQHGZLWKDQDXWKRUL]HG signatureGDWHGDQGUHWXUQHGYLDHPDLOVFDQ'RQRWXVH
FRUUHFWLRQIOXLGDQ\ZKHUHRQWKHIRUPV
$OODWWDFKPHQWVPXVWEHFRPSOHWHGIRU\RXUFRQWUDFWSDFNDJHWREHSURFHVVHG
x
CONTRACTOR AUTHORIZED SIGNATORY LISTING (CASL)
$&RQWUDFWRU$XWKRUL]HG6LJQDWRU\/LVWLQJ&$6/IRUPPXVWEHVLJQHGZLWKDQDXWKRUL]HG signature
GDWHGDQGUHWXUQHGYLDHPDLOVFDQIRUHDFKQHZFRQWUDFWRUDPHQGPHQWFRQWUDFWSDFNDJH
(QFORVHGSOHDVHILQGD6WDQGDUG&RQWUDFWSDFNDJHIRU\RXWRUHYLHZVLJQDQGUHWXUQYLDHPDLOVFDQ3OHDVHWDNH
QRWHRIWKHIROORZLQJ
,I\RXKDYHDQ\TXHVWLRQVDERXW\RXUcontract package,SOHDVHFRQWDFW
3OHDVHVLJQZLWKDQDXWKRUL]HG signatureDQGUHWXUQWKHFRQWUDFWSDFNDJHYLDHPDLOVFDQWR
WWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWQRODWHUWKDQFORVHRIEXVLQHVV
6LQFHUHO\
%XUHDX'LUHFWRU
$FFHSWDEOHIRUPVRI$XWKRUL]HGVLJQDWXUHV
7UDGLWLRQDOKDQGGUDZQ³ZHWVLJQDWXUH´LQNRQSDSHU
6FDQ&RS\RIKDQGGUDZQVLJQDWXUH
(OHFWURQLFVLJQDWXUHWKDWLVHLWKHU
D +DQGGUDZQXVLQJDPRXVHRUILQJHULIZRUNLQJIURPDWRXFKVFUHHQGHYLFH
E $QXSORDGHGSLFWXUHRIWKHVLJQDWRU\¶VKDQGGUDZQVLJQDWXUH
(OHFWURQLFVLJQDWXUHVDIIL[HGXVLQJDGLJLWDOWRROVXFKDV$GREH6LJQRU'RFX6LJQ
3OHDVH1RWH
7KHW\SHGWH[WRIDVLJQDWXUHHYHQLQFRPSXWHUJHQHUDWHGFXUVLYHVFULSWRUDQHOHFWURQLFV\PERODUHQRW
DFFHSWDEOHIRUPVRIHOHFWURQLFVLJQDWXUH
Derek Westhaver at
Derek.A.Westhaver@mass.gov.
Kevin Cranston
Bureau of Infectious Disease & Laboratory Sciences
Derek Westhaver
at Derek.A.Westhaver@mass.gov,
06/27/2023.
COMMONWEALTH OF MASSACHUSETTS ~ STANDARD CONTRACT FORM
8SGDWHG3DJHRI
5IJTGPSNJTKPJOUMZJTTVFEBOEQVCMJTIFECZUIF0GGJDFPGUIF$PNQUSPMMFS $53
UIF&YFDVUJWF0GGJDFGPS"ENJOJTUSBUJPOBOE'JOBODF "/'
BOEUIF0QFSBUJPOBM
4FSWJDFT%JWJTJPO 04%
BTUIFEFGBVMUDPOUSBDUGPSBMM$PNNPOXFBMUI%FQBSUNFOUTXIFOBOPUIFSGPSNJTOPUQSFTDSJCFECZSFHVMBUJPOPSQPMJDZ5IF$PNNPOXFBMUIEFFNTWPJE
BOZDIBOHFTNBEFPOPSCZBUUBDINFOU JOUIFGPSNPGBEEFOEVNFOHBHFNFOUMFUUFSTDPOUSBDUGPSNTPSJOWPJDFUFSNT
UPUIFUFSNTJOUIJTQVCMJTIFEGPSNPSUPUIF4UBOEBSE
$POUSBDU'PSN*OTUSVDUJPOT BOE $POUSBDUPS$FSUJGJDBUJPOT UIF $PNNPOXFBMUI5FSNTBOE$POEJUJPOT UIF$PNNPOXFBMUI5FSNTBOE$POEJUJPOTGPS)VNBOBOE4PDJBM
