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Business License 38250 Sierra Highway Palmdale, CA 93550 661/247-8384 661/267-5434 [EMAIL REDACTED] [EMAIL REDACTED] Page 1 of 3 Tobacco/Smoking Product Retailer Business Permit Application REV. 10/11/22 TOBACCO/SMOKING PRODUCT RETAILER BUSINESS PERMIT APPLICATION No permit shall be issued to authorize tobacco/smoking product retailing at any place other than a fixed location. Tobacco/Smoking Product Retailing from vehicles or on foot is prohibited (PMC Section 5.04.670.B.2) Conditions of Approval: 1. All permittees, agents and employees are required to comply with all federal, state and local laws and regulations with regards to tobacco or smoking products, tobacco/smoking paraphernalia or tobacco/smoking product retailing. 2. No drug paraphernalia may be sold at the business seeking the permit. 3. No transaction involving tobacco or smoking products shall be undertaken with any person who appears under the age of 27 without first examining their identification to confirm that the recipient is over the minimum age required under State law. 4. No retailer shall permit any person under the age of 18 years to engage or participate in the sale of tobacco or smoking products or paraphernalia. 5. Self-service display, such as vending machines, of tobacco or smoking products is prohibited. Any tobacco/smoking products retailer who violates any federal, state or local law regulating the sale, advertisement or display of tobacco products and/or paraphernalia shall be subject to the penalties as outlined within Section 5.04.670(H) of the Palmdale Municipal Code. ---PAGE BREAK--- Business License 38250 Sierra Highway Palmdale, CA 93550 661/267-5434 Fax 661/267-5233 [EMAIL REDACTED] Page 2 of 3 Tobacco/Smoking Product Retailer Business Permit Application REV. 10/11/22 TOBACCO/SMOKING PRODUCT RETAILER BUSINESS PERMIT APPLICATION Application is for (check one): New Permit Annual Renewal Reissuing a Revoked Permit Business Name: Business Address: Telephone Number and Email: Business Mailing Address (if different): Full description of business activity: Seller’s Permit Tobacco Retailers License No.: OWNER INFORMATION Individual/Sole Proprietorship Partnership Corporation Applicant Name: (If a Corporation, the name shall be as set forth in its Articles of Incorporation) Applicant’s Address: Telephone Number: Driver’s License No.: Date of Birth: Partnership – provide Names and Addresses of each general partner. Corporations (if not publicly traded) - provide names and addresses of all directors, each executive officer, stockholders holding 10% or more of shares, and an officer who is duly authorized to accept service of process. Name: Address: Name: Address: Name: Address: ---PAGE BREAK--- Business License 38250 Sierra Highway Palmdale, CA 93550 661/267-5434 Fax 661/267-5233 [EMAIL REDACTED] Page 3 of 3 Tobacco/Smoking Product Retailer Business Permit Application REV. 10/11/22 Within the past five years, have any of the individuals identified above been convicted in criminal proceedings or subject to pending criminal proceedings? Yes No If yes, the applicant may attach documentation explaining any mitigating circumstances. Emergency Contact No. 1: Address: Telephone Number: Emergency Contact No. 2: Address: Telephone Number: OFFICE USE ONLY Recommend ( ) Not Recommended ( ) Los Angeles County Sheriff’s Department: Signature Date Planning Manager: Signature Date I have read and agree to abide by the conditions of conducting retail Tobacco/Smoking Products sales within the City of Palmdale. I agree that no Drug Paraphernalia is or will be sold at the business seeking this permit. I declare under penalty of perjury that this application is true and correct to the best of my knowledge and belief. Signature Title Date