City's Cigarette and Tobacco Products License Application

No person may directly or indirectly or by means of any device keep for retail sale, sell at retail, offer to sell or otherwise dispose of any tobacco products or delivery devices at any place in White Bear Lake without first having obtained a license from the City Council to do so.

To apply, complete and submit both city and state applications to the White Bear Lake city clerk. Please direct questions to the City Clerk, clerk [at] whitebearlakemn.gov (subject: Cigarette%20and%20Tobacco%20Products%20License%20Inquiry) (clerk[at]whitebearlakemn[dot]gov), 651-429-8508.

Business Information

Business Name

Business Street Address

Business Phone Number

MN Tax Identification Number

Federal Tax Identification Number

Business Owner Contract

First and Last Name

Full Home Address

Email Address

Daytime Phone Number

Insurance Requirements

Proof of Insurance

I have no employees

I am self-insured (upload your permit to self-insure)

I have no employees who are covered by workers' compensation law (these include spouse, parents, children and certain farm employees)

I have proof of Workers' Compensation

Proof of Workers’ Compensation liability insurance is required by MN Statute, Section 176.182.

Upload Proof of Insurance

One file only.
1 MB limit.
Allowed types: gif jpg jpeg png html pdf doc docx.

Minnesota Statute 176.182 requires local licensing agencies to withhold the issuance or renewal of a license or permit to operate a business in Minnesota until the applicant presents acceptable evidence of compliance with workers’ compensation insurance coverage as required pursuant Section 176.181, Subd. 2., and this information will be furnished upon request to the Department of Labor and Industry to ensure compliance with this Statute. This information is required by law and if not provided, or falsely reported, may result in a penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry.

Background Check Authorization

Unless otherwise indicated, the data in this application will be used to approve your license or permit. Upon approval of the license or permit, the information contained in this application shall be deemed public unless classified as private by state law. Private data is available to you and the city or state who need this information to perform their duties, but is not available to the public. You are not legally required to provide this data, but the city may not be able to approve your license or permit if you do not provide it.

Minnesota Statute, section 270C, Subd. 4 requires all licensing authorities to require applicants to provide their social security number or individual taxpayer identification number and Minnesota business identification number, as applicable, and to provide that information to the Minnesota Department of Revenue upon request. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, the City is required to advise you of the following regarding the use the information requested herein:

This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales tax, employer’s withholding or motor vehicle excise taxes;
Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Internal Revenue Service; and
Failure to supply this information may jeopardize or delay processing of your license or renewal.

By applying your electronic signature and submitting this application, you are acknowledging:

You have access to and are familiar with the provisions of White Bear Lake Municipal Code 1104: “Tobacco and Related Products”.
You know you can sign up for “Notify Me” on the City’s website at www.whitebearlake.org to receive email notifications anytime the city posts a Public Notice. Public Notices may contain information relating to Ordinance revisions or updates, which could potentially modify business license fees and requirements.
You declare that the information provided on this application is truthful and you understand that falsification of answers or failure to provide the required data may result in denial of the application
You authorize the City of White Bear Lake to investigate your background and make whatever inquiries necessary to verify accuracy of the information provided.
You authorize the White Bear Lake Police Department to request a copy of your consumer credit report for purpose of conducting a license background investigation.

Electronic Signature

Date of Electronic Signature

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