Loading...
HomeMy WebLinkAboutThe Store (Kanku, Inc.) - 12/31/20200 Town of i lansf field - Board of ilealth ,tee PERMIT NUMBER: Town of Mansfield 6 Park Row Mansfield, MA 02048 Application for theSale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. By signing this application, I declare that I have read the regulation and am responsible for tobacco product sales regarding federal, state and local laws. This permit expires on December 31st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: - LOCATION OF SALE OF TOBACCO PRODUCTS: 12 � f p r( J�C_ }zpQ D j TELEPHONE AT LOCATION: 50e; 39— �c� OWNER OF BUSINESS;] _- ADDRESS OF OWNER: - l j® _ �u4RCrld1 _ ST'-s_-P5a4? ft ( iv+4 - I °I�fJ _ TELEPHONE OF OWNER:Q FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $160.00 CT-3T NUMBER: FEDERAL ID/SS NUMBER: ell - 35' - �( � SIGNATURE: 'r / , I,/ PATE: .__. M_1_1-Ij t -- - - Asa �u'atr- C�CwlhdM hu'eAls LdI.a ID. LW17I4W,2 Max w"A wam R dmd:tax#x 42018 ChistcjAw G Hming, C4mdr4ma AcaauA ID. CRL-iMA4290-lkk2 ��`F�a ,w's' irr�g�Wldar RETAILER L I CENSE FOR SALE OF CIGARS AND SMOKING TOBACCO IIII"IIIIIiI'I'111111"III'I'IIIliilllllll'll'illll'lll'llll'i'I KANKUINC THE STORE 213SMAINST ® MANSFIELD MA 02048-2519 Attaelled below is your Reel ter License for Sale of Cigars" Smoking Tobacco (Form CT-3T). Cut along the dotted I ine and display at your business location. At any time, you can log into your MassTexConnect account at mas gov/massIaxconned to view and reprint a copy of this license If you have any questions about your license, call us at (617) 887-6367 or toll-freein Massachusettsat (800) 392-6089, Monday through Friday, 8:30 am. to 4:30 p.m. DETACH HERE "I,,, MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco f a IJ' 'o,�.�;,�` This license must beposted and visible atalltimes The sale oftobacco products to anyone under 18years of age is prohibited. KANKUINC Account ID: CRL-10884290-009 THE STORE License Number: 42100736 213SMAIN ST MANSFIELD MA 02048-2519 Thi s certifi es that the taxpayer named above is I icelsed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above This license is non-trensferableald may be suspended or revoked for failureto comply with state laws and regulations Effective Data October 1, 2018 Expiration Date: September 30, 2020 „ar"g"k Cw NT"weWth d Mmachoutts LAW ID: L0100827M �.. NWc DWSg,,bw4.2018 GTWOW C. H Amwad 11) CGL-IOW42WOW �*i:vr �+s� rrT�gm+hbr RETAILER LICENSE FOR SALE OF CIGARETTES KANKUINC ® THE STORE 213SMAINST MANSFIELDMA 02048-2519 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted IIne and display at your business location. At any tirr>e, you can log into your MasTaxConned aceount at 1masagovlmasstaxoonnec8 to view and re -print a copy of this license. If you have any questionsabout your lionse, call uset (617) 887-6367 or toll -free in Massachusettsat (800) 392-6089, Monday through Friday, 8:30 am. to4:30 p.m. DETACH HERE W, MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T 15'at'!r th ? Retailer Licensefor Saleof Cigarettes 4!a�� This license must beposted and visibleat all times. Thesaleof tobacco products to anyone under 18 year s of age is prohibited. KANKUINC Account ID: CGL-10884290-006 THE STORE License Number: 367302656 213 S MAI N ST MANSFIELD MA 02048-2519 Thi s certifi e; that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above, This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations Effective Date October1, 2018 Expiration Date: September 30, 2020 SELLING TOBACCO PRODUCTS TEST Far each queshon, please dieck IN I the correct answer 1, it is against the tow to sell tobacco products to anyone Under age: D 18 W 21 0 27 2, You must check the I.D. of customers wishing to purchase tobacco products if they took younger than; 021 V 27 3. If a young person gives you a note from his/her parent, giving permission to buy cigarettes, you should: Refuse the sale ❑ Proceed with the sate ❑ Proceed with sale only it the note is signed by the parent 4. Which of the following I.D's can you accept as proof of age for someone buying tobacco? d Library card ❑College I.D. 8'/out-of-State Driver's License 5. if today's date is July 9 2819, which of the following people may legally buy tobacco products? ❑ Birthday is July 27. 1989 ❑/Birthday is July 25, 1989 tX Birthday is July 8,1998 6. Which of the following are ways youth try to outsmart sales clerks? 