ATTACHMENT I
DECLARATION OF FOR-PROFIT ENTITY
This declaration is to affirm that
is requesting exemption under provision of Section 113789(c) (4) of the California Retail Food Code, and will be giving or selling food at:
TASTE OF PLACENTIA (Name of Event)
TRI-CITY PARK, 2301 N. KRAEMER BLVD. (Address or Location)
PLACENTIA, 92870 (City, Zip)
Date(s) of Event
-
Month
-
Day
Year
Date
For the benefit of PLACENTIA CHAMBER OF COMMERCE
(Name of Sponsoring Nonprofit Association)
I declare under penalty of perjury that the above information is true and correct to the best of my knowledge and belief. I further certify that the above named for-profit entity (retail food facility) will not receive any monetary benefit and will donate all proceeds to the nonprofit association organizing this event. The only benefit the for-profit entity will receive will be recognition for participating in the event.
Name
First Name
Last Name
Phone
Format: (000) 000-0000.
Email
example@example.com
Facility Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
Title
Approved by:
Date
-
Month
-
Day
Year
Date
(Environmental Health Specialist)
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