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Tobacco Retailer Application Form

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Please correct the field(s) marked in red below:

City of Santa Maria
TOBACCO RETAILER LICENSE APPLICATION
(Pursuant to Ordinance No. 2019-11)

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BUSINESS INFORMATION

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Business Name:
 *
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DBA (if applicable:)
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Business Telephone:
 *
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Business e-mail:
 *
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Which is your preferred contact?
Which is your preferred contact?
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Business Address:
 *
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Business Mailing Address:
 *
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City of Santa Maria Business License #:
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State of California Board of Equalization Tobacco License #:
 *
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If the preceding question is not applicable, explain why a conditional use permit is not required:

OWNERSHIP INFORMATION

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Ownership Type:
 *
Ownership Type:
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Primary Owner(s):
 *
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Address:
 *
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Telephone:
 *
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Has any owner or agent of the owner violated the City's Tobacco Retailer regulations contained in Title 6, Chapter 13, within the previous five years?

Has any owner or agent of the owner violated the City's Tobacco Retailer regulations contained in Title 6, Chapter 13, within the previous five years?
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If the answer is Yes, list the dates and locations of all violations:

ACKNOWLEDGEMENT:

I have read and understand all requirements of the Santa Maria Municipal Code Chapter 13 of Title 6 (Sections 6-13.01 to 6-13.16). I certify that I will sell tobacco products in accordance with all applicable Federal, State, and local laws and regulations. I further certify that no drug paraphernalia is or will be sold or offered for sale at the business location.

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Signature of owner(s):
 *
Signature of owner(s):
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Have you read the Frequently Asked Questions about Tobacco Retail License Application and Municipal Code Chapter 6, Title 13? (top of this form)

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Date:
 *
To Be Completed by the Santa Maria Police Department

Collected Annual Tobacco Retailer License Fee: $____________

License Application Reviewer (Name & ID):______________________________________

__ Approved

__ Denied; Reason(s): ______________________________________________________

Business Notified Date: _____________________________________________________

Tobacco Retailer License Issued by (Name & Date): ______________________________

 

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