TOBACCO RETAIL PERMIT RENEWAL

I further understand, and my signature binds all proprietors for the business, that if any requirements for a General Tobacco Retailer are violated this permit may be revoked by the issuing health department.

I Understand and Accept Terms.

There are two types of Tobacco Retailer permits. Please read the following descriptions and choose the type of permit you need for your tobacco retail location, and sign indicating you understand the requirements for the permit you are seeking.

Retail Tobacco Specialty Business – This type of retail location typically specializes in the sale of tobacco products, electronic cigarette products, or nicotine products.* 35% or more of the total quarterly gross receipts are from the sale of tobacco products, electronic cigarette products, or nicotine products, or; 20% or more of the retail floor space is allocated to the offer, display, or storage of tobacco products, electronic cigarette products, or nicotine products, or; 20% or more of the total shelf space is allocated to the offer, display, or storage of tobacco products, electronic cigarette products, or nicotine products, or; the retail space features a self-service display for tobacco products, electronic cigarette products or nicotine products, or; the business sells “flavored” electronic cigarette products, or; the business holds itself out as a retail tobacco specialty business and causes a reasonable person to believe the commercial establishment is a retail tobacco specialty business.

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 understand that retailers are responsible for knowing and complying with local, state, and federal laws and regulations.

I further understand, and my signature binds all proprietors for the business, that if any requirements for a Retail Tobacco Specialty Business are violated, this permit may be revoked by the issuing health department.
I Understand and Accept Terms.                                                                 

*Tobacco products include any cigar, cigarette, electronic cigarette, chewing tobacco, or any substitute for a tobacco product, including flavoring or additives to tobacco, and tobacco paraphernalia. Electronic cigarette products include any electronic cigarette, electronic cigarette substance, or a prefilled electronic cigarette. Nicotine product includes any alternative nicotine product or a nontherapeutic nicotine product. Please refer to Utah Code 76-10-101 for specific definitions.

**Community location public or private K-12 school; licensed child-care or preschool; trade or technical school; church; public library; public playground; public park; youth center or other place used primarily for youth oriented activities; public recreational facility; public arcade; homeless shelter.

***Beginning July 1, 2021 (businesses grandfathered prior to 12/31/2018) and July 1, 2022 (businesses grandfathered prior to 12/31/2020), a retail tobacco specialty business may not be located within 1,000 feet of a public or private kindergarten, elementary, middle, junior high, or high school, even if the business had "grandfather status" prior. Refer to Utah Code 10-8-41.6(7) and 17-50-333(7).

Section 1: Business Information:
Required*

Section 2: Contact and Address Information
An individual to contact about the application and business must be included.
Required*

Section 3: Owner Information (Proprietor)
Must include information for each individual that is a proprietor or owner. If the proprietor is a corporation, must also include corporate ownership information.
Required*

Authorized to receive permit-related communications and notices.
YesNo

Add Another Owner

Authorized to receive permit-related communications and notices.
YesNo

Have any of the owners (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:

Section 4:
Attach a copy of the current Utah State Tax Commission tobacco license. The application cannot be processed without a current license.
Upload a copy of your Utah Tobacco License (required)

Section 5: Permit Fees:
Required*
Permit renewal $20.00

Must bring payment to Tricounty Health Department or call to do over the phone processing (435) 247-1160 or (435) 722-6310 No permit will be issued without the payment of the permit fee.

Or mail to TriCounty Health Department C/O Jeramie Tubbs 409 South 200 E, Roosevelt, UT 84066

Section 6: Acknowledgement/Agreement
I certify that the information provided is true and accurate to the best of my understanding. I understand that any incorrect information may result in the suspension or revocation of the tobacco retailer permits. I also understand that the health department may recommend to the business licensing entity that the business license be suspended or revoked. Any such action will be reported to the Utah State Tax Commission.
I agree to the terms and conditions listed above