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HomeMy WebLinkAboutRte. 106 Wine & Spirits (RNR Liquors Corp.)- 12/31/2020Town of Mansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: Application for the Sale 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: A)1\ ( ( C.0 t�Cr�':s1 :"'!dji' ok _i/C A C LOCATION OF SALE OF TOBACCO PRODUCTS: f i-p r r /t d (' f TELEPHONE AT LOCATION: 7 7 o OWNER OF BUSINESS:L,- ADDRESS OF OWNER: u &' -f 1_ f— 1 ,f_� _ ✓ l f TELEPHONE OF OWNER: 0 I; -2.',vr / ! L FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. f J Z,11-F fdit.+ /` ` f ,fir _,,, l._ F'L��- / t c cr ifs/I'r rt.r'rr' t=f ii:? Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation ILA' i ~`:� j_Le + CV) Ci (f f _ _�d C��-�. �` z_<-�- � `" �—i- JA 7 r 7 J r t - to ) 9}a ) r rt i b� 1 i�� i c �p r'5� `^��E� C '-C' �- rL`�.± ' t�':ic° t c�-r'y �� F==;--�-�`i �'� +� : �i`l C:4'�tr'CO< * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3T NUMBER: i' i `l i C, FEDERAL ID/SS NUMBER: c7. _ r` SIGNATURE: DATE:P 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. !1 C-i�(lvt�',S Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) , t ,� .) i �- t d if **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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM,doc A check mark signifies your understanding and agreement. I understand and agree that: 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. C�/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. EJ/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. al 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. R The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. Gkf 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. 9f Tobacco vending machines are prohibited. [1// Non-residential Roll -Your -Own machines are prohibited. Blunt wraps are prohibited. r 9'` Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. D/ 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. ,,Y`I must prominently display a copy of th� "Permit to Sell Tobacco and Nicotine Delivery Devices". Q /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). Elf I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". L✓j 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 is E Print Name 1 4 S1f /J r > ' i r� r Date iC I Li 6 �Ps�" Ss�f MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T a Retailer License for Sale of Cigars and Smoking Tobacco Fm oF�� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. RNR LIQUORS CORP Account ID: CRL-18958749-009 ROUTE 106 WINE & SPIRIT License Number: 1629890560 377 CHAUNCY ST MANSFIELD MA 02048-1169 This certifies 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: November 19, 2018 Expiration Date: September 30, 2020 MASSACHUSETTS DEPARTMENT OF REVENUE Retailer License for Sale of Cigarettes This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. RNR LIQUORS CORP ROUTE 106 WINE & SPIRIT 377 CHAUNCY ST MANSFIELD MA 02048-1169 Form CT-3T Account ID: CGL-18958749-006 License Number: 1135220736 This certifies 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: November 20, 2018 Expiration Date: September 30, 2020 ---- --- -- - -------------------- saOH�sF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco P't,F.ti7 oFa'� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. RNR LIQUORS CORD Account ID: CRL-18958749-009 ROUTE 106 WINE & SPIRIT License Number: 1629890560 377 CHAUNCY ST MANSFIELD MA 02048-1169 This certifies 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: November 19, 2018 Expiration Date: September 30, 2020 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: rk hI j ` �' ZL3 U r Address: 177, J 7, (. � t /% C, /_ Ci /State/Zi �/ f] � " ' Phone #: "/„ tY p� l ��,� �r c~1 � � v � �, �i'i Are you an employer? Check the appropriate box: Busr'nes§ Type (required): 1. ❑ l am a employer with L-'j employees (full and/ 5. [�etail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity. B. ❑ Non-profit [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* It. Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #I must 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, a workers' compensation policy is required and such an organization should check box #I. I out an employer that is providing workers' compensation insurance for my employees. Below is the policy inforvnation. Insurance Company Name: L l (' 1" + I `-'i ' r �p't' � 3 ` 5 f' Insurer's Address: [ C { 4 } i i G City/State/Zip: r [ vt i I ) <'. i ! t l ,r t L2 - Policy # or Self -ins. Lie. # 'X ix ;< f > ( < i i`Expiration 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 Fine 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, radethe paths and/penalties ofperjury that the information provided above is true and correct. Signature:rtf f tj �(— Date• (U P �-`1 Phone # Official use only. Do not write in this area, to be completed by city or 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 Person: Phone www.mass.gov/dia Age -Restricted Products Policy & Procedures: Tobacco LOCATION L� Every Employee at this location has the legal and moral responsibility to control the sale and distribution of age -restricted items to ensure these items do not get sold to minors) l TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all laws and procedureof this,Policy related to the sale of tobacco products including cigarettes, smoke) ssttibacco, loose tobacco, pipe tobacco, rolling paper&,, cigars, ecigaretes, va{� and lighters. The minimum age to purchase tobacco proditots isyears of age. It is our responsibility as a retailer and members of the community to prevent the sale of tobacco to anyone under the age` of tVuenty o'ne (21). i 1 a Ytsn PROCEDURES: 1. This policy will beifeviewed v all 1ii?1N employees before they can H Ty 4� operate a cash register and sell ucts. 2. All store Employees tp tar based training and successfully pass with-100%o prior to starting register. This certification to be updated on an arifidOEbasis priorto previous,year expiration. & ,- vl�ss alid form of idertification will be required for all tobacco purchases ardof ageor frequency of customer visits. Valid M forms`of id are as follows: License Valid Massachusetts state id Valid US passport Valid Out of State License No expired identification will be accepted. Photos must be visually matched to the customer purchasing and licenses scanned into the register. Driver's License is to be scanned into the register system. All other identification from the acceptable list will require manual entry of the date of birth listed on the documentation. 