Clean Indoor Air Act (CIAA)
Application for Exception to Permit Smoking
Section I
Business Name: *
Trade Name of Business:
Sales Tax License Number: * * '999999999'
Date Business Established: * Business Telephone: () - *
Business Physical Address: *
City: * State:    Zip Code:   * County: *
Business Mailing Address:
City: State:    Zip Code:   County:
Section II
Establishment Description: See Guidance Document pages 2 & 3 for definitions.
(Check one relevant box.)*
The CIAA provides for two types of Cigar Bar exceptions.

The CIAA provides for two types of Drinking Establishment exceptions.

The CIAA provides for one type of Tobacco Shop exception.
Section III
Select appropriate Establishment Description in Section II.
Section IV
Enter your hours of Operation:
(Please enter the time in HH:MM AM/PM format)
Day From To Closed
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Is the facility a Dance Club/Hall on certain days? *
Does the facility ever have dancing? *
Is entertainment ever provided? (Disc Jockey, Bands, etc.)? *
Is there ever an admission charged? *

Section V - Owner/Manager Contact Information:
Name: *
Address: *
City: * State: * Zip Code:   * County: *
Owner/Manager Contact Mailing Address:
City: State: Zip Code:   County:
Telephone: () - * Fax: () -
Email Address:
Section VI

The Department of Health recognizes that the establishment may not be able to provide the required sales and use tax information for the previous twelve months. For purposes of this application for exception, the Clean Indoor Air Act allows cigar bars, drinking establishments and tobacco shops to project annual gross sales and sales of on-premises food or sales of tobacco and tobacco-related products.

Attached are copies of the following documents: (check one relevant box)
Cigar Bar: A Sales and Use Tax report provided to the Department of Revenue for the previous twelve months that documents the proposed exception location had total annual sales of tobacco products, including tobacco, accessories or cigar storage lockers or humidors of at least 15% of the combined gross annual sales of the establishment.
Drinking Establishment: A Sales and Use Tax report provided to the Department of Revenue for the previous twelve months that documents the proposed exception location had total annual sales of food sold for on-premise consumption of less than or equat to 20% of the combined gross annual sales of the establishment.
Tobacco Shop: A Sales and Use Tax report provided to the Department of Revenue for the previous twelve months that documents the proposed exception location whose sales of tobacco and tobacco related products, including cigars, pipe tobacco and smoking accessories, comprised of at least 50% of the gross annual sales of the establishment.
Applicant does not have tax records documenting the required on-premise food sales or tobacco and tobacco related product sales for the previous twelve months. A sales projection for the next twelve months is attached.
Section VII - Form 1455 PLCB Approval Letter

When the PLCB approves an application for a liquor license, the approval letter notes the areas that are licensed. If the area for which the exception is sought has already been approved, please submit the approval letter showing the licensed areas and circle the proposed smoking area.
Section VII - Establishment Floor Plan
For Drinking Establishment Type IIs only:
Section IX
By submitting this application I agree to the following: Access to records. A Cigar Bar, Drinking Establishment, and Tobacco Shop shall make available all books, accounts, revenues, receipts and other information to the Department of Health, the Department of Revenue, State licensing agency or county board of health as necessary to enforce the Clean Indoor Air Act.

By submitting this application, you authorize the Pennsylvania Department of Health to access any and all financial or business records filed with the Commonwealth of Pennsylvania or any of its political subdivisions or any agency, board, or commission of the Commonwealth on behalf of the establishment for which you seek an exception.

Sample Affidavit

Affidavit of Business Owner:

I am aware that the information contained in this application is subject to reporting to and auditing by the Pennsylvania Department of Health, Pennsylvania Department of Revenue, Pennsylvania Liquor Control Board, the Pennsylvania State Police and/or the Bureau of Liquor Control Enforcement. The undersigned hereby affirms that the foregoing information is true and correct to the best of said person’s knowledge, information and belief; said affirmation being made subject to the penalties prescribed by 18 Pa.C.S.A §4904 (unsworn falsification to authorities)

Signature of Authorized Representative: ___________________________________________________

Printed Name of Authorized Representative: _________________________________________

Date: ___________________ Title of Authorized Representative: _______________________________

(Space for Notary):




Commonwealth of ______________________ County of ______________________________________

Subscribed and sworn to before me this _________ day of ________ , 20_____.

Notary Public of the Commonwealth of Pennsylvania

MY COMMISSION EXPIRES _____________. By. ______________________________________________

Please send your completed form to:

Division of Tobacco Prevention and Control
Attention: Clean Indoor Air Act
Pennsylvania Department of Health
Room 1032 Health & Welfare Building 
625 Forster Street
Harrisburg, PA 17120-0701 Fax: (717) 214-6690 Email: RA-CIAA@pa.gov