Tobacco Retailer: Permit Applications

TYPE OF RETAILER PERMIT


General Tobacco Retailer

This type of retail location typically sells a wide variety of products so that the sale of tobacco products* accounts for less than 35% of the total quarterly gross receipts. In addition, less than 20% of the retail floor space and less than 20% of the total shelf space is allocated to the offer, display or storage of tobacco products. There is no self-service display for tobacco products.

I understand that in order to be permitted as a General Tobacco Retailer, the business identified in this application may not at any time:
Have any self-service display of tobacco products; or
Have 20% or more of the total retail floor space allocated to the offer, display, or storage of tobacco products; or
Have 20% or more of the total shelf space allocated to the offer, display, or storage of tobacco products; or
Have 35% or more of total quarterly gross receipts from the sale of tobacco products.

Retail Tobacco Specialty Business
This type of retail location typically specializes in the sale of tobacco products*. 35% or more of the total quarterly gross receipts are from the sale of tobacco products, or; 20% or more of the retail floor space is allocated to the offer, display, or storage of tobacco products, or; 20% or more of the total shelf space is allocated to the offer, display, or storage of tobacco products, or; the retail space features a self-service display for tobacco products.

I understand that in order to be permitted as a Retail Tobacco Specialty Business, the business identified in this application may not at any time, be within:

1) 1,000 feet of a community location**; or
600 feet of another retail tobacco specialty business; or,
600 feet of property used or zoned for agricultural or residential use.

I further understand, and my signature binds all proprietors listed on this application, that if any of these requirements for a Retail Tobacco Specialty Business is violated, this permit may be revoked by the issuing health department.

Map of Proposed Location for Retail Tobacco Specialty Businesss

PROPRIETOR INFORMATION



PROPRIETOR 1

* Name
Street 1
Street 2
City
State
Postal Code
* Phone
* Email

* Authorized to receive permit-related communications and notices


PROPRIETOR 2

Name
Street 1
Street 2
City
State
Postal Code
Phone
Email

Authorized to receive permit-related communications and notices


Has any of the proprietors listed above been determined to have violated any state or federal tobacco laws in the past 24 months? If so, list all violations and dates of each violation:

BUSINESS INFORMATION


* Business Name
Street 1
Street 2
City
State
Postal Code
County
* Phone
* Email

TAX COMMISSION LICENSE


* Tax Comission Tax License



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