Staff stamps date here when form is filed
TOBACCO RETAILER’S PERMIT APPLICATION
as required under Red Bluff Municipal Code (RBMC), ARTICLE XXVII Community Development Department
555 Washington Street, Red Bluff, CA 96080
www.cityofredbluff.org Phone 530-527-2605
Application Date: ____________ (Each Tobacco Retailer location requires a separate permit.) Application Type (check one): New License Renewal Change of Ownership Business Information.
Business Name:
Business Type: Individual Sole Proprietor Corporation Partnership LLC Other Business Address: Date established at this location:
Business Phone:
Existing License/Permit Information. Please provide copies of all licenses and permits listed below.
Business License #________________ Red Bluff Tobacco Retail License #______________ California Cigarette & Tobacco Products Retailer License # _______________ CUP # (if applicable)_________________ Proprietor Information. (All Proprietors must be listed.) Attach additional pages as necessary. License and future correspondence will be mailed to the mailing address listed below. #1 Proprietor Name: Phone #: Email:
Mailing Address:
Date of Birth: DL / ID #: Expiration:
#2 Proprietor Name: Phone #: Email:
Mailing Address:
Date of Birth: DL / ID #: Expiration:
Within five years from the date of this application, has the applicant, proprietor, or any other employee of the business, been found to have violated any federal, state, or local laws or regulations applicable to tobacco products or tobacco retailing? _________________________________________________________ Pursuant to City of Red Bluff Tobacco Retail Permit Ordinance No. 1096 (Red Bluff Municipal Code (RBMC) Chapter 25, ARTICLE XXVIII, a Red Bluff Tobacco Retailer Permit is required for the sale of tobacco products. Permittees are required to comply with all local, state, and federal laws in the operation of their business. By signing this application, each Proprietor: 1) Acknowledges that he or she has been informed of RBMC Chapter 25, ARTICLE XXVIII, which includes the performance standards and regulations applicable to tobacco retailers; and 2) Authorizes City Code Enforcement Officers to enter the business premises for the purpose of investigation, provided they do so in a reasonable manner, whenever necessary to the investigation of violations of the Ordinance.
Your signature below represents your agreement to comply with the Tobacco Retailer Permitting application requirements per the Ordinance.
I hereby apply for a Tobacco Retailer Permit with the appropriate fees attached to operate at the above-listed address in the City of Red Bluff. I also hereby declare under penalty of perjury the information on this application and any attachments submitted herewith are true and correct. #1 Proprietor (Printed) #1 Proprietor (Signature) Date
#2 Proprietor (Printed) #2 Proprietor (Signature) Date
FOR OFFICE USE ONLY
Date Received: Processed By: Existing licenses/Permits Submitted: CATPRL ____ UsePermit ____ Bus. License ____ APN: Zoning: GP/SP: Misc:
TRL: Amount Due: $ Amount Paid: $ Payment Method
Used: Credit __ Cashier’s/Check # ____ MO # ____