2. Is the Tobacco Retail establishment also registered as Deemed Approved with the City (i.e. is this establishment also permitted or conditionally permitted for alcohol sales)?*

   1. Yes

   1. No
4. The business is eligible for a Combination License, which allows for a discounted license fee and the scheduling of both tobacco and alcohol businesss inspections concurrently. Applicant should proceed to complete this application. Once submitted, a City technician will invoice the applicable fees. Once the fees are paid, the technician will schedule an inspection date. *

   1. I understand and acknowlege my eligibility for a Combination License.
6. Business Information
8. Business Name*
10. Street Address*

    Business Address

11. City*
12. State*
13. Zip code*
15. California Dept. of Tax & Fee Administration (CDFTA) Number*

    Tobacco Permit License Number

16. Expiration Date*
17. Number of Employees*
19. Upload Tobacco Retail Permit
21. Mailing Address*

    Business Mailing Address

22. City*
23. State*
24. Zip*
26. Person to Contact Regarding Inspection Scheduling and Business Compliance
28. Contact Name*
29. Contact Phone*
30. Contact Email*
34. Ownership/Proprietor Information

    Definition of Proprietor: A person with an ownership or interest in a business. An ownership interest shall be deemed to exist when a person has a 10% or greater interest in the stock, assets, or income of a business other than the sole interest of security for debt.

36. Type of Ownership:*

    1. Sole proprietorship
    2. LLC
    3. Corporation
    4. Partnership
37. Partnership, Corporation, or LLCs must submit a separate page with proprietors who have 10% ownership interest in the business.*

    Please convert to PDF before submitting

39. Mailing Address*

    Owner Mailing Address

40. City*
41. State*
42. Zip*
44. Phone Number*
45. Email Address*
47. Have any of the business owners or any agent of the business owners admitted violating, or have been found to have violated any local, state, or federal law governing the sale of tobacco products?*

    1. Yes

    1. No
49. *Please provide an explanation with the dates and locations of all such violations within the previous five years:
53. Acknowledgement and Signature

    I declare under penalty of perjury, under the laws of the State of California, that this application is true and correct to the best of my knowledge. I certify that I will sell tobacco products in accordance with all applicable federal, state, and local laws and regulations. I further understand that any false statements made in this application are grounds for denial or revocation of the Tobacco Retail License. I authorize the City to seek verification of the information contained in the application.
    

55. Signature of Owner/Proprietor*
56. Date*
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field