Local Tobacco Permit Application - Southwest Utah Public Health Department

Tobacco Retailer: Permit Applications

General Tobacco Retailer

General Tobacco Retailers typically sell a wide variety of products so that the sale of tobacco products* accounts for less than 35% of the total quarterly gross receipts. Examples include: convenience stores, grocery stores, etc.
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

Retail Tobacco Specialty Businesses specialize in the sale of tobacco and and/or vaping products.
I understand that in order to be permitted as a Retail Tobacco Specialty Business, the business identified in this application anticipates:
- 35% or more of the total quarterly gross receipts from the sale of tobacco products, or
- 20% or more of the retail floor space 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.
The business identified in this application MAY NOT at any time, be within:
- 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.
- Note: Businesses licensed and conducting business prior to December 31, 2015 may not be in compliance but qualify to maintain business due to grandfathering

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

Please refer to UCA 17-50-333 for a complete list of community locations public or private

Compliance Check: Local Permit Application

Mailing Address
Store Name*
Tobacco Specialty Shop
General Tobacco Retailer
Map of Proposed Location for Retail Tobacco Specialty Business (Required for all retail tobacco specialty businesses, must show on the map the location of the business and distances from the noted locations above.)
Street Address 1*
Street Address 2
City
State
Zip Code
Phone Number
Store E-mail Address
Cigarette/Tobacco Products License*
Date of Application
Street Address 1*
Street Address 2
City
State
Zip Code
Proprietor 1 Details
Name*
Address 1*
Address 2
City*
State*
Zip Code*
Phone Number*
E-mail Address*
Authorized to receive tobacco permit and permit-related communications and notices*
Proprietor 2 Details
Name
Address 1
Address 2
City
State
Zip Code
Phone Number
E-mail Address
Have any of the proprietors applying for a tobacco license 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:

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.

If the information required in this application changes a tobacco retailer may not renew their permit and must apply for a new permit no later than 15 days after the information changed.

By clicking submit I am signing this application and my signature binds all proprietors for the business listed on this application to the above agreements.

I agree to the Terms*

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Tobacco Retailer: Permit Applications

Compliance Check: Local Permit Application

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