San Juan County Public Health
             
San Juan County Health Department
735 S 200 W STE 2, Blanding, UT, 84511
Phone (435) 587-3838

Application for Tobacco Retailer Permit
*Please enter your business and payment information below.


Retailer Type

There are two types of Tobacco Retailer Permits. PLEASE READ the following descriptions and CHOOSE Sthe 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, 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 is no self-service display for tobacco products, electronic cigarettes, 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:

Have any self-service display of tobacco products, electronic cigarette products, or nicotine products;
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;
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;
Have 35% or more of total quarterly gross receipts from the sale of tobacco products, electronic cigarette products, or nicotine products
Sell flavored electronic cigarette products** (See Utah Code 76-10-101 for definition);
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:

1,000 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 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.

If this is your permit type, a map of the proposed retail tobacco specialty business location MUST be attached that shows the location of any community location***, other retail tobacco specialty business, agricultural or residential property. The retail tobacco specialty business application cannot be processed without the map. Attach it below.
*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. Electronic cigarette products include any electronic cigarette, electronic cigarette substance, or a prefilled electronic cigarette. Nicotine product includes any alternative nicotine product or a nontherapeutic nicotine product. Please refer to Utah Code 76-10-101 for specific definitions.

**Utah Code 76-10-101(7) definition: “Flavored electronic cigarette product” includes an electronic cigarette product that has a taste or smell of any fruit, chocolate, vanilla, honey, candy, cocoa, dessert, alcoholic beverage, herb, or spice. “Flavored electronic cigarette product” does not include an electronic cigarette product that: has a taste or smell of only tobacco, mint, or menthol; or has been approved by an order granting a premarket tobacco product application of the electronic cigarette product by the United States Food and Drug Administration under 21 U.S.C. Sec. 387j(c)(1)(A)(i).

***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.
 

Select your Retailer Type

Select your Retailer Type Here

Contact and Mailing Information

An individual to contact about the application and other permit-related notices must be included. By listing the information you certify that this person is authorized to receive permit-related communications.

Contact & Mailing Information
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone:
Email:

 

Business Information

Please list the information about the PHYSICAL LOCATION of the business.

Business Name
DBA (other name(s) this business location goes by)
Address of PHYSICAL location
City
Postal/Zip Code
Phone Number


Owner/Proprietor Information

Must include information for EACH individual that is a proprietor or owner. If the proprietor is a corporation, you must also include corporate ownership information.

Name
Address 1
City
Postal/Zip Code
Phone
Email
Percentage Ownership
Owner 2 Information (if applicable)
Have any of the owners/proprietors for the business violated any state or federal tobacco laws in the past 24 months? If so, list all violations and dates of each violation. Answer this question in the box below:

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 Fees

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.

*Please select below the permit/services that you are requesting
NEW Permit:   $30.00   Select:   Item Subtotal:  
$0.00
Tobacco Retailer Permit RENEWAL:   $20.00   Select:   Item Subtotal:  
$0.00
Permit REINSTATEMENT:   $30.00   Select:   Item Subtotal:  
$0.00
Retail Tobacco Specialty Business Plan Review:   $250.00   Select:   Item Subtotal:  
$0.00
(Retail Tobacco Specialty Business Plan Review is REQUIRED for all new retail tobacco specialty business permit applications)
Total:
$0.00

Acknowledgement / Agreement

I certify that the information provided is true and accurate. I understand that any incorrect information may result in the suspension or revocation of the tobacco retailer 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.

By paying and submitting I am signing this application and my signature binds all proprietors for the business to the above agreements.
Print Name

Payment Information:
Processing Fee Rates:
Cards: 2.5% ($1.50 min)
(4% for foreign cards)
eCheck (ACH): $0.75
Method of Payment:
 Update Name from Personal/Organizational Information
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
 Change Payment Method
 
Submitting ...
SIP Program & Data © 2006-2021 Instant Payments All rights reserved.
~ Terms & Conditions ~ Privacy Policy ~ Contact Us ~
SIP Version 3.05.14365; (API: 2.17)
RSI Security PCI DSS Compliance Instant Payments BBB Business Review