E-5 - Tobacco License Renewal - Fareway

Instructions on the reverse side For period (MM/DD/YYYY) _07_ / _01_ / _2022_ through June 30, _2023_ I/we apply for a retail permit to sell cigarettes, tobacco, alternative nicotine, or vapor products: Business Information: Trade name/Doing business as: Fareway Stores, Inc. # 193 Physical location address: 500 Croell Ave City: TIFFIN ZIP: 52340 Mailing address: 500 Croell Ave City: TIFFIN State: IA ZIP: 52340 Business phone number: 319 645-2126 Legal Ownership Information: Type of Ownership: Sole Proprietor ☐ Partnership ☐ Corporation ☒ LLC ☐ LLP ☐ Name of sole proprietor, partnership, corporation, LLC, or L.L.P. Fareway Stores, Inc. Mailing address: PO Box 70 City: Boone State: IA ZIP: 50036 Phone number: 515-433-5336 Fax number: 515-433-4416 Email: [email protected] Retail Information: Types of Sales: Over-the-counter ☒ Vending machine ☐ Do you make delivery sales of alternative nicotine or vapor products? (See Instructions) Yes ☐ No ☒ Types of Products Sold: (Check all that apply) Cigarettes ☒ Tobacco ☒ Alternative Nicotine Products ☒ Vapor Products ☒ Type of Establishment: (Select the option that best describes the establishment) Alternative nicotine/vapor store ☐ Bar ☐ Convenience store/gas station ☐ Drug store ☐ Grocery store ☒ Hotel/motel ☐ Liquor store ☐ Restaurant ☐ Tobacco store ☐ Has vending machine that assembles cigarettes ☐ Other ☐ ________________________________ If application is approved and permit granted, I/we do hereby bind ourselves to a faithful observance of the laws governing the sale of cigarettes, tobacco, alternative nicotine, and vapor products. Signature of Owner(s), Partner(s), or Corporate Official(s) Name (please print): Garrett S Piklapp Name (please print): Signature: __________________________ Signature: __________________________ Date: May 9, 2022 Date: __________________________ Send this completed application and the applicable fee to your local jurisdiction. If you have any questions contact your city clerk (within city limits) or your county auditor (outside city limits). FOR CITY CLERK/COUNTY AUDITOR ONLY – MUST BE COMPLETE • Fill in the amount paid for the permit: $75 ck575435 • Fill in the date the permit was approved by the council or board: __________________________ • Fill in the permit number issued by the city/county: __________________________ • Fill in the name of the city or county issuing the permit: City of Tiffin • New ☐ Renewal ☒ Send completed/approved application to Iowa Alcoholic Beverages Division within 30 days of issuance. Make sure the information on the application is complete and accurate. A copy of the permit does not need to be sent; only the application is required. It is preferred that applications are sent via email, as this allows for a receipt confirmation to be sent to the local authority. • Email: [email protected] • Fax: 515-281-7375