4FSWJDFT PSUIF$PNNPOXFBMUI*55FSNTBOE$POEJUJPOTXIJDIBSFJODPSQPSBUFECZSFGFSFODFIFSFJO"EEJUJPOBMOPODPOGMJDUJOHUFSNTNBZCFBEEFECZ"UUBDINFOU
$POUSBDUPSTBSFSFRVJSFEUPBDDFTTQVCMJTIFEGPSNTBU$53'PSNTIUUQTXXXNBDPNQUSPMMFSPSHGPSNT'PSNTBSFBMTPQPTUFEBU04%'PSNTIUUQT
XXXNBTTHPWMJTUTPTEGPSNT
CONTRACTOR LEGAL NAME:
COMMONWEALTH DEPARTMENT NAME:
MMARS Department Code:
Legal Address: (W-9, W-4):
Business Mailing Address:
Contract Manager:
Billing Address (if different):
E-Mail:
Phone:
Fax:
Contractor Vendor Code:
Phone:
Fax:
Vendor Code Address ID (e.g. “AD001”): AD
.
(Note: The Address Id Must be set up for EFT payments.)
MMARS Doc ID(s):
RFR/Procurement or Other ID Number:
@@@/&8 $0/53"$5
130$63&.&/5 03&9$&15*0/5:1& $IFDLPOFPQUJPO POMZ
4UBUFXJEF$POUSBDU 04%PS BO 04%EFTJHOBUFE%FQBSUNFOU
$PMMFDUJWF1VSDIBTF "UUBDI04% BQQSPWBM TDPQF CVEHFU
%FQBSUNFOU 1SPDVSFNFOU JODMVEFT BMMHSBOUT $.3
4PMJDJUBUJPO
/PUJDFPS 3'3 BOE 3FTQPOTFPS PUIFS QSPDVSFNFOU TVQQPSUJOH EPDVNFOUBUJPO
&NFSHFODZ$POUSBDU "UUBDIKVTUJGJDBUJPOGPS FNFSHFODZ TDPQF CVEHFU
$POUSBDU &NQMPZFF "UUBDI &NQMPZNFOU 4UBUVT 'PSN TDPQF CVEHFU
0UIFS1SPDVSFNFOU&YDFQUJPO "UUBDIBVUIPSJ[JOHMBOHVBHFMFHJTMBUJPOXJUI
TQFDJGJDFYFNQUJPOPSFBSNBSLBOEFYDFQUJPOKVTUJGJDBUJPOTDPQFBOECVEHFU
___ $0/53"$5".&/%.&/5
, 20
.
&OUFS$VSSFOU$POUSBDU&OE%BUF 1SJPS UP
"NFOENFOU &OUFS"NFOENFOU"NPVOU
PSiOPDIBOHFw
".&/%.&/5 5:1& $IFDLPOFPQUJPO POMZ"UUBDIEFUBJMTPG"NFOENFOUDIBOHFT
"NFOENFOU UP 4DPQF PS #VEHFU "UUBDI VQEBUFE TDPQF BOE CVEHFU
*OUFSJN $POUSBDU "UUBDI KVTUJGJDBUJPO GPS *OUFSJN $POUSBDU BOE VQEBUFE TDPQFCVEHFU
S $POUSBDU &NQMPZFF "UUBDI BOZ VQEBUFT UP TDPQF PS CVEHFU
0UIFS 1SPDVSFNFOU &YDFQUJPO "UUBDI BVUIPSJ[JOH MBOHVBHFKVTUJGJDBUJPO BOE VQEBUFE
TDPQFBOECVEHFU
5IF4UBOEBSE$POUSBDU'PSN*OTUSVDUJPOT$POUSBDUPS$FSUJGJDBUJPOTBOEUIFGPMMPXJOH$PNNPOXFBMUI5FSNTBOE$POEJUJPOTEPDVNFOUJTJODPSQPSBUFECZSFGFSFODFJOUPUIJT$POUSBDU
BOEBSFMFHBMMZCJOEJOH $IFDL0/&PQUJPO
$PNNPOXFBMUI5FSNTBOE$POEJUJPOT$PNNPOXFBMUI5FSNTBOE$POEJUJPOT'PS)VNBOBOE4PDJBM4FSWJDFT $PNNPOXFBMUI*55FSNTBOE$POEJUJPOT
