Fillable APPLICATION FOR SMOKING EXEMPTION (Government of the District of Columbia)

Fill Online, Printable, Fillable, Blank APPLICATION FOR SMOKING EXEMPTION (Government of the District of Columbia) Form

Use Fill to complete blank online GOVERNMENT OF THE DISTRICT OF COLUMBIA (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

APPLICATION FOR SMOKING EXEMPTION (Government of the District of Columbia)

On average this form takes 12 minutes to complete

The APPLICATION FOR SMOKING EXEMPTION (Government of the District of Columbia) form is 6 pages long and contains:

  • 2 signatures
  • 11 check-boxes
  • 35 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Government of the District of Columbia

BROWSE GOVERNMENT OF THE DISTRICT OF COLUMBIA (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
APPLICATION FOR SMOKING EXEMPTION
1
This form is to be used to apply for the smoking exemption from the Department of Health Functions
Clarification Amendment Act of 2006 (D.C. Official Code § 7-741.01 et seq.) and the exemptions
requirements provided in 20 DCMR § 2105. Return this form only if you believe your establishment
qualifies for a smoking exemption and you intend to permit smoking in your establishment. The following
guidelines and checklist are being provided for you to review and help ensure you have submitted the
application successfully.
Application Guidelines and Checklist
The Department of Health Functions Clarification Amendment Act of 2006 offers an exemption from the
smoking ban for some establishments that operate in the District of Columbia. In order to be considered for
an exemption the Department of Health Functions Clarification Amendment Act of 2006 regulations clarify
that exemptions are not automatic and must be supported by appropriate documentation and reviewed by the
Department of Health (D.C. Law 16-90; D.C. Official Code § 7-741.05). An establishment may apply for an
exemption by completing the application which includes the following items:
Completed DC Health Application for Smoking Exemption
o Establishment owner signature
o Notarized Declaration Form
o Acknowledgement by Certified Public Accountant
Tobacco sales revenue as a percentage of your gross revenue. (Tobacco is taxed at a different rate than
other products, therefore revenue for on-site tobacco sales cannot be bundled with revenue for any other
products in your reporting).
o Submission of a summary Excel/Quickbooks sheet to document this information is
recommended.
Signed IRS tax returns for the previous two years
Current certificate of occupancy, cigarette retail or wholesale license, and business licenses.
o Please ensure you submit licenses that account for the previous two years.
Letter verifying that you have not allowed smoking in your establishment in compliance with the law.
Applicants may contact the Department of Health’s Tobacco Control Program at 202-442-5433 or
tobaccocontrol@dc.gov for assistance during the application process. Upon completion of the application please
submit this form to the Department of Health either through mail, fax, or e-mail:
Mail: Smoking Exemption Application Form
Department of Health – Tobacco Control Program
899 N. Capitol Street, NE, 3
rd
Floor, DC 20002
Fax: 202-442-4825
Email: Tobaccocontrol@dc.gov
Updated 11/5/18
APPLICATION FOR SMOKING EXEMPTION
2
Affidavit of Business Operator
Ownership Information (as shown on the District’s Basic Business License application). Submit a
complete and legible copy of the applicable business license with this form.
1.
Type of Business License
2. Business Name
3.
Business Establishment Street Address
City State Zip Code
4. Mailing Address of Business (if different than Question #3)
5. Business Establishment Phone Number 6. Business Establishment Fax Number
7. Business Establishment Email
8. Business License Number 9. Cigarette License Number
10. Name of Primary Owner(s) as Listed on the Business License
11. Street Address of Primary Business Operator
City State Zip Code
Updated 11/5/18
Retailer Wholesaler
APPLICATION FOR SMOKING EXEMPTION
3
12. Mailing Address of Primary Business Operator (if different from address provided in Question #9)
City State Zip Code
13. Telephone Number of Business Operator 14. Email of Primary Business Operator
15. Registered Agent’s Name (Secondary Contact) 16. Telephone Number of Registered Agent (Secondary Contact)
17. Email of Registered Agent (Secondary Contact)
Updated 11/5/18
APPLICATION FOR SMOKING EXEMPTION
4
Declaration Form
ATTENTION: The declaration must be consistent with the establishment’s existing business license.
Lack of consistency may jeopardize the establishment’s license(s).
I hereby declare that I am eligible for an exemption in D.C. Law 16-90; D.C. Official Code § 7-741.01,
which prohibits smoking in places of employment and public places, because one of the following applies:
I own or operate a tobacco bar.
1. I am licensed as a restaurant, tavern, brew pub, club, or nightclub.
2. My business generates 10% or more of its total annual revenue from the on-site sale of tobacco
products, excluding sales from vending machines, or the rental of on-site humidors.
I am opening a new establishment and smoking has never been permitted within my business.
I own or operate a retail store that does not share space with any other establishment and is used