4. If it is suspected that someone is purchasing tobacco for anyone under the age of twenty-one (21) a valid Id will be required from''all members of the party. and nicotine deliveryproc fail to follow store policy any person under the lega I agree to the following ru I will not sell anytobacco a note from In turn, mar above:' Failure tc terminafi FM s Mansfield Board c age, I could lose my jol es about the sale of tot follow this Store Operator Signature HealthRegulations which prohibits the,sale of tobacco age of twenty-one,(21) years. I also understand that if I out the sale of tobacco or nicotine delivery products to >r be fined. co products; fttes, cigars, chewing tobacco, bidis, or any other form person under the age of 21. If any person regardless of an acceptable, I will not make the sale. I will not accept under the age of 21 to buy tobacco products. rt my judgment not to make the 'sale —in any of the cases described nay result in disciplinary action up to and including I C) — Z'Y— 117 Date Date (This form will be maintained in your personnel file as a part of your permanent employee record) Age -Restricted Products Policy & Procedures: Tobacco LOCATION iiw t -t in t Every Employee at this location has'the legal and moral responsibility to control the sale and distribution of age -restricted items to ensure these items do not get sold to minors!! TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all laws,-.,, procedures of this,golicy ry J related to the sale of tobacco products includftpcigarettes, sacco, loose tobacco, pipe tobacco, rolling papers, cigars; e=cigJr. es, va a'nd lighters. The minimum age to purchase tobacco products is turenty ohe (2T) years of age. It is our responsibility as a retailer and meers othe community to prevent the sale of tobacco to anyone under the age` oti Twenty oe21). PROCEDURES: 1. This policy will bo viewed i all ne rlmployees before they can v operate a cash regtstdr any! sell tobacco products. 2. All store Employees tp take ctutr based training and successfully pass with3.00,% prior to sterxlr g on aregister. This certification to be updated ort,an anrior tp previous year expiration. 3 � ` valid for o tderitification will be required for all tobacco purchases t ard1, of a ar freauencv of customer visits. Valid id are as follows: License Valid Massachusetts state id Valid US passport Valid Out of State License No expired identification will be accepted. Photos must be visually matched to the customer purchasing and licenses scanned into the register. Driver's License is to be scanned into the register system. All other identification from the acceptable list will require manual entry of the date of birth listed on the documentation. 4. If it is suspected that someone is purchasing tobacco for anyone under the age of twenty-one (21) a valid Id will be required frori.41I members of the party. I have read and understand the Mansfield Board of Health Regulations which prohibits the sale of tobacco and nicotine deliveryproducts to anyone under the age oftwenty-one (21) years. I also understand that if fan. to fnilnw ctnra nnliry and Inral and statp laws ahnut the tale oftnhacco or nicotine delivery oroducts to e4ttempts to make a tobacco purchase u In turn, management agre above. Failure to follow this terminafi�:d ' Employee fined, roducts: ,cigars; chewing tobacco, bidis or any other form on under the age of 21. If any person regardless of cceptable, k will not make the sale. I will not accept . or age of 21 to buy tobacco products. o support my judgment not to make the sale in any of the cases described (Icy may result in disciplinary action up to and including Store Operator Signature Date f 161 1j 2.` Date (This form will be maintained in your personnel file as a part of your permanent employee record) Age -Restricted Products Policy & Procedures: Tobacco LOCATION % `- i - e na P I Every Employee at this location ha"s the legal and `moral `responsibility to control the sale and distribution of age -restricted items to ensure these items do not get sold to minors! I TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all laws related to the sale of tobacco products includift,.x loose tobacco, pipe tobacco, rolling papers, cigars; The minimum age to purchase tobacgp,,prod"'61 is It is our responsibility as a retailer ar sale of tobacco to anyone under, the PROCEDURES: lii p and lighters. years of age. community to prevent the {21). 1. This policy will be euiewed all h,e ,Employees before they can operate a cash register and selroducts. 2. All store Erployees takoipufer based training and successfully pass with;1.00% prior to staftrng on a register. This certification to be updated on ', -,,,an is prior to previous year expiration. 