$0.1&/4"5*0/ $IFDL 0/& PQUJPO
5IF %FQBSUNFOU DFSUJGJFT UIBU QBZNFOUT GPS BVUIPSJ[FE QFSGPSNBODF BDDFQUFE JO BDDPSEBODF XJUI UIF UFSNT PG UIJT $POUSBDU XJMM CF
TVQQPSUFE JO UIF TUBUF BDDPVOUJOH TZTUFN CZ TVGGJDJFOU BQQSPQSJBUJPOT PS PUIFS OPOBQQSPQSJBUFE GVOET TVCKFDU UP JOUFSDFQU GPS $PNNPOXFBMUI PXFE EFCUT VOEFS $.3
@@ 3BUF $POUSBDU /P .BYJNVN 0CMJHBUJPO "UUBDI EFUBJMT PG BMM SBUFTVOJUTDBMDVMBUJPOT DPOEJUJPOT PS UFSNT BOE BOZ DIBOHFT JG SBUFT PS UFSNT BSF CFJOHBNFOEFE
__ .BYJNVN0CMJHBUJPO$POUSBDU &OUFS5PUBM.BYJNVN0CMJHBUJPOGPSUPUBMEVSBUJPOPGUIJT$POUSBDU PSOFX 5PUBMJG$POUSBDUJTCFJOHBNFOEFE
$
.
PROMPT PAYMENT DISCOUNTS (PPD): Commonwealth payments are issued through EFT 45 days from invoice receipt. Contractors requesting accelerated payments must
identify a PPD as follows: Payment issued within 10 days _@@_% PPD; Payment issued within 15 days @@@@% PPD; Payment issued within 20 days @@@@% PPD; Payment
issued within 30 days @@@@% PPD. If PPD percentages are left blank, identify reason: __agree to standard 45 day cycle __ statutory/legal or Ready Payments (G.L. c. 29, §
23A); __ only initial payment (subsequent payments scheduled to support standard EFT 45 day payment cycle. See Prompt Pay Discounts Policy.)
BRIEF DESCRIPTION OF CONTRACT PERFORMANCE or REASON FOR AMENDMENT: (Enter the Contract title, purpose, fiscal year(s) and a detailed description of the scope
of performance or what is being amended for a Contract Amendment. Attach all supporting documentation and justifications.)
"/5*$*1"5&%45"35%"5& $PNQMFUF0/&PQUJPOPOMZ
5IF%FQBSUNFOUBOE$POUSBDUPSDFSUJGZGPSUIJT$POUSBDUPS$POUSBDU"NFOENFOUUIBU$POUSBDUPCMJHBUJPOT
NBZCFJODVSSFEBTPGUIF&GGFDUJWF%BUF MBUFTUTJHOBUVSFEBUFCFMPX
BOEOPPCMJHBUJPOTIBWFCFFOJODVSSFEQSJPSUPUIF&GGFDUJWF%BUF
NBZCFJODVSSFEBTPG
XFSFJODVSSFEBTPG
, 20
, BEBUF-"5&3UIBOUIF&GGFDUJWF%BUFCFMPXBOEOPPCMJHBUJPOTIBWFCFFOJODVSSFEQSJPS UPUIF&GGFDUJWF%BUF
, 20
, BEBUF13*03UPUIF&GGFDUJWF%BUFCFMPXBOEUIFQBSUJFTBHSFFUIBUQBZNFOUTGPSBOZPCMJHBUJPOTJODVSSFEQSJPSUPUIF&GGFDUJWF%BUFBSF