primarily for the sale of tobacco products and accessories in which the total annual revenue generated
by the sale of non-tobacco products or accessories is no greater than 25% of the total revenue of the
establishment.
I hereby authorize the Department of Health to access my financial records to determine whether I qualify
for an exemption under D.C. Law 16-90; D.C. Official Code § 7-741.03 and to perform annual audits to
determine my continued eligibility for exemption.
I attach hereto true copies of the certificates of occupancy for the premises at which the
proposed exempt establishment is located as of to the date of this application.
I acknowledge that the information contained in this application is subject to reporting to and
auditing by the Department of Health.
Check one:
The proposed exempt establishment is a freestanding establishment that is not located in
whole or in part within another establishment at which smoking is prohibited pursuant in
D.C. Law 16-90; D.C. Official Code § 7-1703.
The proposed exempt establishment is located within another establishment at which
smoking is prohibited pursuant in D.C. Law 16-90; D.C. Official Code § 7-1703.
Updated 11/5/18
APPLICATION FOR SMOKING EXEMPTION
5
I hereby swear or affirm under penalty of perjury that each of the foregoing statements is true to the best of my
knowledge.
Applicant’s Name
Applicant’s Signature
Subscribed and sworn to before me this day of 20
Notary Public
My Commission expires:
Updated 11/5/18
click to sign
signature
click to edit
APPLICATION FOR SMOKING EXEMPTION
6
Acknowledgement by Certified Public Accountant
18. Business Name of Proposed Exempt Establishment
I am a Licensed Certified Public Accountant
I am aware that the information contained in this application is subject to reporting and auditing by the
District of Columbia Department of Health.
19. Name of Certified Public Accountant 20. CPA License Number
21. CPA Phone Number 22. CPA Email
23. Signature
_____________________________________________________________________________________
For office use only:
Application received: _________ Application reviewed on: ________ Staff: ________
Updated 11/5/18
click to sign
signature
click to edit
APPLICATION FOR SMOKING EXEMPTION
7
Application Review Process
Upon receiving an application, the following steps will be taken by the Department of Health to conduct the
review:
The Department of Health Tobacco Control Program will send a confirmation receipt.
The application will undergo an initial review for completeness.
If an application is deemed incomplete, the Department of Health Tobacco Control Program will
contact the applicant to request any missing information.
Once the application is complete the program will review the application and issue a recommendation
for approval or disapproval of the application to the Director of the Department of Health.
The Director of the Department of Health will make a final determination. (All applications meeting
statutory requirements will be approved).
If approved, a certificate of exemption is mailed to the establishment. If denied, a letter of denial is
mailed to the establishment.
The list of establishments with approved exemptions will be updated regularly on the Smokefree
Workplaces website page (https://doh.dc.gov/node/122542).
Updated 11/5/18
APPLICATION FOR SMOKING EXEMPTION
8
Definitions
The following are definitions of words and terms used in D.C. Law 16-90; D.C. Official Code § 7-741.01 et
seq.
"Smoking" or "to smoke" means the inhaling, exhaling, burning, or carrying of a lighted or heated cigar,
cigarette, pipe, electronic smoking device, or any other tobacco or plant product intended for human
consumption through inhalation, in any manner or in any form.
"Tobacco product" means any product made from or containing any percentage of the dried processed leaves
of the plant genus nicotiana or any byproduct thereof used primarily for the purpose of smoking.
“Public place” means an enclosed area to which the public is invited or in which the public is permitted,
including banks, educational facilities, health care facilities, laundromats, public transportation facilities,
reception areas, restaurants, retail food production and marketing establishments, nightclubs, retail service
establishments, retail stores, shopping malls, sports arenas, taverns, theaters, and waiting rooms. This term does
not apply to a private residence unless it is used as a child development center, adult day care facility, or health
care facility.
“Place of employment” means an enclosed area under the control of a public or private employer that
employees normally frequent during the course of employment, including work areas, employee lounges,
restrooms, conference rooms, classrooms, employee cafeterias, hallways, and vehicles owned by a private
employer, if the vehicle is used by more than one person, and excludes a private residence, unless it is used as a
child care, adult day care, or health care facility.
“Tobacco Bar” means a restaurant, tavern, brew pub, club, or nightclub that generates 10% or more of its total
annual revenue from the on-site sale of tobacco products, excluding sales from vending machines, or the rental
of on-site humidors.
Updated 11/5/18
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

APPLICATION FOR SMOKING EXEMPTION (Government of the District of Columbia)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document