Fillable City-of-lb-tobacco-retail-permit-application-fill City of Long Beach Tobacco Permit Application

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City-of-lb-tobacco-retail-permit-application-fill City of Long Beach Tobacco Permit Application

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The City-of-lb-tobacco-retail-permit-application-fill City of Long Beach Tobacco Permit Application form is 1 page long and contains:

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  • 10 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Long Beach California

BROWSE CITY OF LONG BEACH CALIFORNIA (CA) FORMS

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City of Long Beach Department of Health and Human Services
Tobacco Retail Enforcement Program
2525 Grand Avenue Room 220, Long Beach, CA 90815
Phone: (562) 570-7905 Fax: (562) 570-4038
APPLICATION
TOBACCO RETAIL PERMIT
LONG BEACH MUNICIPAL CODE 5.81
This Application is for:
New Permit Change of Ownership
(Check box)
Change of Business Name Change of Location
Name of Business (DBA): ________________________________________________________________________
(Please print)
Type of Ownership: Individual Corporation Partnership Other________
(Check box)
Name of Owner(s): ______________________________________ ______________________________________
(Please print) (Please print)
Business Address: ______________________________________________________________________________
(Please print)
Mailing Address:____________________________________City:__________________State:____Zip:__________
(Please print) (Please print)
Phone: (_____)_________________ Fax: (_____)_________________ Email: _______________________________
City of Long Beach Business License #: _____________________________________________________________
CA State Board of Equalization Cigarette & Tobacco License#: __________________________________________
This application must be completed, signed and returned to the address above by mail or fax, even if you do not require a permit.
Please check the appropriate box:
I am a tobacco retailer and hereby apply for a City of Long Beach Tobacco Retail Permit.
I am not a tobacco retailer and do not sell any tobacco products, or tobacco paraphernalia.
I declare under penalty of perjury under the laws of the State of California that the foregoing statement is true and correct.
Name: ________________________________________ Signature: ________________________________________
(Please print) (Authorized Person)
Title: ____________________________________________ Date: __________________________________________
(Please Print)
By signing this application, you agree that you will not violate any federal, state, or city laws relating to youth and tobacco products/paraphernalia.
DO NOT WRITE BELOW THIS LINE
(Office Use Only)
Approved ______________ Denied ___________ Date: ____________________ HY Account #: ___ ___ ___ ___ ___ ___ ___ ___
Comments:
Rev. 2/10
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City-of-lb-tobacco-retail-permit-application-fill City of Long Beach Tobacco Permit Application

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Completed 13 July 2020

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