BVUIPSJ[FEUPCFNBEFFJUIFSBTTFUUMFNFOUQBZNFOUTPSBTBVUIPSJ[FESFJNCVSTFNFOUQBZNFOUTBOEUIBUUIFEFUBJMTBOEDJSDVNTUBODFTPGBMMPCMJHBUJPOTVOEFSUIJT$POUSBDUBSF
$0/53"$5&/%%"5&$POUSBDUQFSGPSNBODFTIBMMUFSNJOBUFBTPGXJUIOPOFXPCMJHBUJPOTCFJOHJODVSSFEBGUFSUIJTEBUFVOMFTTUIF$POUSBDUJTQSPQFSMZBNFOEFE
QSPWJEFEUIBUUIFUFSNTPGUIJT$POUSBDUBOEQFSGPSNBODFFYQFDUBUJPOTBOEPCMJHBUJPOTTIBMMTVSWJWFJUTUFSNJOBUJPOGPSUIFQVSQPTFPGSFTPMWJOHBOZDMBJNPSEJTQVUFGPSDPNQMFUJOH
BOZOFHPUJBUFEUFSNTBOEXBSSBOUJFTUPBMMPXBOZDMPTFPVUPSUSBOTJUJPOQFSGPSNBODFSFQPSUJOHJOWPJDJOHPSGJOBMQBZNFOUTPSEVSJOHBOZMBQTFCFUXFFOBNFOENFOUT
$&35*'*$"5*0/4/PUXJUITUBOEJOHWFSCBMPSPUIFSSFQSFTFOUBUJPOTCZUIFQBSUJFTUIFi&GGFDUJWF%BUFwPGUIJT$POUSBDUPS"NFOENFOUTIBMMCFUIFMBUFTUEBUFUIBUUIJT$POUSBDUPS
"NFOENFOUIBTCFFOFYFDVUFECZBOBVUIPSJ[FETJHOBUPSZPGUIF$POUSBDUPSUIF%FQBSUNFOUPSBMBUFS$POUSBDUPS"NFOENFOU4UBSU%BUFTQFDJGJFEBCPWFTVCKFDUUPBOZSFRVJSFE
BQQSPWBMT5IF$POUSBDUPSDFSUJGJFTUIBUUIFZIBWFBDDFTTFEBOESFWJFXFEBMMEPDVNFOUTJODPSQPSBUFECZSFGFSFODFBTFMFDUSPOJDBMMZQVCMJTIFEBOEUIF$POUSBDUPSNBLFTBMMDFSUJGJDBUJPOT
SFRVJSFE VOEFS UIF 4UBOEBSE $POUSBDU 'PSN *OTUSVDUJPOT BOE $POUSBDUPS $FSUJGJDBUJPOT VOEFS UIF QBJOT BOE QFOBMUJFT PG QFSKVSZ BOE GVSUIFS BHSFFT UP QSPWJEFBOZ SFRVJSFE
EPDVNFOUBUJPO VQPO SFRVFTU UP TVQQPSU DPNQMJBODF BOE BHSFFT UIBU BMM UFSNT HPWFSOJOH QFSGPSNBODF PG UIJT $POUSBDU BOE EPJOH CVTJOFTT JO .BTTBDIVTFUUTBSF BUUBDIFE PS
JODPSQPSBUFECZSFGFSFODFIFSFJOBDDPSEJOHUPUIFGPMMPXJOHIJFSBSDIZPGEPDVNFOUQSFDFEFODFUIJT4UBOEBSE$POUSBDU'PSNUIF4UBOEBSE$POUSBDU'PSN*OTUSVDUJPOT$POUSBDUPS
$FSUJGJDBUJPOTUIFBQQMJDBCMF$PNNPOXFBMUI5FSNTBOE$POEJUJPOTUIF3FRVFTUGPS3FTQPOTF 3'3
PSPUIFSTPMJDJUBUJPOUIF$POUSBDUPST3FTQPOTFBOEBEEJUJPOBMOFHPUJBUFEUFSNT
QSPWJEFEUIBUBEEJUJPOBMOFHPUJBUFEUFSNTXJMMUBLFQSFDFEFODFPWFSUIFSFMFWBOUUFSNTJOUIF3'3BOEUIF$POUSBDUPST3FTQPOTFPOMZJGNBEFVTJOHUIFQSPDFTTPVUMJOFEJO$.3
JODPSQPSBUFEIFSFJOQSPWJEFEUIBUBOZBNFOEFE3'3PS3FTQPOTFUFSNTSFTVMUJOCFTUWBMVFMPXFSDPTUTPSBNPSFDPTUFGGFDUJWF$POUSBDU
AUTHORIZING SIGNATURE FOR THE CONTRACTOR:
X:
. Date:
.
