Fillable APPLICATION FOR CIGARETTE LICENSE (The Tulalip Tribes)

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APPLICATION FOR CIGARETTE LICENSE (The Tulalip Tribes)

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  • 28 check-boxes
  • 106 other fields

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LIC NUMBER
OFFICIAL USE ONLY
BUS LIC NUMBER APPLICABLE YEAR
CHECK / MONEY ORDER # RECEIPT NUMBER
APPLICATION FOR CIGARETTE LICENSE
Please type or print in dark ink
BLANKSPACESARENOTPERMITTED.IFANYITEMISNOTAPPLICABLE,ORNOINFORMATIONIS
AVAILABLE,THESPACEMUSTBEMARKEDTOINDICATETHAT.INCOMPLETEAND/ORILLEGIBLE
APPLICATIONSWILLBERETURNEDTOAPPLICANT.
The Tulalip Tribes of Washington
Communit Dev Development Depa
rtment
TAX X & LIC LICENSING DIVISION
6406 Marine DR NW
Tulalip,Tulalip, WA 98271 WA 98271
Telephone: (360) 60) 716-4204
PAYMENT SUMMARY - Applications received without payment in full will not be accepted. PAYMENT SUMMARY - Applications received without payment in full will not be accepted.
FEE(s) FEE(s)
Cigarette License - NEW
$ 50.00
Cigarette License - Renewal
$ .00
Penalties / Other
$ .00
Enclose payment for total amount due, including application and applicable
penalty fees. Accepted forms of payment are cash, check, and money order
made payable to The Tulalip Tribes / TLD. License fees are not pro-rated
and are nonrefundable
.
Please choose:
NEW NEW OWNERSHIP RENEWAL
NAME / ADDRESS CHANGE PENALTIES: _______________
TOTAL APPLICABLE FEES PAID $
BUSINESS INFORMATION – GENERAL
SOLE PROPRIETOR INDIVIDUAL - No employees LIMITED LIABILITY PARTNERSHIP
PARTNERSHIP LIMITED LIABILITY COMPANY DOMESTIC CORPORATION
FOREIGN CORPORATION RETAIL WHOLESALE MANUFACTURER
ORGANIZATION
STATUS / TYPE
Corporations & Partnerships:
Attach sheet identifying all owners,
partners, managers, members,
and officers.
Firm / Trade Name
Web
site:
www.
Business Address (Tulalip Location OR Primary Physical Location)
City State Zip County
Business Telephone Number
(
)
-
Alt or Toll Free Number
(
)
-
FAX Number
(
)
-
Business Mailing Address (If Different From Above)
City State Zip County
Date business first conducted
(opened) under current ownership at
this WA location:
/ /
Does business maintain an office or
store located within the exterior
boundaries of the Tulalip
Reservation?
YES NO
If Yes, state zoning designation:
Business Telephone Number
(
)
-
Alt or Toll Free Number
(
)
-
FAX Number
(
)
-
Agent or Contact Name Title Is Contact located at physical location of business to
apply requesting license?
YES NO
Office Mailing Address (Street or Route, P.O. Box, City, State, Zip)
REGISTERED AGENT /
LICENSE CONTACT
Licensing documents and rel ated
correspondence wi ll be dir ected to
person listed
Telephone Number
(
)
-
Fax Number
(
)
-
Email Address
Describe in detail the nature of business, principle products sold, and services provided on the Tulalip Reservation. Indicate if sales are retail or wholesale and if products are manufactured on the
reservation:
Estimated Gross Annual Income for TOBACCO sales on the Tulalip Indian
Reservation for current year:
$
Is this an Indian Owned Business?
YES NO If Yes; Percentage Indian Owned: %
Tribal Enrollment # Name of Federally Recognized Tribe: ATTACH PROOF
A
B
RECOMMENDATION: FOR OFFICIAL USE ONLY
[ ] APPROVE [ ] APPROVE WITH CONDITIONS:
Conditions:
[ ] DENY
Cause for Denial:
Cigarett License App revised 03/2013 (ah)
1 of 3
AUTHORIZATION - REGISTRATIONS - OTHER
Do you m tai a WA State Cigarette OR Tobacco Retailer license? ain n
YES NO If Yes, attach copy of license or endorsement
WA State Unified Business Identification
Number (WA UBI #)
Reseller’s Permit Number
Federal Employer I.D. Number (FEIN)
