Tobacco Retailer Application Form

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

1

Frequently Asked Questions about the Tobacco Retailer License Application

Municipal Code Title 6, Chapter 13: Tobacco Retailers

2

 

New Application

Renewal

BUSINESS INFORMATION

3

Business Name:

 *

Business Name:

4

DBA (if applicable:)

DBA (if applicable:)

5

Business Telephone:

 *

Business Telephone:ext.

6

Business e-mail:

 *

Business e-mail:

7

Which is your preferred contact?

Which is your preferred contact?

Business Telephone

Business e-mail

8

Business Address:

 *

Business Address:

9

Business Mailing Address:

 *

Business Mailing Address:

10

City of Santa Maria Business License #:

City of Santa Maria Business License #:

11

State of California Board of Equalization Tobacco License #:

 *

State of California Board of Equalization Tobacco License #:

12

If the preceding question is not applicable, explain why a conditional use permit is not required:

If the preceding question is not applicable, explain why a conditional use permit is not required:

OWNERSHIP INFORMATION

13

Ownership Type:

 *

Ownership Type:

Sole Proprietorship

Partnership

Corporation

LLC

14

Primary Owner(s):

 *

Primary Owner(s):

15

Address:

 *

Address:

16

Telephone:

 *

Telephone:ext.

17

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?

No

Yes

18

If the answer is Yes, list the dates and locations of all violations:

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.

19

Signature of owner(s):

 *

Signature of owner(s):

Signature of owner(s):

Signature of owner(s):

Signature of owner(s):

Signature of owner(s):

Signature of owner(s):

20

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

Yes

21

Date:

 *

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): ______________________________

 

PD 300

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