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HomeMy WebLinkAboutCigarette-Tobacco-Electronic-Vaping-Device-Retail-ApplicationCigarette, Tobacco, and Electronic Vaping Device Retail License Application CTV-100 (R. 3-25)Wisconsin Department of Revenue Form CTV-100 Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietor) 2. Business Trade Name or DBA 3. FEIN 4. Wisconsin Seller’s Permit Number 6. State of Organization 7. Date of Organization 8. Wisconsin DFI Registration Number 9. Premises Address (do not use PO Box) 11. State 14.Governing Municipality: of: 12. Zip Code 15. Aldermanic District 10. City 18. State 19. Zip Code17. City 21. Premises Email 22. Website20. Premises Phone 13. County 16. Mailing Address (if different from premises address) 5.Entity Type (check one) 1. What products will be sold at this business location? (check all that apply) 3. Is the applicant business owned by another business entity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, provide the name(s) and FEIN(s) of the business entity(s) below. Attach additional sheets if necessary 3a. Name of Business Entity: 3b. FEIN of Business Entity: 2. How will cigarettes, tobacco, and/or electronic vaping devices be sold? (check all that apply) 23.Premises Description - Describe the building or buildings where cigarettes, tobacco products, and electronic vaping devices are to be sold and stored. Describe all rooms including living quarters, if used, for the sales and/or storage of cigarettes, tobacco products, and electronic vaping devices and records. Cigarettes, tobacco products, and electronic vaping devices may be sold and stored ONLY on the premises described in this application. Attach a floor plan if possible. Sole Proprietor Cigarettes Over the counter Partnership City Town Village Tobacco Products Vending machine Limited Liability Company Electronic Vaping Devices Corporation Part B: Questions Municipality License Period FOR CLERKS ONLY - 1 - - 2 - Part C: Individual Information List the name, title, and phone number for each person or entity holding the following titles or positions in the applicant business and any businesses listed in Part B, Question 3: sole proprietor: all officers, directors, and agents of a corporation: all partners of a partnership: and all members and agents of a limited liability company. Attach additional sheets if necessary. Include Form CTV-101, Individual Questionnaire, for each person listed below. Last Name PhoneFirst Name Title Part D: Attestation READ CAREFULLY BEFORE SIGNING: I understand and agree to the following: • I will only purchase cigarettes, tobacco, and vapor products from distributors, jobbers, or subjobbers permitted by the Wisconsin Department of Revenue, unless I also hold the proper distributor’s permit and pay all applicable excise taxes. • I will not purchase or exchange products from another retailer, including transferring existing stock to a new owner. • I will provide tobacco sales training that has been approved by the Wisconsin Department of Health Services to my employees. (https://witobaccocheck.org). • I will not sell single cigarettes. • I will not sell, give, or otherwise provide cigarettes, tobacco, or any nicotine products to minors. • I will keep product invoices on the licensed premises for two years and ensure the records are available for inspection by law enforcement. Failure to comply with this will result in criminal penalties, including loss of inventory. • I will not sell cigarettes or roll-your-own (RYO) tobacco products unless listed on the Wisconsin Department of Justice’s directory of certified tobacco manufacturers and brands. Further, under penalty provided by law, I state that this application has been truthfully answered to the best of my knowledge. I agree to operate this business according to law and that the rights and responsibilities conferred by the license(s), if granted, cannot be assigned to another. Any lack of access to any portion of a licensed premises during inspection will be deemed a refusal to allow inspection. Such refusal is a misdemeanor and grounds for revocation of this license. Any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. One of the following must sign and attest to this application: • sole proprietor • one general partner of a partnership • one corporate officer • one managing member of an LLC Signature Date Name (Last, First, M.I.) Title Email Phone Part E: For Clerk Use Only Date application was filed with clerk License numberDate license expiresDate license issued Signature of Clerk/Deputy ClerkLicense fees CTV-100 (R. 3-25) Who needs a cigarette, tobacco, and electronic vaping device retail license? Any individual or entity that wants to sell cigarettes, tobacco products, or