North American Industry Classification
System Number (NAICS)
State(s) or Tribe of Incorporation or Formation
Number of Corporate Officers, Members, or Partners:
CREDENTIALS
AND AFFILIATE(S
)
It is a violation of for a
licensee, their agents, and
employees, to violate any
local, state, or federal law
applicable to Tobacco
Products. Licensee is
responsible for obtaining all
required certifications.
Is business affiliated with any other business(es), including subsidiaries?
YES NO If yes, please explain affiliation (business relationship) and
list active and inactive licenses below – attach additional sheets if necessary:
DBA / Other Trade Name
Is this trade name registered with the state of WA? YES NO
If No, list state(s) / Tribes in which trade name is registered:
Is trade Name to appear on license? YES NO
If Yes; ONLY DBA Name or In Addition to Firm Name
DBA / Other Trade Name
REGISTERED
TRADE NAMES
(‘DBA’s’)
DBA’s must be registered
with the WA Secretary of
State or equivalent. DO NOT
complete this section if dba is
not a registered trade name.
Is this trade name registered with the state of WA?
YES NO
If No, list state(s) / Tribes in which trade name is registered:
Is trade Name to appear on license? YES NO
If Yes; ONLY DBA Name or In Addition to Firm Name
AUTHORIZATION - REGISTRATIONS - TRIBAL
TULALIP TRIBAL EMPLOYMENT RIGHTS ORGANIZATION
Does business have a Tulalip TERO Compliance Contract? YES NO If No, do intend to enter into a Tulalip TERO Compliance Contract?
YES NO Is Business listed on the Tulalip TERO Native Owned Business Registry? YES NO
TRIBAL
CREDENTIALS
AND AFFILIATE(S)
QUIL CEDA VILLAGE & TRIBAL GAMING
Does this business possess a current vendor’s license issued by the Tulalip Tribal Gaming and/or Special Operators License issued by the Quil Ceda Village
Administration?
YES NO If Yes, Gaming (Vendor) License # and/or attach a copy of Quil Ceda Village Special Operators
ALCOHOL / LIQUOR (Title 10.35)
Do your business operations include manufacturing, distribution, and/or sale of alcohol
/ liquor products?
YES NO If yes, attach copies of document(s)
FOOD AND BEVERAGE (Title 11.20)
Does your business prepare food and/or beverage goods for customer consumption?
YES NO If yes, complete addendum FP1 and attach required documents
List all ACTIVE Tulalip licenses held by business, including licenses held by business partners, managers, members, and/or affiliates. Indicate business name, license number, business type,
and owner(s):
BUSINESS NAME LIC # BUSINESS TYPE OWNER(S):
_______________________________ __________ _______________________________ __________________________________________
_______________________________ __________ _______________________________ __________________________________________
_______________________________ __________ _______________________________ __________________________________________
List all INACTIVE Tulalip licenses held by business, including any licenses previously held by business partners, managers, members, and/or affiliates. Indicate business name, license number,
start/end year, and purpose of dissolution:
BUSINESS NAME LIC # YEARS LIC ACTIVE PURPOSE OF DISSOLUTION:
_______________________________ __________ ________ to ________ __________________________________________________
_______________________________ __________ ________ to ________ __________________________________________________
_______________________________ __________ ________ to ________ __________________________________________________
TULALIP TRIBAL GOVERNMENT
TERO COMPLIANCE PLAN TERO (360) 716-4747
Tulalip TERO Titles 9 #09.05 and 2UGLQDQFH# 89:
TERO is the Equal Employment Opportunity Commission Representative (EEOC) on the Tulalip
