Environmental Health Services
Elliot Schulman, MD, MPH Director/ Health Officer Michael D. Harris Deputy Director Richard Merrifield, REHS Director of Environmental Health
225 Camino Del Remedio Santa Barbara, CA 93110 805/681-4900 FAX 805/681-4901 2125 S. Centerpointe Pkwy. #333 Santa Maria, CA 93455 805/346-8460 FAX 805/346-8485
Request for Exemption from Regulation as a Food Facility per Health and Safety Code Section 113785 Date: _____________________ In order to be considered for exemption from regulation, we certify the following: 1. All profits from the operation of the - food booth named __________________________
- operated by the for-profit business __________________________ - operating at the festival named - on the date of - will be donated in total, to the non-profit organization named - with tax id number __________________________ __________________________ __________________________ __________________________
2. The for-profit business operating the food booth will receive no monetary benefit, except that resulting from recognition for participating in the event. We understand this permit exemption may only be granted for an occasional event that occurs not more than 3 days in any 90-day period (Health and Safety Code Section 113825). Signed this date:______________________
Officer of Non-profit Organization Signature Date
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Printed Name
__________________________
Contact Telephone Number
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Officer of For-Profit Business Signature
__________________________
Date
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Printed Name EHS 16-24 (Rev. 10/05)
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Contact Telephone Number