electronic vaping devices to consumers over the counter or through a vending machine must obtain a retail cigarette, tobacco, and electronic vaping device license. Who issues cigarette, tobacco, and electronic vaping device retail licenses? Municipal clerks of cities, villages, and towns issue cigarette, tobacco, and electronic vaping device retail licenses. Specific Instructions Part A: Business Information • Box 1: Enter the legal business name. • Box 2: Enter the business trade name or “doing business as” name, if different than the name in box 1. • Box 4: Seller’s permits issued by the Wisconsin Department of Revenue begin with the digits “456.” For questions about obtaining a seller’s permit, see the department’s Seller’s Permit Common Questions. • Box 5: Check one entity type to indicate how the business is legally organized. • Box 14: Check a municipality type and write the name of the governing municipality where the business is located. This may be different from the city listed in the premises address. • Box 20 – 23: All requests for “premises” information are requests for the physical location within the municipality and contact information to reach the business during open hours. • Box 23: Describe the premises in detail. Attach a floor plan if possible. ◦ Example: The premises is located at 1234 Main St., Realtown, WI 12345 and includes only the first-floor sales floor, humidor, north storage room, and south office of the 5,000 square foot building. Part B: Questions 1. Check the box(es) corresponding to each type of product you intend to sell. You may check multiple boxes. 2. Check the box(es) corresponding to the type of retail sale intended. This license does not authorize any online sales. Cigarette vending machine retailers must also obtain a Cigarette Vending Machine Operator by completing Form CT- 129. 3. If you answer yes to this question, provide the Legal Business Name and FEIN of the business entities listed in boxes 3a and 3b. Part C: Individual Information • Provide basic information for all persons involved in the applicant business who are sole proprietors, partners, officers, members, or agents. Example titles: President, Treasurer, Chief Financial Officer, Member, Partner, etc. • If the applicant is owned by another business entity as indicated in Part B, Question 3, include information about the business entity’s officers, members, and agents in the table, including the completion of Form CTV-101. • Include an Individual Questionnaire (Form CTV-101) for each person listed with the submission of this application. Part D: Attestations • Read the attestation carefully, then sign and date. Part E: For Clerks Use Only • “Date license issued” means the date the municipal clerk issued the license certificate document. Form CTV-100 Instructions Cigarette, Tobacco, and Electronic Vaping Device Retail License Application CTV-100-INST Form CTV-100 Instructions (R. 3-25) - 1 -Wisconsin Department of Revenue Completion and Submission of Form CTV-100 •Submit the completed application to the clerk of the municipality in which you are applying for a license. •In addition to Form CTV-100, include: ◦ Form CTV-101 for the sole-proprietor; all officers, directors, and agent of a corporation; all partners of a partnership; all managing members and agent of a limited liability company ◦ Form CTV-102 if the applicant is an LLC or corporation ◦ Proof the applicant holds a seller’s permit, such as a copy of the seller’s permit document. Search for active sales tax accounts at revenue.wi.gov under My Tax Account, click on “Search Account Number” under the Businesses section. If you have questions about whether a person holds a seller’s permit, contact the Department of Revenue at 608-266-2776 ◦ All other information and documents required by your municipality Open Records This application is an open record under state law (sec. 19.35, Wis. Stats.) and may be provided to the public. If this license is issued by your municipality, your municipality must report the license to the Wisconsin Department of Revenue. The department publishes a list of cigarette, tobacco product, and electronic vaping device licensees reported by municipalities. The department will not disclose personal information such as residential addresses, home phone numbers, social security numbers, age, birth date, and place of birth of individuals, including partners, officers, directors, members, managers, and agents of corporations or LLCs. Assistance This form is designed by the Department of Revenue for use by municipal governments. Reach out to your municipal clerk for assistance with the following: •Submission of the retail license application and supplemental forms •Availability and cost of certain licenses If