Documentation of Exemption form (for non-profit food vendors)
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10 MAIN OFFICE E NVIRONMENTAL OFFICE 517 North Bright Leaf Boulevard LAND USE CENTER Smithfield , NC 27577 - 4407 309 East Market Street 919 989 - 5200 Smithfield , NC 27577 - 3919 Fax 919 989 - 5208 Admin Fax 919 989 - 5199 Med Rec 919 989 - 5180 Fax 919 989 - 5190 Linda Allen , RN Mabel Yelvington Board Chairman Board Vice Chairman MARILYN R PEARSON , MD Director DOCUMENTATION OF EXEMPTION EVENT ______________________________________________________________ Name of Organization ____________________________________________________ Address _______________________________________________________________ Name of Responsible Person & Title _________________________________________ Phone Number s ________________________________________________________ Tax ID Number ________________________________________________________ List of foods to be sold ___________________________________________________ When are you claiming an exemption Dates _________________________________ How many days will you operate ___________________________________________ Where else have you operated event and date Will you be operating any where else this year , if so where and when It is the responsibility of the non - profit organization to prove that they are a non Signature of responsible person ____________________________________________Page