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November 5, 2024 Application for a Tobacco Retail License Cayuga County Health Department http://cayugacounty.us/environmental Section A: Application Information 8 Dill Street, Auburn, NY 13021 (ALL INFORMATION MUST BE COMPLETELY FILLED IN) Fee Due $100 Tobacco Retail Name (must match DTF License) Tobacco Retail Address (must match DTF License) Email Address Retail Shop Telephone Number ( ) Fax Number ( ) Responsible Party/Owner Name DBA (if any) Responsible Party/Owner Address City State Zip Email Address (if different than above) Telephone Number ( ) Fax Number ( ) Section B: Facility Information Facility Type (check all that apply): Convenience Gas Discount Store Grocery/Supermarket Pharmacy Mobile/Stand Restaurant Bar/Lounge Tobacco Business Liquor/Beverage Store Other (specify): Does the facility possess a current NYS Department of Taxation & Finance Retail Dealer Certificate? Yes No ID# Date of Expiration Has the business/owner ever had a Tobacco Retail License issued under this Cayuga County local law revoked? Yes No Does the Applicant have any outstanding fees, fines, penalties, or other charges owed to Cayuga County? Yes No Section C: Signature & Certification FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW. Failure to sign this form may delay issuance of your license. Operation without a valid license is a violation of Cayuga County Local Law 8 for the year 2024. Signature of Responsible Party/Owner Print name of person signing Title Date Section D: FOR OFFICE USE ONLY License Issuance recommended? Yes No License Effective Date License Expiration Date Conditions of Approval Signature Title Date