you have questions about cigarette, tobacco product, and electronic vaping device laws and regulations, you may contact the Department of Revenue using the contact information below. Website: https://www.revenue.wi.gov/Pages/Businesses/Tobacco.aspx Email: DORExcise@wisconsin.gov Telephone: (608) 264-4248 Resources Provided by the Department of Revenue Publication 304, Cigarette, Tobacco, and Vapor Products Tax and Regulatory Information Wisconsin Department of Revenue Cigarette, Tobacco, and Vapor Product Landing Page Permit Predetermination Common Questions Vapor Products Tax Common Questions Fact Sheet 3501, Vapor Products Tax Other Resources Tobacco Sales Training – Wisconsin Department of Health Services Tobacco 21 – Wisconsin Department of Health Services - 2 -CTV-100-INST Form CTV-100 Instructions (R. 3-25) Cigarette, Tobacco, and Electronic Vaping Device - Individual Questionnaire CTV-101 (R. 3-25)Wisconsin Department of Revenue Form CTV-101 Date Part A: Business Information 1. Legal Business Name (individual name if sole proprietor) 2. Business Trade Name or DBA 3.Entity Type (check one) Sole Proprietor Partnership Limited Liability Company Corporation Part B: Individual Information 1. Name (Last) 4. Relationship to Business (Title) 7. Home Address 5. Email 6. Phone 8. City 12. Drivers License/State ID Number 9. State 10. Zip Code 11. Date of Birth 13. Drivers License/State ID State of Issuance 2. Name (First)3. Name (M.I.) Part C: Individual’s Address History List in chronological order all of your addresses within the last 5 years. Attach additional sheets if necessary. Previous Address 1 City State Zip Code Previous Address 2 City State Zip Code Previous Address 3 City State Zip Code If applicable, list all states and counties you have lived in as an adult. Attach additional sheets if necessary. State County State County State County State County Previous Address 4 City State Zip Code Previous Address 5 City State Zip Code Continued → Previous Address 6 City State Zip Code State County State County State County State County Part D: Individual’s Criminal History Law/Ordinance Violated 1. Have you ever been convicted of any offenses (other than traffic offenses) for violation of any federal, Wisconsin, or another state’s laws, or of any county or municipal ordinances? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes to question 1, please list details of each conviction below: Penalty Imposed Law/Ordinance Violated Penalty Imposed Was sentence completed?. . . . . Yes No Was sentence completed?. . . . . Yes No 2. Are charges for any offenses currently pending against you (other than traffic offenses) for violation of any federal, Wisconsin, or another state’s laws or any county or municipal ordinances? . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes to question 2, describe nature and status of pending charges using the space below. Attach additional sheets as needed. Penalty Imposed Was sentence completed?. . . . . Yes No Law/Ordinance Violated Trial Date Trial Date Trial Date Part E: Attestation by Individual READ CAREFULLY BEFORE SIGNING: I understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on an application for ciga- rette, electronic vaping devices, and tobacco products retail license may be required to forfeit not more than $1,000 if convicted. I declare under penalties of the law that I have examined this information and, to the best of my knowledge, it is true, correct, and complete to the best of my knowledge and belief. Signature Date Part F: Licensing Authority Approval I hereby certify that I have checked municipal and state criminal records. To the best of my knowledge, with the available information, this individual does not have a criminal record that would disqualify them from having an interest in a cigarette, tobacco product, or electronic vaping device retailer license according to sec. 134.65(1m), Wis. Stats. Name of Local Official DateSignature of Local Official Title - 2 -CTV-101 (R. 3-25) Location Location Location Form CTV-101 Instructions Cigarette, Tobacco, and Electronic Vaping Device - Individual Questionnaire Who must complete Form CTV-101? This form must be submitted with a retail license (Form CTV-100) or permit (CTV-200) application and must be completed by each person involved in the applicant business. This includes: a sole proprietor; all officers, agents of a corporation; all partners of a partnership; and all members and agents of a limited liability company. Note: Your applications (Forms CTV-100 or CTV-200) are not complete until all required Individual Questionnaires are submitted. Where do I submit Form CTV-101? Submit this form with the following applications, as applicable: • With Form CTV-100, Cigarette, Tobacco, and