(Signature and Date Must Be Handwritten At Time of Signature)
Print Name:
.
Print Title:
.
AUTHORIZING SIGNATURE FOR THE COMMONWEALTH:
X:
. Date:
.
(Signature and Date Must Be Handwritten At Time of Signature)
Print Name:
.
Print Title:
.
BUUBDIFEBOEJODPSQPSBUFEJOUPUIJT$POUSBDU"DDFQUBODFPGQBZNFOUTGPSFWFSSFMFBTFTUIF$PNNPOXFBMUIGSPNGVSUIFSDMBJNTSFMBUFEUPUIFTFPCMJHBUJPOT
E-Mail:
Contract Manager:
CITY OF SOMERVILLE
Department of Public Health
93 HIGHLAND AVE SOMERVILLE, MA 02143
250 Washington Street, Boston MA 02108
Kelley Hiland
khiland@somervillema.gov
Derek Westhaver
[phone removed]
Derek.A.Westhaver@mass.gov
VC6000192138
[phone removed]
INTF5264P01223127055
223127
06/30
300,000.00
900,000.00
Renewal with Maximum Obligation Change
07/01
06/30
23
001
DPH
✔
24
✔
✔
23
✔
✔
Commonwealth of Massachusetts
CONTRACTOR AUTHORIZED SIGNATORY LISTING
This form is jointly issued and published by the Office of the Comptroller (CTR) and the Operational Services Division (OSD) as the default form for all Commonwealth
Departments when another form is not prescribed by regulation or policy.
Page 1 of 1
Signature for Corporation (C or S), Partnership, Trust/Estate, Limited Liability Company
(must match Form W-9 tax classification)
Contractor Legal Name
Contractor Vendor/Customer Code
LIDYDLODEOHQRWWKH7D[SD\HU,GHQWLILFDWLRQ1XPEHURU6RFLDO6HFXULW\1XPEHU
INSTRUCTIONS: Any Contractor (other than a sole-proprietor or an individual contractor) must provide a listing of individuals who
are authorized as legal representatives of the Contractor who can sign contracts and other legally binding documents related to the
contract on the Contractor’s behalf. In addition to this listing, any state department may require additional proof of authority to sign
contracts on behalf of the Contractor, or proof of authenticity of signature (a notarized signature that the Department can use to verify
that the signature and date that appear on the Contract or other legal document was actually made by the Contractor’s authorized
signatory, and not by a representative, designee or other individual.)
For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social
security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do
not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized
signatories of contractors.
There are three types of electronic signatures that will be accepted on this form: 1) Traditional “wet signature” (ink on paper); 2)
Electronic signature that is either: a. hand drawn using a mouse or finger if working from a touch screen device; or b. An
upload picture of the signatory’s hand drawn signature; 3) Electronic signature affixed using a digital tool such as Adobe
Sign or DocuSign. Typed text of a name not generated by a digital tool, computer generated cursive, or an electronic symbol are not
acceptable forms of electronic signature.
Authorized
Signatory Name
Signature (Signature
as it will appear on contract
or other documents)
Title
Phone
Number
Email Address
Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by the Contractor challenging
the existence of a valid Contract due to an alleged lack of actual authority to execute the document by the signatory.
I certify that I am a responsible authorized officer of the Contractor and as an authorized officer of the Contractor I certify that the
names of the individuals identified on this listing are current as of the date of execution and that these individuals are authorized to
sign contracts and other legally binding documents related to contracts with the Commonwealth of Massachusetts on behalf of the
Contractor. I understand and agree that the Contractor has a duty to ensure that this listing is immediately updated and communicated
to any state department with which the Contractor does business whenever the authorized signatories above retire, are otherwise
terminated from the Contractor’s employ, have their responsibilities changed resulting in their no longer being authorized to sign
contracts with the Commonwealth or whenever new signatories are designated.
Please note you cannot self-certify your own signature as a single signer listed above.
Signature
Date
Print Name
Phone Number
Title
Email Address
A copy of this listing must be attached to the “record copy” of a contract filed with the department.
