Tobacco Form

Kandiyohi County Health And Human Services

2200 23^rd Street NE, Suite 1080

Willmar, MN 56201

320-231-7800

2026 License Application for Tobacco Sales

New licensees must provide a floor plan/diagram for all areas within said location to be used for display and sale of tobacco. Please mail it with your check

Renewal New Owner

Establishment Information

Establishment Name:

Establishment Address:

City: State:

Zip:

Telephone:

Email:

Owner Information

Owner Name:

Mailing Address:

City: State:

Zip:

Telephone:

Email:

Where should license information be sent: Licensee Address Establishment Address

Workers Compensation Information:

Pursuant to Minnesota Statutes 176.182 & 270C.72, the following applicable information is required of each license applicant:

Minnesota Tax ID Number:

Federal Tax ID Number:

Worker's Comp Policy Number:

Name of Worker's Compensation Insurance Company:

Address:

Dates of Insurance Coverage: From: To:

Fee $300.00

Make checks payable to: Kandiyohi County Health and Human Services

Mail to: Kandiyohi County Health and Human Services, 2200 23^rd St. NE, Suite 1080, Willmar, MN 56201.

I consent to a check of law enforcement records to verify the statements on this application.

Drop files here to upload
If form needs resubmission all files will be saved, but not shown
except in the case of session expiration

This is to certify that I am the individual who is the subject/business owner of the requested application.

This statement is to certify that all of the information in this application is true and correct and has been provided by the above named subject/business owner.

I certify that the information provided on this application is accurate and complete.

Online Application Completed

ByDate

Credit/debit cards will be charged a 2.5% fee with a minimum fee of $1.50 and eChecks will be charged a flat fee of $.65

Enter in your federal tax ID to prepopulate the form with last years values

Federal Tax ID