Electronic Vaping Device Retail License Application, to the clerk of the municipality in which the applicant business is located. • With Form CTV-200, Application for Cigarette, Tobacco, and Vapor Products Permits, to the Department of Revenue. Specific Instructions Date Date you are preparing this form using the format MM/DD/YYYY. Part A: Premises/Business Information • Box 1: Enter the legal business name. If the applicant is a sole proprietor, enter the individual’s first and last name. • Box 2: Enter the trade name or “doing business as” name, if different than the name in box 1. • Box 3: Check one entity type to indicate how the business is legally organized. Note: This business information must match the information on the license or permit application (Form CTV-100 or CTV-200). Part B: Individual Information • Provide all requested personal information. • Box 2: Enter your title or describe your relationship to the business. Examples: President, Treasurer, Chief Financial Officer, Member, Partner, Agent, etc. Part C: Address History • In chronological order starting with your most recent residential address, list your addresses within the past five years. • List any states and counties you have lived in not already listed in Part C. Part D: Criminal History • Question 1: Disclose any civil or criminal violations of law in any jurisdiction (federal, state, or local ordinance). • Question 2: Disclose any pending charges against you in any jurisdiction. Note: Subject to the Wisconsin Fair Employment Law (Ch. 111, Wis. Stats.), persons with convictions or pending charges may, if the offenses are sufficiently relevant, be prohibited from holding a cigarette, tobacco, and electronic vaping device license or permit under secs. 134.65(1m) and 139.34, Wis. Stats. See the Department of Revenue’s Permit Predetermination Common Questions for offenses that may prevent someone from holding a license or permit. Part E: Attestation: • Read the attestation carefully, then sign and date. Form CTV-101 Instructions (R. 3-25)Wisconsin Department of Revenue- 1 - Part F: Licensing Authority Approval This section is for use by the appropriate municipal official to attest to the qualifications of the individual. Assistance This form is designed by the Department of Revenue. If you have questions about retail license applications and costs of licenses, contact your municipal clerk for assistance. If you have questions about permit applications or general questions about cigarette, tobacco, and electronic vaping device laws and regulations, contact the Department of Revenue using the contact information below. Website: https://www.revenue.wi.gov/Pages/Businesses/Tobacco.aspx Email: DORExcise@wisconsin.gov Telephone: (608) 264-4248 Resources Provided by the Department of Revenue Publication 304, Cigarette, Tobacco, and Vapor Products Tax and Regulatory Information Wisconsin Department of Revenue Cigarette, Tobacco, and Vapor Product Landing Page Permit Predetermination Common Questions Vapor Products Tax Common Questions Fact Sheet 3501, Vapor Products Tax Other Resources Tobacco Sales Training – Wisconsin Department of Health Services Tobacco 21 – Wisconsin Department of Health Services - 2 -Form CTV-101 Instructions (R. 3-25) Cigarette, Tobacco, and Electronic Vaping Device Appointment of Agent Form CTV-102 CTV-102 (R. 3-25)Wisconsin Department of Revenue Date Limited Liability Company Corporation Part A: Agent Information Part C: Business Information 1. Last Name 2. First Name 1. Legal Business Name (individual name if sole proprietor) 6. Home Address 3. Entity Type (check one) 4. Email 2. Business Trade Name or DBA 5. Phone 3. M.I. 7. City 4. Premises Address 11. Drivers License/State ID Number 5. City 8. State 6. State 9. Zip Code 7. Zip Code 10. Date of Birth 12. Drivers License/State ID State of Issuance Part B: Questions 1.Have you completed Form CTV-101, Cigarette, Tobacco, and Electronic Vaping Device - Individual Questionnaire? Submit a completed Form CTV-101 with this form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes No 2. If this is a change of agent, please describe the reason for the agent change. Attach additional sheets if necessary. Part D: Attestations READ CAREFULLY BEFORE SIGNING: I, the Licensee or Permittee, authorize the above-named individual to act for the above-named corporation or limited liability company with full authority and control of the premises and of all business relative to cigarettes, tobacco products, and/ or electronic vaping devices conducted therein. I certify that I am authorized by the entity to authorize this individual to act on behalf of the entity. If I am appointing a successor agent, I rescind all previous agent appointments for this premises. Further, I understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Signature of Licensee or Permittee (officer, member, or authorized signatory) Name of Person Signing Date Title Agent Type (check one):Original Change READ CAREFULLY BEFORE SIGNING: I, the Agent, herby accept this appointment as agent for the above-named corporation or limited liability company and assume full responsibility for the conduct of all business relative to sales of cigarettes, tobacco products, and/or electronic vaping devices conducted on the premises for the above-named business. I further understand that I may be prosecuted for submitting false statements and affidavits in connection with this form, and that any person who knowingly provides materially false information on this form may be required to forfeit not more than $1,000 if convicted. Signature of Agent Date Form CTV-102 Instructions Appointment of Agent Who must complete Form CTV-102? Corporations and limited liability companies (LLCs) must appoint an agent that takes responsibility for the licensed or permitted premises where business activities relative to cigarettes, tobacco products, and/or electronic vaping devices are conducted. Where do I submit Form CTV-102? Submit this form with your application for a retail license (CTV-100) or a permit (CTV-200), or submit it separately to report a change in appointed agent. • For retail licenses, submit this form to the clerk of the municipality in which the applicant business is located. • For permits, submit this form to the Department of Revenue at the mailing address shown below. Specific Instructions Date: Date you are preparing this form using the format MM/DD/YYYY. Agent Type: Select original appointment if you are appointing an agent with your license or permit application (Form CTV-100 or CTV-200). Select change if you are reporting a change of agent. Part A: Agent Information Provide all requested personal information for the appointed individual. Part B: Agent Questions • These questions should be answered by the appointed individual. • Question 1: Submit a completed Form CTV-101, Individual Questionnaire, with this form. • Question 2: Describe the reason why the business entity must appoint a new agent. ◦ Examples include: the previous agent is no longer an employee of the entity, the previous agent is no longer eligible to be an agent of the premises, the previous agent was not responsive to business needs. Part C: Business Information • Box 1: Enter the legal business name. • Box 2: Enter the trade name or “doing business as” name, if different than the name in box 1. • Box 3: Check one entity type in to indicate how the business is legally organized. Note: This business information must match the information on the license or permit application (Form CTV-100 or CTV- 200) or match the name on the issued license or permit if reporting a change of agent. Part D: Attestations • An authorized representative of the licensee or permittee should read the first attestation carefully and sign to acknowledge the appointment of this agent. • If the business in Part C is a corporation, the attestation must be signed by an authorized corporate officer or director. • If the business in Part C is an LLC, the attestation must be signed by an authorized LLC member (i.e., managing member). • The agent should read the second attestation carefully and sign to accept the appointment. • An authorized representative of the licensee or permittee may appoint themselves as the agent by signing both attestation sections. CTV-102-INST Form CTV-102 Instructions (R. 3-25) - 1 -Wisconsin Department of Revenue Assistance This form is designed by the Department of Revenue. If you have questions about retail license applications and costs of licenses, contact your municipal clerk for assistance. If you have questions about permit applications or general questions about cigarette, tobacco, and electronic vaping device laws and regulations, contact the Department of Revenue using the information below. Website: Email: https://www.revenue.wi.gov/Pages/Businesses/Tobacco.aspx DORExcise@wisconsin.gov Telephone: (608) 264-4248 Write: Wisconsin Department of Revenue Excise Tax Unit P.O. Box 8900 Madison, WI 53708-8900 Resources Provided by the Department of Revenue Publication 304, Cigarette, Tobacco, and Vapor Products Tax and Regulatory Information Wisconsin Department of Revenue Cigarette, Tobacco, and Vapor Product Landing Page Permit Predetermination Common Questions Vapor Products Tax Common Questions Fact Sheet 3501 Vapor Products Tax Other Resources Tobacco Sales Training – Wisconsin Department of Health Services Tobacco 21 – Wisconsin Department of Health Services CTV-102-INST Form CTV-102 Instructions (R. 3-25) - 2 -