New Permit Application

Please complete all required sections and submit the application.

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Section 1 - Business Information
Section 2 - Permit Information
Broad retail business with limited tobacco sales and no self-service displays.
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; 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.
Business primarily focused on tobacco or nicotine product sales.
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.
Section 3 - Contact / Mailing Information

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Section 4 - Proprietor Information
Proprietor 1
Section 5 - Violations

Has any of the proprietors 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:

Section 6 - Attestation

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