3 valid form of) lenV i_ation will be required for all tobacco purchases iegardl,s of ageupr frequency of customer visits. forms' of id are as follows: Valid Massachusetts License Valid Massachusetts state id Valid US passport Valid Out of State License No expired identification will be accepted. Photos must be visually matched to the customer purchasing and licenses scanned into the register. Driver's License is to be scanned into the register system. All other identification from the acceptable list will require manual entry of the date of birth listed on the documentation. 4. If it is suspected that someone is purchasing tobacco for anyone under the age of twenty-one (21) a valid Id will be required fromall members of the pa rty. s, I -have read and understand the Mansfield Board of Health Regulations which prohibits the:sale of tobacco and nicotine delivery products to anyone under the age of twenty-one (21) years. I also understand that if I fail to follow store policy and local and state laws about the sale of tobacco or nicotine delivery products to any person under the legal age; I could lose myjob or be fined. I agree to the following rules about the sale of tobacco products I will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis, or any other form of tobacco, or any nicotine delivery product to any person under the Iage of 21. If any person regardless of age attempts to make a tobacco purchase without an acceptable, I 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 thesale in any of the cases described above Failure,t4 follow this pgllcy may result in disciplinary action up to and including terminatiCrr>' Employee rignatiare Date c lc"12( fll Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) Age -Restricted Products Policy & Procedures: Tobacco 0140�LI► Every Employee at this location has the legal and moral responsibility to control the sale and distribution of age -restricted items to ensure these items do not get sold to minors!! TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all laws related to the sale of tobacco products including ,c loose tobacco, pipe tobacco, rolling papers, cigars;' nlp The minimum age to purchase tobacco prot� is It is our responsibility as a retailer an sale of tobacco to anyone under.the PROCEDURES: 1. This policy will operate a cash 2. All store EMblc n annua,t lid forme rdless of fo Valid f thisp.olicy e and lighters. years of age. e community to prevent the (21). before they can egist6i'�" 0 sell tobacco products. eesAo tale ci xtputar based training and successfully pass to startling on a 6gister. This certification to be updated its prioi-to previous year expiration. 1entiticatf n will be required for all tobacco purchases or frequency of customer visits. id are as follows: License Valid Massachusetts state id Valid US passport Valid Out of State License No expired identification will be accepted. Photos must be visually matched to the customer purchasing and licenses scanned into the register. Driver's License is to be scanned into the register system. All other identification from the acceptable list will require manual entry of the date of birth listed on the documentation. 4. If it is suspected that someone is purchasing tobacco for anyone under the age of twenty-one (21) a valid Id will be required froth all members of the party. 1, have read and understand the Mansfield Board of Health Regulations which prohibits the"sale of tobacco and nicotine delivery products to anyone under the age of twenty-one (21) years. I also understand that if I fail to follow store policy and local and state taws about the sale of tobacco or nicotine delivery products to any person under the legal age; I could lose my job or be fined. I agree to the following rules about the sale of tobacco products: 1"will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis, or any other form of tobacco, or any nicotine delivery product to any person under the age of 21. if any person regardless of age attempts to make a tobacco purchase without an acceptable, I will not make the sale. l 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. y result in disciplinary action up to and including Store Operator Signature /o %-3 //� Date ME (This form will be maintained in your personnel file as a part of your permanent employee record) RNRLI-1 Op ID: MK ,a►Ill CERTIFICATE OF LIABILITY INSURANCE DA10/29/2019TE Y) 10/29/2019 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER 508.528-3310 Keefe Insurance Agency 51 West Central Street CONTACT Matthew Keras PHONE 508-528-3310 FAX 508-528.3887 (A/c, No, Esq: (A/C, No): Franklin, MA 02038 Matthew Korea _ E-MAIL -- -- oDRESS: INSURER(S) AFFORDING COVERAGE NAICN INSURER A: Liberty Mutual Insurance jry$�1R HNK LIg UOrS INSURER B: _ INSURER C: Dan Patel Mans leld� tJYA 02046 INSURER D : INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: RFV]glOtd NIIMFi 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DDL NSD UOR POLICY NUMBER MID EFF "I POLICYEXP IMMIDDIYYYYi LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR BZS59334896 01/2212019 01122/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) 1,000,000 $ MED EXP An one erson _ $ 15,000 X Ligor Liability PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F JECT LOC GENERAL AGGREGATE $ 210001000 PRODUCTS-COMP/OP AGG $ 2,000,000 11 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _CEa acc'denU BODINJURY Per ILYperson . $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURV Peraaident $ PROPERTY DAMAGE Per accitlent _ $ HIRED NON -OWN D AUTOS ONLY AUTOS OILY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I RETENTION$ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE (Mandatory In NH)EXCLUDED4 It yes, describe under DESCRIPTION OF OPERATIONS below N/A XWS59334896 01/22/2019 01/2212020 PER FORT - TUTE ER E.L. EACH ACCIDENT $ 100,000 _ E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Liquor Store MANSFIO Town of Mansfield 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 Matthew Keras ACORD 25 (2016103) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD