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


*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. Please refer to UCA 59-14-102; UCA 76-10-101; and UCA 76-10-104.1 for specific definitions of tobacco products.

**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.


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


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 health department’s tobacco permit. 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.

Payment must be submitted with the application. No permit will be issued without the payment of the permit fee. A plan review will not be conducted until payment of the plan review fee. It is the responsibility of the applicant to verify zoning restrictions. Fees cannot be refunded if it is later determined that the identified location does not meet zoning requirements.

* required fields

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Our mission is to protect and promote the health of all San Juan County residents by preventing illness and injury, establishing and promoting healthy environments, advocating policy based on scientific knowledge of issues relating to public health, promoting services which address personal health and well-being, informing and educating the community regarding issues of public health, and providing a committed, educated and effective public health professional work force.