0 Telling the clerk the cigarettes are for a parent ❑ Going to a store where a friend works el Both of the above 7, Which of the following are acceptable forms of I.D.? ❑ State- Issued Drivers License ❑ Military I.D. Massachusetts Liquor License Ig"AII of the Above B. Cigarettes may be sold in amounts smaller than the smallest package made by the manufacturer. True False EMPLOYEE AGREEMENT 10/17/2019 "Whoever sells a cigarette, chewing tobacco, snuff, E-cig in any of its forms to any person under the age of twenty one or, not being his parent or guardian, gives a cigarette, chewing tobacco, snuff or tobacco in any of its forms to any person under the age of twenty one shall be punished by a fine of not less than one hundred dollars for the first offense, not less than two hundred dollars for a second offense and not less than three hundred dollars for any third or subsequent offense:' 1 understand that Massachusetts's law prohibits the sale of tobacco products to anyone under age 21.1 also understand that if I fail to follow store policy and state law about the sale of tobacco to minors I could lose my job or be fined. I agree to the following rules about the sale of tobacco products: I will not sell any tobacco products, including cigarettes, E- Cig ,cigars, chewing Tobacco, bidis, or any other form of tobacco, to any person under the age of 21. If a person attempting to buy a tobacco product looks under 27 years old,1 Will ask for photo identification (I.D.). If there is any doubt about the Person's age,1 will not make the sale. I will not accept a note from an adult giving permission to a person under The age of 21 to buy tobacco products. In turn, management agrees to support my judgment not to make the sale in any of the cases described above. Employee's signature Date le /!7 / Inj Store manager's signature Date (This agreement will be maintained in your personnel file as part of your permanent Employee record.) A check mark signifies your understanding and agreement. I understand and agree that: df It Is against the law to sell any tobacco product and/or nicotine delivery product (e.g. e-cigarettes) to anyone less than 21 years of age, regardless of how old the person looks. Anyone selling tobacco products and/or nicotine delivery products must conclusively establish the customer's age as over 21 years old, by means of government -issued photographic ID. / Anyone selling tobacco products and/or nicotine delivery products must check and verify official government photo ID for anyone less than 27 years of age. v/ I must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. Self-service tobacco product and/or nicotine delivery product displays from which the customer may select products are prohibited. The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. V I may not distribute any free samples of tobacco products or nicotine delivery products (e.g. e-cigarettes) and I may not accept any means, instruments or devices that allow for the redemption of tobacco products for free or cigarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue. Tobacco vending machines are prohibited. 1j Non-residential Roll -Your -Own machines are prohibited. .;- " Blunt wraps are prohibited. CE l Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. v i may not allow any employee to sell tobacco products or nicotine delivery products (e.g. e-cigarettes) until such employee reads this regulation, state and federal laws regarding the sale of tobacco and signs a statement, a copy of which will be placed on file, that he/she has read the regulation and applicable state laws. s " I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". I must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts Department of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license). j I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". I must display signs provided by the Board of Health that discloses referral information about cessation. g If I sell nicotine delivery devices (e.g. e-cigarettes) I must display signs stating that sale of nicotine delivery devices to anyone below the minimum legal sales age is prohibited and that the used of e-cigarettes at indoor establishments is prohibited by local law. I have received, read and understand the Board of Health regulation "Regulation Affecting Smoking and the Sale, Vending, and Distribution of Tobacco and Nicotine Delivery Products" and agree to abide by it. Signature /2� 0 Date �� t `i % i Print Name ___1" L40 9 i �t� 4't TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. %�inaJ dC tJ (.0 G NISI �n )Cinnc✓I P� Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) O It - .3Sa IIAg "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. CAUsm\s1ei16Dcsk1op\Sc0trs Dommm sTood Establishments- TempSl"AX CERTIFICATION F01W.