E-5 - Tobacco Licenses Approval

Iowa Retail Permit Application for Cigarette/Tobacco/Nicotine/Vapor tax.iowa.gov Additional instructions are on the final page. For period (MM/DD/YYYY) 07 / 01 / 2024 through 06/30/2025 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): Kum & Go #137 Iowa sales and use tax account number: 152022420 Retail address: 101 Village Dr City: Tiffin State: IA ZIP: 52340 Mailing address: 1150 Locust St. Suite 301 City: Des Moines State: IA ZIP: 50309 Phone: 515-274-7793 Legal Ownership Information: Type of ownership: Sole Proprietor ☐ Partnership ☐ Corporation ☑ LLC ☐ LLP ☐ Name of sole proprietor, partnership, corporation, LLC, or LLP: Kum & Go LC Primary office address: 1150 Locust St. Suite 301 City: Des Moines State: IA ZIP: 50309 Phone: 515-274-7793 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): See Attached 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: Charles Maggelet Title: President Address: 185 South State Street City: Salt Lake City State: UT ZIP: 84111 Name: Tyler Call Title: Vice President Address: 185 South State Street City: Salt Lake City State: UT ZIP: 84111