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Temporary Food Establishment Non-Profit Application

2. Each vendor in Richmond County that is claiming exemption from North Carolina regulation requiring an operational permit to prepare and sell food or drink for pay shall complete the Documentation of Exemption form. Submit the Documentation of Exemption form along with a copy of the exemption letter from the North Carolina Department of Revenue stating of non-profit status, a copy of 501c, or a political committee as defined in North Carolina General Statute 163-278.6(14).

   Each vendor in Richmond County that is claiming exemption from North Carolina regulation requiring an operational permit to prepare and sell food or drink for pay shall complete the Documentation of Exemption form. Submit the Documentation of Exemption form along with a copy of the exemption letter from the North Carolina Department of Revenue stating of non-profit status, a copy of 501c, or a political committee as defined in North Carolina General Statute 163-278.6(14).

4. Upload Exemption Documentation

8. Date Submitted
   Date Submitted

10. Event

12. Location Address

14. Event Dates
    Event Dates Start Date

    —

    Event Dates End Date

16. Hours
    Hours Start Time

    —

    Hours End Time

18. Event Coordinator Name

20. Event Coordinator Phone Number

22. Tax ID Number

24. Organization Name

26. Organization Address

28. Organization Phone Number

30. Organization Email Address

32. Name/Location of Previous Events Worked This Year

34. Name/Location of Upcoming Events This Year

36. List Foods to Be Sold

40. Proof of Non-Profit
    It is the responsibility of the non-profit organization to prove that they are a non profit. The responsible persons should include with this application a copy of the exemption letter from the North Carolina Department of Revenue stating of non-profit status, a copy of 501c, or a political committee as defined in North Carolina General Statute 163-278.6(14).

    It is the responsibility of the non-profit organization to prove that they are a non profit. The responsible persons should include with this application a copy of the exemption letter from the North Carolina Department of Revenue stating of non-profit status, a copy of 501c, or a political committee as defined in North Carolina General Statute 163-278.6(14).

42. Approval of Application
    Applicants will be contacted via email upon approval. This approval is for events submitted only in Richmond County. Approval of this application does not indicate compliance with any other code, law or regulation that may be required (i.e. Fire Marshall, federal, state, and local authorities).

    Applicants will be contacted via email upon approval. This approval is for events submitted only in Richmond County. Approval of this application does not indicate compliance with any other code, law or regulation that may be required (i.e. Fire Marshall, federal, state, and local authorities).

44. Keep a Copy
    Applicant should keep a copy of documentation onsite during your event to show any Richmond County Health Inspector should they visit your event.

    Applicant should keep a copy of documentation onsite during your event to show any Richmond County Health Inspector should they visit your event.

46. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
48. Responsible Person Electronic Signature*

50. Date*
    Date

52. Forms can be faxed to Richmond County Environmental Health at 910-997-8372 or mailed to Richmond County Environmental Health, at 127 Caroline Street, Rockingham NC, 28379. They also may be hand delivered to 127 Caroline Street, Rockingham NC, 28379.

    Forms can be faxed to Richmond County Environmental Health at 910-997-8372 or mailed to Richmond County Environmental Health, at 127 Caroline Street, Rockingham NC, 28379. They also may be hand delivered to 127 Caroline Street, Rockingham NC, 28379.

54. Date Approved
    Date Approved

56. Approved By

Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field