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 1Vashhtgton Street Boston, MA 02111 wK,minass,govAlia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: KAAj u 13 1 it fJ 6t 7A6, fro Address: Are ou an employer? Check the appropriate box: L 1 am a employer with employees (full and/ or pan -time).' 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required]' 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.j Phone #: Business Ty (required): 5. ® Retail 6. Q Restaurant/Bar/Eadng Establishment 7, Office and/or Sales (incl, real estate, auto, etc.) R. QNon-profit 9. Entertainment 10.Fj Manufacturing I Ln Health Care 12.0 Other `Any applicant that checks box 4I most also fill out the section below showing their workers' compensation policy information. "'If the corporate officers have exempted themselves, but the corporation has other employees, aworkers' compensation policy is required and such an orgartication should check box R 1. I ant an emptover that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: y u G ME:, AA45cr-t A Al OU 1,a ptm-a Insurer's Address:c:t,6c� la,01 jpkyLh�) 1�tj 5 G-(' City/State/Zip: (,)'I j ,�d 1,5 � ,_I e i A- 01 ¢;Q$,-1 Policy # or Self -ins. Lic. # 0 i k d tl 50 3a�If 941 141 Expiration Date: at 1 rj /' oev-6 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Cute up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct signature: N P/. Date' 14 Phone #: 5d fS 339 — 9.5for Official use only. Do nor write in this area, to be completed by ei(p a town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass,gov/dia Phone #: L ,� ® A CERTIFICATE OF LIABILITY INSURANCE W10118/ )DfYYVYI ,gl,Bl2019 ,►./ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of tho policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER HUB NE Association Programs 300 Ballardvale Street Wilmington, MA 01887 NAME C PHONE EMAIL —.. - — AooREss __.. INSURER(Sj AFFORDIND COYFRAOE I— NAICA _ INSURERA: MA Retail Merchants WC Group Inc. INSURED INSURERS: — msURERC;_ i I Kanku,lnc. INSURER D_ d;bla The Store 213 South Main St. — . Mansfield, MA 02048 INSURER E: INSURER F: roorrvrrwrc unu000• onrin1 REVISION NUMBER: 00001 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �TRI TYPEOFINSURANce �INSR I .LOENERAL LIABILITY I -ICOMMERCIAL GENERAL UABIUTY _. I GWMS-MADE n OCCUR i I II I POLICY NUMBER POLICY F MMIOOIYW POLK:Y EXP MMIO I t LIMITS ( EACH OCCURRENCE I5 -LWMA5TO RENTED PREMISES (Ea arurtencel —.— �MED IXP(Any ane parses) { s $ -- I PERSONAL S ADV INJURY 5 GENERAL AGGREGATE 5 _ ti I ( I I 1 PRODUCTS AGG i5— F GENL AGGRE(GATE LIMIT APjP�L'I�EISPER. u� POLICY I PST i LOG AUTOMOBILE LMRUTY ANY AUTO ALL ONNED SCHEDULED I AUTOS NON-0WNED UTOS HIRED AUT09 AUTOS COMBINED SINGLE UMn AE2 amigene —1 15 5 BODILY INJURY(Per person) 5 BODILY INJURY ire, a.ddeon 5 PROPERTY DAMAGE er acddanc S 5 1 UMBRELLACC EAC__OCCURRENCE AGGREGATE 55 AIOFR O(CE55 LWUAS�B ClM _I IDEO RErENTINS WORKERS COMPENSATION AND EMPLOYERS LIABILITY YIN ANY PROPRIEfORIPARTNERIEXECUTIVE ❑ CERBAEMBER EXCLUDED? (MandatM in NH) 1! es descrion under DESCRIPTION OF OPERATIONS Wax NIA ! iI 014005032484119 1/01/2019 1/01/2020 y.,C yTATU OTH-j X 70 _ E.L EACH ACCIDENT IS iOO,000 EL. DISEASE EA EMPLOYEFjs 100,000 _ I S 600,000 EL DISEASE POLICY OMIT I DESCRIMt NOFOPERATIONS1LOCATIONS1VEHICLES(Arlach ACORD 101,AddMonal Remarks Schedule, if more space is required) Town Of Mansfield ATTN:Jane Doucette 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD Standard Operating Procedure Kanku Inc, DB/A The Store 213 South main street Mansfield, Ma 02048 (508)339-8568 • NO ID. No Sale! Check photo ID of everyone under age 27 who attempts to purchase cigarettes, cigarette tobacco, or RYO tobacco. • Check photo ID before getting the requested product. • Compare the ID photo to the customer. Does it match? Check for fake IDs. Have the customer remove the ID from their wallet and check to make sure the ID is not tempered with (plastic peeling, smudges, and misaligned numbers). • Check the expiration date. An ID must be current and not expired to be valid. • Is the license vertical? this means the customer is under 21. Check the "Under 21 Until" date to verify they are at least 21 before selling them tobacco. • Only sell cigarettes, cigarette tobacco, or RYO tobacco to customers age 21 and older.* • Only sell cigarettes, cigarette tobacco, and RYO tobacco in a direct, face-to-face exchange.** • Do NOT sell flavored cigarettes, cigarette tobacco, or RYO tobacco.*** • Do NOT give away free samples of cigarettes, cigarette tobacco, or RYO tobacco, including any of their components or parts. • Do NOT sell cigarette packages containing fewer than 20 cigarettes or single cigarettes, known as "loosies."