Retail Tobacco Product, Vapor Product, and/or Smoking Paraphernalia Business Permit Application

Please complete and submit the following application.

The Erie County Department of Health (ECDOH) Retail Tobacco Product, Vapor Product, and/or Smoking Paraphernalia Business Permit Application is NOT a permit. Operation of a regulated facility without a valid permit is a violation of the Erie County Sanitary Code.

Incomplete applications will delay processing. If you have any questions, please call (716) 961-6800 or send an email to TVP@erie.gov.

If you prefer you can print and mail a paper copy at Tobacco, Vaping Product and Smoking Paraphernalia Permit Application.

This application must be submitted at least 30 days before: (please check appropriate box)

October 1, 2024 for existing facilities

The start of operation, after October 1, 2024, for new facilities

The expiration date of the existing permit

Check all boxes that apply

Tobacco Products

Vapor Products

Smoking Paraphernalia Products

Facility Information

Name (as it will appear on permit)

Address

City/Town

State

ZIP Code

Phone

Confirm email

Owner/Operator Information

Corporation Name

Owner/Operator Name

Address

City/Town

State

ZIP Code

Phone

Confirm email

Mailing Address

Select the mailing address you want to use

All correspondence to be sent to facility address as above

All correspondence to be sent to Owner/Operator address as above

All correspondence to be sent to alternate address

Address

City/Town

State

ZIP Code

Workers Compensation and Disability Insurance Information

(Contact NYS Workers Compensation Board for information)

Indicate below the form provided as proof

Workers Compensation Insurance

Form C-105.2

Form U-26.3

Form SI-12

Form GSI-105.2

Please attach a copy of the Workers Compensation Insurance

One file only.
2 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

NYS Disability Insurance

Form DB-120.1

Form DB-155

Please attach a copy of the NYS Disability Insurance

One file only.
2 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Certification of Attestation of Exemption from NYS Workers Compensation and/or Disability Benefits Coverage

Form CE-200

For CE-200, you can apply at https://www.businessexpress.ny.gov. You will be asked to create a NY.gov account if you do not already have a login.

Please attach a copy of the Certification of Attestation of Exemption

One file only.
2 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Water/Sewage Facilities at Establishment

Select the appropriate type

Public Water

Private Water (Well)

Public Sewer

Private On-Site Waste-Water Treatment System

If private water/sewage please specify operator/responsible party

Corporation/Partnership/Llc/Additional Officers/Directors/Managers

List all below

Re-order	Name	Title	Adress	Phone	Email	Weight	Operations
	Name	Title	Adress	Phone	Email	Item weight

more items

Days/Hours of Operation

We are open 24/7

Label	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Opening Time	Time 1	Time 2	Time 3	Time 4	Time 5	Time 6	Time 7
Closing Time	Time 8	Time 9	Time 10	Time 11	Time 12	Time 13	Time 14

Electronic Signature

By checking this box, I agree that if this application is approved, I hereby agree to operate the facility described in complete compliance to the New York State Public Health Law, Erie County Sanitary Code and any other rules, codes, regulation applicable to its operation. I also acknowledges that workers compensation and disability benefits insurance are in force as required.