Local Tobacco Permit Application

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*