reservation. Tulalip TERO laws and ordinances enforce specific r
equirements upon businesses, contractors, and subcontractors doing business within the exterior
boundaries of the Tulalip Reservation including regulating their employme
nt practices and obligating them to provide preference in recruiting, hiring, training and
promotions to certified Native Americans
.
QUIL CEDA VILLAGE / TRIBAL GAMING AGENCY
QCV:
Businesses and vendors operating within the boundaries of the Consolidated Borough of Quil Ceda Village (QCV) are required to enter into a lease agreement
and/or obtain a special operators license. For more information, contact the QCV Business Park at 360.716.5000.
TGA: Vendors providing services at or for any of the Tulalip Casino or Bingo entities are required to obtain a vendors license issued by the Tribal Gaming Agency
(TGA). For more information, contact the Tulalip TGO Office at 360.716.2000.
FOOD & BEVERAGE, LIQUOR, TRANSIENT ACCOMMODATIONS, AND FIREWORKS LICENSE REQUIREMENTS
Tulalip Tribes Liquor License Title 10 #10.35 and Tulalip Liquor Regulations:
LIQUOR LICENSE(S) REQUIRED
Tulalip Fireworks Code: Amended Title 10 #10.25:
WHOLESALE AND RETAIL LICENSE(S) REQUIRED - Sale of retail fireworks in Tulalip is
restricted to enrolled members of the Tulalip Tribes of WA; sale of wholesale fireworks is unrestricted.
Tulalip Tribes Food Service Sanitation Title 11 #11.20: PERMIT REQUIRED - Food and beverage related businesses show proof of Tribal and/or State
health inspection certificate, food permit, and/or food handler card.
INSPECTIONS: CONTACT MIKE COONEY AT 360.716.5129
D
E
C
Cigarette License App Revised 03/2013 (ah)
2 of 3
INDIAN TRADERS LICENSE
For information pertaining to Indian Trader’s Licenses, please visit/ contact the Bureau of Indian Affairs, Puget Sound Agency at:
2707 Colby Avenue, Suite #1101, Everett, WA 98201 - (425) 258-2651
SUPPLEMENTARY DOCUMENT REQUIREMENTS
The Tax & Licensing Division may require proof of insurance, tribal enrollment, certification, permits, contracts, other licensure (local, county, state, and federal),
vehicle registration, criminal background investigation, and additional information and/or documentation as defined in Tulalip Business License Title 10 #10.10
INCOMPLETE AND ILLEGIBLE FORMS WILL NOT BE ACCEPTED / PROCESSED
Incomplete and/or illegible applications and/or failure to remit fee or required supplemental documents are not accepted and may result in penalty fees.
SIGNATURE REQUIRED (Sole proprietor, partner(s), corporate officer(s), limited liability manager(s), or member(s))
Your signature attests to the accuracy of the information provided and that your business will comply with all applicable Tribal and Local Laws
BY SIGNING BELOW, I UNDERSTAND AND AGREE TO THE FOLLOWING:
I DECLARE THAT I HAVE EXAMINED THIS APPLICATION AND THE INFORMATION CONTAINED HEREIN, AND TO THE BEST OF MY
KNOWLEDGE AND BELIEF, IT IS TRUE AND CORRECT. I SWEAR OR AFFIRM THAT I WILL COMPLY WITH ALL TRIBAL LAWS APPLICABLE TO
MY BUSINESS AND CONSENT TO THE JURISDICTION OF THE TRIBAL COURT OF THE TULALIP TRIBES AND SERVICE OF PROCESS IN
MATTERS ARISING FROM THE CONDUCT OF BUSINESS.
Signature
X
Printed Nam
e
Titl
e
Date
Signature
X
Printed Nam
e
Titl
e
Date
Application prepared by (Indicate if prepared by other than authorized owner, officer, manager, or member) Telephone Number
( ) -
Signature of Preparer
X
Title Date
F
Cigarette License App revised 03/2013 (ah)
3 of 3
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APPLICATION FOR CIGARETTE LICENSE (The Tulalip Tribes)

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Completed 20 July 2020

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