20 CAR pt. 6, Appendix A
| Name of Owner or Operator | |
|---|---|
| Name of Business | |
| Address (Street & number, P.O. Box or Route number) | Phone (Area code and number) |
| City, State, ZIP code |
I, the owner or operator named above, claim an exemption from the Arkansas Clean Indoor Air Act of 2006. I am entitled to an exemption for the following reasons (initial beside each category that applies):
☐ I own or operate a hotel and motel that rents rooms to guests that are designated as smoking rooms. If the hotel or motel that I own or operate has more than twenty-five (25) guest rooms, I understand that no more than twenty percent (20%) of rooms rented to guests in a hotel or motel may be designated as smoking rooms.
☐ I am an employer with fewer than three (3) employees. I understand that this exemption does not apply to any public place within the workplace.
☐ I own or operate a restaurant or bar licensed by the State of Arkansas. I do not permit any person less than twenty-one (21) years of age to enter or work on the premises at any time. I will prominently display a health warning sign as defined by the State Board of Health.
I understand that it is a violation of these rules to claim an exemption from the prohibitions of the Clean Indoor Air Act of 2006 under false pretenses. Further, I understand that I have a continuing obligation to inform the Department if circumstances dictate that I no longer qualify for an exemption.
| Owner or Operator | Title | Date |
|---|---|---|
THIS IS A SMOKING AREA. OCCUPANTS WILL BE EXPOSED TO SECONDHAND SMOKE.
IT IS UNLAWFUL FOR ANYONE UNDER 21 YEARS OF AGE TO ENTER OR WORK IN ANY PART OF THIS ESTABLISHMENT AT ALL TIMES.
ARKANSAS STATE BOARD OF HEALTH, 2006