Form Ct-Rl - Application For Tobacco Retailer License
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1Rev. 2/12
Form CT-RL
Massachusetts
Application for
Department of
Tobacco Retailer License
Revenue
This application is for a tobacco retailer license for the period October 1, 2012 through September 30, 2014. Please read the instructions below. License
fee is $50 for over-the-counter cigarette sales, and $50 for each cigarette vending machine. Complete a separate application for each vending machine.
There is no fee if you are only selling cigars and/or smoking tobacco.
Registration Information.
Please print. Note: You must be registered for sales tax before applying.
How are cigarettes sold?
Over the counter
Vending machine
Please check all that apply:
Cigarettes
Cigars and/or smoking tobacco
Legal name of business
Federal Identification number
Application number (DOR use only)
CODE-3
Mailing address
City/Town
State
Zip
Telephone
Trade name
Street address of retail sale location
City/Town
State
Zip
Telephone
Name(s) of owner(s)
Type of business
E-mail address
I hereby certify that I agree to conform with the provisions of the Massachusetts General Laws, Chapters 62C and 64C, as amended, and with
all rules and regulations made thereunder, and have complied with all laws of the Commonwealth relating to taxes. Signed under the penalties
of perjury.
Signature
Title
Date
Mail to: Massachusetts Department of Revenue, PO Box 7004, Boston, MA 02204.
General Instructions
You must obtain a tobacco retailer license before purchasing and
Address of retail sale location. Enter the address of the retail
selling cigarettes and/or cigars and smoking tobacco. You must
sale location. If this address is the same as the mailing address,
be registered to collect sales tax before applying for a to-
leave this section blank. Also enter the telephone number for the
bacco retailer license. If you have not registered for sales tax, go
sale location, including the area code.
to DOR’s website at or call the Customer Serv-
Enter the name(s) of the owner(s) of the business.
ice Bureau at (617) 887-MDOR.
Enter the type of business in which you sell cigarettes, cigars and/
Enter all information on application as shown on sample.
or smoking tobacco; for example, grocery store, gas station, etc.
Check the box which indicates how you sell cigarettes (cigarettes
Enter the e-mail address, if any, of the business owner.
include “little cigars” and smokeless tobacco). If you sell cigarettes
Signature. Be sure to sign your name above, and enter your title
over the counter, there is a $50 fee for obtaining or renewing your
license. If you sell cigarettes in vending machines, there is a $50
and the date on this application. Your application will not be proc-
fee for each machine. Complete a separate application for each
essed without your signature. Make your check(s) payable to the
Commonwealth of Massachusetts. Mail your application along with
vending machine. There is no fee if you are only selling cigars
and/or smoking tobacco.
any required fee to: Massachusetts Department of Revenue,
PO Box 7004, Boston, MA 02204.
Legal name of business. Enter the legal name of your business
for mailing purposes. For most retailers this will be the same as
their trade name.
Rev. 2/12
Form CT-RL
Massachusetts
Application for
Department of
Federal Identification. Enter your Federal Identification (FID)
Tobacco Retailer License
Revenue
number. Under Massachusetts law, if you are not a sole proprietor,
This application is for a tobacco retailer license for the period October 1, 2012 through September 30, 2014. Please read the instructions below. License
fee is $50 for over-the-counter cigarette sales, and $50 for each cigarette vending machine. Complete a separate application for each vending machine.
you must have a FID number to sell cigarettes and/or cigars and
There is no fee if you are only selling cigars and/or smoking tobacco.
Registration Information.
smoking tobacco.
Please print. Note: You must be registered for sales tax before applying.
✓
SAMPLE
How are cigarettes sold?
Over the counter
Vending machine
✓
Please check all that apply:
Cigarettes
Cigars and/or smoking tobacco
Mailing address. If you want your application sent to a location
Legal name of business
Federal Identification number
Application number (DOR use only)
A A B B C C I I n n c c . .
1 1 2 2 3 3 - - 4 4 5 5 6 6 - - 7 7 8 8 9 9
CODE-3
other than the retail sale location, enter that address here. Be sure
Mailing address
City/Town
State
Zip
Telephone
P P O O B B o o x x 1 1 2 2 3 3
S S c c i i t t u u a a t t e e
M M A A
0 0 2 2 0 0 6 6 6 6 7 7 8 8 1 1 - - 5 5 5 5 5 5 - - 9 9 9 9 9 9 9 9
to include the Zip code. Also enter your telephone number for that
Trade name
C C h h a a r r l l i i e e s s S S t t e e a a k k & & A A l l e e
Street address of retail sale location
City/Town
State
Zip
Telephone
address, including the area code.
4 4 4 4 4 4 S S p p r r i i n n g g R R o o a a d d
S S c c i i t t u u a a t t e e
M M A A
0 0 2 2 0 0 6 6 6 6
7 7 8 8 1 1 - - 5 5 5 5 5 5 - - 1 1 1 1 1 1 1 1
Name(s) of owner(s)
Type of business
E-mail address
C C h h a a r r l l e e s s D D . . B B u u r r n n s s
R R e e s s t t a a u u r r a a n n t t
c c d d b b u u r r n n s s @ @ a a o o l l . . c c o o m m
Trade name. If the retail sale location is different from the mailing
address, enter the trade name of the retail sale location here. If the
retail sale location and mailing address are the same, leave this
section blank.
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