Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Tobacco Application

  1. Retail Sales Tobacco Permit/ Registration Application

    No permit will be given until payment is received in full and processed by the City of Gardner Health Department

  2. Fee: $100.00

  3. Owner Information

  4. I, the above mentioned, hereby apply for a permit to sell any product containing tobacco within Gardner, MA. Tobacco includes but is not limited to cigarettes, cigars, chewing tobacco, snuff, pipe tobacco, and smokeless tobacco. I acknowledge that I have read the City's Board of Health Regulations concerning the sale and distribution of tobacco in Gardner.

  5. Business Information:

  6. This list only needs to be updated with the Board of Health when applying for the annual permit. The Board recognizes that there may be staffing changes throughout the year.

  7. Under the laws of the Commonwealth of Massachusetts, Chapter 233 Section 35, Acts of 1983, You are Required to Complete the Following

    Pursuant to M.G.L. CH. 62c, Sec. 49A, I certify under penalties of perjury, that I, to the best of my knowledge and belief, have filed all State tax returns and paid all State Taxes required by Law.

  8. By typing my name above I certify that all of the information is correct and in compliance with all of the necessary laws and regulations.

  9. This Permit Expires on December 31 of Each Year

  10. Payment:

    No permit will be issued until payment is received in full and processed by the City of Gardner Health Department. Please send payment to Gardner Health Department, Gardner City Hall Rm 29, 95 Pleasant St. Gardner, MA 01440. The fee for this permit is $100.

  11. Leave This Blank:

  12. This field is not part of the form submission.