EXHIBIT B NONSMOKING EXEMPTION FORM

Office of the City Attorney            Office Use Only

44 West Washington Street            Rec’d:              Resp.              

Shelbyville, Indiana 46176

Tel: [phone] Fax: [phone]

 

BUSINESS INFORMATION

Name of business claiming exemption

Business address

Business telephone number

Owner

Owner’s address

Owner’s telephone number

 

 

ALCOHOL AND TOBACCO COMMISSION PERMIT INFORMATION

Permit Type

Permit Number

 

 

NONSMOKING EXEMPTION

Type of exemption claimed (circle one):       BAR      PRIVATE CLUB      SELF-ENCLOSED BAR AREA

Description of facility or area to be exempted

 

By completing and submitting this registration form to the City Attorney, I hereby give notice that the above-described business qualifies for the exemption claimed herein, as it meets all of the criteria set forth in § 99.05 of the Shelbyville City Code of Ordinances.

I hereby declare that all of the information that has been provided is complete, accurate, and responsive, and fully understand that any inaccuracies in the information herein provided may invalidate any exemption that may be claimed herein.

Signature:                                                           Date:                                                      

Printed Name:                                                     Title:                                                      

(Ord. 06-2564, passed 4-17-06; Am. Ord. 18-2848, passed 11-26-18)