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/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

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LBdvITLHbtuPqCe9zKS7u

Tobacco Retail License Application

Please complete the Tobacco Retail License Application below.

Background: In November 2022, the City of Lawrence Commission unanimously adopted a policy which codifies a tobacco retail licensing program. Consistent with other public health regulations and licensing, the policy endows Lawrence-Douglas County Public Health with the authority to manage the Tobacco Retail Licensing Program and administer related compliance checks. Your business is listed in the State of Kansas database for tobacco retailers, and we are reaching out to make you aware of the planned process for implementation of the Tobacco Retail Licensing Program. This policy takes effect on January 1^st. Please visit www.ldchealth.org/tobaccoretail for a set of comprehensive information related to the Tobacco Retail Licensing Program. The application needs to be accompanied by a payment for the license fee, which is $260. The license fee can be paid online (https://ldchealth.org/312/Pay-Fees-Online) or by mailing payment to: LDCPH c/o Tobacco Retail Licensing, 200 Maine Ste. B, Lawrence, KS 66044. During the first year of operation (2023), applications and license payments need to be submitted no later than January 31, 2023. Businesses operating without a license are subject to penalties

We look forward to working with your business to ensure timely licensure and ongoing compliance. If you have any questions or need assistance navigating the application process, please email us at tobaccoretail@ldchealth.org.

Thank you!

1. Type of License:

* must provide value

New

Renewal

Change of Ownership

reset

A. Store name:

* must provide value

B. Location address (Street address|City|State|Zipcode):

* must provide value

C. Contact person's (e.g., manager) name:

* must provide value

D. Business Telephone (if not applicable, please put N/A):

* must provide value

E. Email (if not applicable, please put N/A):

* must provide value

F. Website (if not applicable, please put N/A):

* must provide value

A. Individual owner name or Corporation LLC, Partnership Name:

* must provide value

B. Mailing address: (Street address|City|State|Zipcode)

* must provide value

C. Owner contact person's name:

* must provide value

D. Address of corporate registered agent:

* must provide value

E. Owner phone:

* must provide value

F. Email:

* must provide value

G. State sales tax number (if not applicable, please put N/A):

* must provide value

A. Address name:

* must provide value

B. Mailing address (Street address|City|State|Zipcode):

* must provide value

C. Email (if not applicable, please put N/A):

* must provide value

Fill-in the Store Hours below. Write/type "All" if the establishment is open 24 hours; "Closed" on days the establishment is not open, or hours (example “8 AM - 8 PM”).

Sunday:

* must provide value

Monday:

* must provide value

Tuesday:

* must provide value

Wednesday:

* must provide value

Thursday:

* must provide value

Friday:

* must provide value

Saturday:

* must provide value

Check all that apply of the following categories that best describe establishment type. (Must check at least one.)

* must provide value

Cigar bar/ shop

Convenience Store

Country/ General Store or Gift Shop

Electronic Smoking Devices/Electronic Liquid/Components

Veterans, or Private Club

Gas Station

Golf club/course or Pro Shop

Grocery Store/Supermarket

Head Shop/Glass

Pharmacy

Redemption Center

Restaurant

Bar

Tobacco Shop

Vending Machine

Other (please explain below)

6a. If vending machines was selected, please record how many vending machines are part of the business.

* must provide value

6b. If other was selected, please explain the category that best describes your establishment type?

* must provide value

Check all that apply for categories which describe products sold at your establishment. (Must check at least one.)

* must provide value

Chewing tobacco

Cigarettes

Cigars/ Cigar wraps

Electronic smoking devices/ E-liquid/ Components/ Vaping Products

Pipe Tobacco/ glass pipes

Rolling Papers

Snuff/ Snus

Other (Please specify)

7a. If other was selected, please specify tobacco products sold at your establishment?

* must provide value

I, [insert name] , the named applicant, do solemnly swear that I have read the contents of this application and that all information and answers herein contained are complete and true. In addition, I have read and understand all rules and regulations as set out in the Code of the City of Lawrence. Furthermore, I hereby agree to comply with all of the laws of the State of Kansas, and all rules and regulations prescribed by the City of Lawrence.

* must provide value

Signature

* must provide value

Add signature

Printed Name

* must provide value

Date

* must provide value

D-M-Y

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