c. In the case of beverages that are manufactured, distributed, and sold under a franchise or trademark name indicated thereon, whereby the person, firm, corporation, or limited liability company owning the franchise or trademark has control over the distribution, such beverages may be exempt from this subsection, if a certified statement is filed with the department, stating the name and address of the manufacturer or distributor, and a statement signed by the manufacturer or distributor that they assume all responsibility and liability for the product named, which is being sold, or offered for sale, under such name within the area of the state designated, which certificate must be in the following form:
NORTH DAKOTA DEPARTMENT OF HEALTH AND HUMAN SERVICES
BISMARCK, NORTH DAKOTA
BEVERAGE LABELING EXEMPTIONS CERTIFICATE
I, _______________________, the undersigned, an agent of and having authority to sign, do hereby certify that the following information is correct: Name and address of company requesting exemption
Name __________________________________________
Street Address ________________________________
City or Town __________________________________
State _________________________________________
Name of Product _______________________________
Brand Name ____________________________________
In order to be exempt from subdivisions a and b of subsection 5 of section 19-02.1-10 of the North Dakota Century Code, relating to misbranding of food, which requires the name and address of the real manufacturer or other persons responsible for placing the product upon the market, I, the undersigned, do bind the company listed above by agreeing to assume all responsibility for the product named in this certificate which is being sold, or offered for sale under such name and brand name within the area consisting of _________________ in the State of North Dakota.
Note: The area must be designated by counties or other legal subdivisions of the city, county, or state.
Firm _____________________________
Signed ___________________________ Title ____________________________
Address __________________________
Note: If signed by a person other than an officer of the company, authorization for signature must accompany this form. This certificate must be acknowledged.
Provided, that under subdivision b reasonable variations must be permitted, and exemptions as to small packages must be established, by regulations prescribed by the department.