Jared Testing Page – Tooele County Health Department

Tobacco Retail Permits

Comments

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Name

First Last

Date of birth

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Permit Type

General Tobacco Retailer ------ This type of retail location typically sells a wide variety of products so that the sale of tobacco products, electronic cigarette products, and nicotine 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 are no self-service displays for tobacco products, electronic cigarette products, or nicotine products. The business does not sell any “flavored” electronic cigarette products. Lastly, the business does not hold itself out as a retail tobacco specialty business and cause a reasonable person to believe the commercial establishment is a retail tobacco specialty business. I understand that in order to be permitted as a General Tobacco Retailer, the business identified in this application may NOT at any time: 1) Have any self-service display of tobacco products, electronic cigarette products, or nicotine products; 2) Have 20% or more of the total retail floor space allocated to the offer, display, or storage of tobacco products, electronic cigarette products, or nicotine products; 3) Have 20% or more of the total shelf space allocated to the offer, display, or storage of tobacco products, electronic cigarette products, or nicotine products; 4) Have 35% or more of total quarterly gross receipts from the sale of tobacco products, electronic cigarette products, or nicotine products; 5) Sell flavored electronic cigarette products** (See Utah Code definition); 6) Hold itself out as a retail tobacco specialty business and cause a reasonable person to believe the commercial establishment is a retail tobacco specialty business. 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 General Tobacco Retailer are violated, this permit may be revoked by the issuing health department.

Retail Tobacco Specialty Business ------ This type of retail location typically specializes in the sale of tobacco products, electronic cigarette products, and/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; 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 2) 600 feet of another retail tobacco specialty business; or 3) 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.

Business Name at this location (as listed on the State Tax Commission License

DBA or other name(s) this business location goes by

Physical Address of Business

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Email

Business Phone

Tax Commission Tobacco License (Attach a copy)

Max. file size: 50 MB.

Map of Proposed Location for Retail Tobacco Specialty Business ONLY

Max. file size: 50 MB.

Contact/ Mailing Information (Name)

First Last

Contact: Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact: Email

Contact: Phone

Proprietor 1: Name

First Last

Proprietor 2: Name

First Last

Proprietor 1: Email

Proprietor 2: Email

Proprietor 1: Phone

Proprietor 2: Phone

Proprietor 1: Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Proprietor 2: Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Proprietor 1: % of ownership

Proprietor 2: % of ownership

Attestation Signature

Credit Card

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