&$6/'
&$6/6
&$6/7
&$6/$61
&$6/($
&$6/3U1
&$6/3K1
&$6/($
&$6/7
&$6/7
&$6/7
&$6/7
&$6/6
&$6/6
&$6/6
&$6/$61
&$6/$61
&$6/$61
&$6/($
&$6/($
&$6/($
&$6/6
&$6/3K1
&$6/3K1
&$6/3K1
&$6/3K1
CITY OF SOMERVILLE
VC6000192138
6FRSHRI6HUYLFHV
" "
"$+
!$+$++
+
INTF5264P01223127055
Renewal for FY 2024 with no change to the scope or delivery of service.
Contract Amendment - Increase
PAYMENT VOUCHER INPUT FORM
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT / ORGANIZATION NAME
Department of Public Health
DOCUMENT ID
TRANS
DEPT
ORG
PRC
DPH
BIDLS
ACTION: (E)
Sch Pay Date FISCAL YEAR
202
CITY OF SOMERVILLE
Denise Holland
93 HIGHLAND AVE
SOMERVILLE, MA 02143
DOCUMENT TOTAL:
/RFDO6XSSRUW)2127055
VC6000192138
CONTRACT NUMBER
QUANTITY
DESCRIPTION
UNIT PRICE
INTF5264P01223127055
1
300,000
300,000.00
RFR 223127 - /RFDO6XSSRUWIRU&29,'DQGRWKHU
LQIHFWLRXVGLVHDVHLQYHVWLJDWLRQDQGUHVSRQVH
TOTAL:
300,000.00
$
REFERENCE ORDER
LN
Trans
Dept
Org
Number
PRC
DPH
BIDLS
INVOICE NUMBER
F2127055
MA #
MA LN#
DATES OF SERVICE
Line Amount
P/F
7/1/202
P
Instructions to vendor:
I hereby certify under the penalties of perjury that all laws of the Commonwealth governing disbursements of public funds and the regulations thereof have been complied with and observed.
o
Fill in shaded areas
PREPARED BY:
TITLE:
DATE:
o Direct inquiries to
ENTERED BY:
TITLE:
DATE:
state organization
The undersigned authorized signatory approving this document certifies that this document and any attachments are accurate and complete and comply with all applicable general
and special laws and regulations
APPROVED BY:
TITLE:
DATE:
PHONE:
Number
APPROPRIATION
ACTIVITY
(Please Sign Here)
VENDOR CODE:
VENDOR PAYMENT REF NUMBER:
Vendor Name and Address
I certify that the goods were shipped or the services rendered as set forth below
TO THE COMPTROLLER OF THE COMMONWEALTH OF MASSACHUSETTS:
SERVICE DESCRIPTION
AMOUNT
VENDOR'S CERTIFICATION
VENDOR'S CERTIFICATION
Department of Public Health
Vendor Name
DPH Bureau/Program Name
CITY OF SOMERVILLE
Bureau of Infectious Disease & Laboratory Sciences
Vendor Code
Fiscal Year
Contract Number
RFR#
Today's Date
VC6000192138
2024
6/20/2023
CURRENT
Proposed
Proposed
Program Component
FTE
BUDGET
Changes +/-
New Budget
Justification
(A)
(B)
(C)
(D)
1. Direct Care/Prog. Support Staff
-
$
-
$
-
$
-
$
-
$
-
$
SUB TOTAL
0.00
-
$
-
$
-
$
Fringe Benefits
#DIV/0!
-
$
1. TOTAL DIRECT CARE/PROGRAM STAFF
-
$
-
$
-
$
CURRENT
Proposed
Proposed
Program Component
BUDGET
Changes +/-
New Budget
Justification
(A)
(B)
(C)
(D)
2. Other Direct Care/Program
-
$
-
$
-
$
-
$
-
$
-
$
2. TOTAL OTHER DIRECT/PROGRAM
-
$
-
$
-
$
Occupancy
Program Facility
-
$
Facility Operations, Maint. and Furn.
-
$
-
$
3. TOTAL OCCUPANCY
-
$
-
$
-
$
$
SUB TOTAL: 1 + 2 + 3
-
$
-
$
-
$
Administrative Support
Max Cap Amount:
#DIV/0!
4. AGENCY ADMIN. SUPPORT
-
$
TOTAL 1+ 2 + 3 + 4
-
$
300,000.00
$
INTF5264P01223127055