Fill and Sign the How to Fill Up Sbi Home Loan Application Form 2009

Edgecombe County Health Department 2909 Main Street Tarboro, NC 27886 Phone: (252)641-7573 Fax: (252) 823-2077 ` TEMPORARY FOOD ESTABLISHMENT PERMIT APPLICATION Event Information Event Name ____________________________________________________ Event Coordinator ____________________________________________________ Set-up Date and Time ___________________________________________________ Event Dates ____/____/____ Time_______ Ending___/___/____ Time______ Vendor Information Organizational/business Name_____________________________________________ Contact Person __________________ (Phone) ( ) ____-_____ Address________________________ (Fax) ( )____-_____ (Cell) ( )____-____ (Pager) ( )____-____ City____________________________ State_____________ Zip___________________ Menu:__________________________________________________________________ _______________________________________________________________________ Food Sources (i.e. Supermarket or Food Distributor)______________________________ *Note: If non-profit, tax exempt or political fund raising group then attach documentation for exemption consideration. *MENU ITEMS ARE SUBJECT TO APPROVAL AND MAY BE RESTRICTED Applicant’s Signature_____________________________________ Date:______________________ Specialist’s Signature___________________________ Date:______________________ FOR ENVIRONMENTAL HEALTH SECTION USE ________Permit is Required ________Permit in not Required-exempt under GS 130A-250(7) or food items not regulated under 15A NCAC 18A .2600 Note: Temporary Food Establishment Permit Fee needs to be submitted with Application. ($75.00 per permit) Note: Application must be submitted at a minimum two weeks prior to event. ($75.00 per permit)