E-5 - Tobacco Licenses Approval

Additional instructions are on the final page. For period (MM/DD/YYYY) 07/01/24 through 06/30/25 Use this form to apply for a retail permit to sell cigarettes, tobacco, alternative nicotine, or vapor products at retail. If you need a different, non-retail cigarette or tobacco permit, use form 70-015. If approved, the permit is only valid for the location listed on the permit. You must obtain a separate retail permit for each location you own or operate. Business Information: Legal name/Doing business as (DBA): Hometown Spirits Iowa sales and use tax account number: ____________________________ Retail address: 119 W. Marengo Rd City: Tiffin State: IA ZIP: 52340 Mailing address: 119 W. Marengo Rd City: Tiffin State: IA ZIP: 52340 Phone: 319 545 2131 Legal Ownership Information: Type of ownership: Sole Proprietor ☐ Partnership ☐ Corporation ☐ LLC ☒ LLP ☐ Name of sole proprietor, partnership, corporation, LLC, or LLP: Shanti LLC Primary office address: 119 W. Marengo Rd City: Tiffin State: IA ZIP: 52340 Phone: 516 710 2324 Fax: ________________ Email: [email protected] Retail Information: Types of Sales: Over-the-counter ☒ Vending machine ☐ Vending machine that assembles cigarettes ☐ Delivery sales of alternative nicotine/vapor products (see instructions) ☐ Mobile sales (see instructions) ☐ VIN: ________________ License plate number: ________________ Types of Products Sold: (Check all that apply) Cigarettes ☒ Tobacco ☒ Alternative nicotine products ☒ Vapor products ☒ Type of Establishment: (Select the options that best describe the establishment) Alternative nicotine/vapor store ☐ Bar ☐ Convenience store/gas station ☐ Drug store ☐ Grocery store ☐ Hotel/motel ☐ Liquor store ☒ Restaurant ☐ Tobacco store ☐ Other (provide description) ☐ _______________________________________________________ Do you have other permits issued under Iowa Code chapter 453A? If yes, provide permit number(s): ____________________________________________________________________________________ Include with this application a list of your suppliers and customers on a separate sheet. Identify partners or corporate officers if the business is not a sole proprietorship. Name: __________________________________________ Title: ____________________________ Address: _________________________________________________________________________ City: __________________________ State: __________ ZIP: ________________ Name: __________________________________________ Title: ____________________________ Address: _________________________________________________________________________ City: __________________________ State: __________ ZIP: ________________