Tobacco Retailer Permit

FORM – English

Please use the form below to apply for a Tobacco Retailer Permit.

NOTE: Retailers that already have a current valid tobacco license from the Utah State Tax Commission on July 1, 2018, will have until January 1, 2019 to obtain a permit from the local health department. All other retailers who want to sell tobacco products (including e-cigarette & vape products) must apply immediately.

Tobacco Retailer: Permit Applications

TYPE OF RETAILER PERMIT

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.
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
2) 600 feet of another retail tobacco specialty business; or,
3) 600 feet of property used or zoned for agricultural or residential use.

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

Map of Proposed Location for Retail Tobacco Specialty Business:

A map of the proposed retail tobacco specialty business location is attached that shows the location of any community location**, other retail tobacco specialty business, agricultural or residential property. The tobacco specialty application cannot be processed without the map.



*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 locations include any 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 space used primarily for youth oriented activities; public recreational facility; public arcade; or 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


Have any of the proprietors for the store/business 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
Please list the information about the physical location of business including the name and address.
* Business Name
* Street 1
Street 2
* City
* State
* Postal Code
* County
* Phone
* Email


TAX COMMISSION LICENSE
* Tax Commission Tobacco License:

Attach a copy of the store's current tax commission tobacco license. The application cannot be processed without a current license.



PERMIT FEEES

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 and proximity restrictions. Fees cannot be refunded if it is later determined that the identified location does not meet zoning or proximity requirements.

New Permit: $30.00
Permit Renewal: $20.00 (not an option until after June 30, 2019)
Permit Reinstatement: $30.00
Retail Tobacco Specialty Business Plan Review: $250.00 (required for all new retail tobacco specialty business permit applications)


ATTESTATION

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

* required fields
Payment Information
Payment may be submitted by:
– Mail
– In person
– Call: 435-792-6510

Payment by Check
Be made payable to BRHD.
Include “Tobacco Permit” in the notes on the check.

Mail to
Bear River Health Department
ATTN: Health Promotions
655 E 1300 N
Logan, UT 84341

Permit Fees

New permit — $30.00
Permit renewal — $20.00
(not an option until after June 30, 2019)
Permit reinstatement — $30.00
Retail Tobacco Specialty Business Plan Review — $250.00
(required for all new retail tobacco specialty business permit applications)

NOTE: If applying for a Retail Tobacco Specialty Business Permit, you will need to pay a $250 plan review fee in addition to the $30 permit fee. A General Tobacco Retailer Permit application will require the $30 permit fee only.

Questions
If you have questions about the form, or the requirements for the permit, please email: tobaccopermit@brhd.org