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HomeMy WebLinkAboutWInes & More (GT Retail, Inc.) - 12/31/2020#l�tl63 _j ° Town of Mansfield Town of Mansfield - Board of HeA � 4 ti, $ 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: Wines & More - Mansfield LOCATION OF SALE OF TOBACCO PRODUCTS: 280 School Street, Suite 140, Mansfield, RI 02048 TELEPHONE AT LOCATION: 508-339-6900 OWNER OF BUSINESS: Kathleen Haronian ADDRESS OF OWNER: 98 A Nipmuc Trail, No. Providence, RI 02904 TELEPHONE OF OWNER: 401-353-4400 FAX NUMBER: 401-353-4469 If a corporation or partnership, give name, title, and home address of officers or partner. Kathleen Haronian, President 98 A Nipmuc Trail, No. Providence, RI 02904 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: $150.00 CT -3T NUMBER: 489965568 FEDERAL ID/SS NUMBER: 27-2176426 SIGNATURE: DATE: 11/11/19 A check mark signifies your understanding and agreement. I understand and agree that: 2 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. EV 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. C�} 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. Fl/ I must consent to unannounced, periodic inspections and compliance checks of the permitted retail /stablishment. LAY Self-service tobacco product and/or nicotine delivery product displays from which the customer may select /products are prohibited. B The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. I/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 /igarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue. G3 Tobacco vending machines are prohibited. 6/ Y Non-residential Roll -Your -Own machines are prohibited. q�Blunt wraps are prohibited. q/Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. U/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. E/ must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". CN 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). C9 I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". U// I must display signs provided by the Board of Health that discloses referral information about cessation. L9 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 Date 11/11/19 Print Name Kathleen Haronian 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. i aTf Individual or Corporate Name 27-2176426 "*Social Security No. (Voluntary) or Federal Identification Number Kathy Haronian By: Corporate Officer (Mandatory, if Applicable) *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.doe The Commotttvealth ofMassitclutsetts Debar Intent of Indus'trlal Accidents Office of. investigations 600 Washington Street Boston, MA 02111 rotvw.mass.gov/slip Worlters' Compensation Insurance Affidavit: General Businesses Applicant Infos mation Please Print LeeiblV Business/Organization Norm: GT Retail Inc. D/BA Wines & More - Mansfield Adch'ess: 280 School Street Suite 140 City/Slate/Zip:Mansfield, MA 020"' _ Are you all employer•? Cheeh the appropriate box; I. © I am a employerwith 16 employees (full and/ or part-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 por c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4, ❑ We are a non-profit organization, staffed by Volunteers, •th no em to ens [No workers' comp, insurance req,] Phone #: 508-339-6900 — Business Type (required): S. ® Retail . , 6, ❑ RestamnnUBar/Bating Establislunent 7, ❑ Office and/or Sales (inch real estate, auto, cte.) 8. ❑ Non-profit 9, ❑ Entertainment 10,❑ Manufacturing I I Health Care 120 Other wt p Y +Any ppplicnat that checks box II I must plso till oat tae section belmv shorvh+g their warkus' compensption poitoy information. *'tone corpomlo 0011CO s novo oxempted Ihemnselves, but the corporation lips oilier employees, a workers' compa+sp0m+ policy is required and such an orsalljoa en should check box III, _ I ant as ewployer that Js provlding ivo•Iters' conrpemsatlan ttsuroree for say eatployees, Belov is sire po!!cy !ryjarutntior• Insurance Company Name: MARETAL_MERCHANTS WC GROUP INC. Insm•er's Address: P,O. BOX 859222-9222 City/Statelzip: BRAINTREE, MA 02185 Policy 8 or Self -ins. Liumiggm 05032982119 BxpratIonDate: 1/I/2— --Attach a copy of the wmpensatlor policy declarationpage (showing fie policy number and. expir'ntion dote).Failure to Semite coverred runlet Sectlen 25A ofMGL c. 157. can lead to the imposition of crhninal penalties of afine up to $1,500,00 anar nitprlsonmen(, as well as civil penalties in the form of a STOP WORK ORDE2 anti a fineof up to $250,00 a dayviolator. Be advised that a nopy of this statement may bo fowardea to IIIc Office ofinvestigations ofthe D•anee coverage verification, 1 do hereby eertlf , m tier the p Ir v and perrnl!ler of perfaty teat tlra Jr fomrr/tom provided above Ls tree pad correct. f"' tea,+ Dnte: 8/5/19 me it, 401-3534io0 Official use only. Do not write Ju lids area, to be completed by div or tolvn offletal. City or Town: Permit/License t5 Issub+g Authority (circle one): 1, Board of Health 2. Building Department 3• City/Town Clerk. 4. Licensing Board 5.5elechuen's Office 6. Other _ Phone 0: Contact Persom www.mnsyaov/dip 4SAC}R�sd, Commomvealth of Massachusetts Department of Revenue n ,a Christopher C. Harding, Commissioner �Nryr ofi� mass.govldor Letter ID: L0021889664 Notice Date: September4, 2018 Ew% Account ID: CGL -I 1451273-008 RETAILER LICENSE FOR SALE OF CIGARETTES �I�Illlll�hllnhlu�uu" ��II�JIfh�b��lbd���lu��h�u�1� GT RETAIL INC R i® WINES & MORE - MANSFIELD m� 1405 DOUGLAS AVE NORTH PROVIDENCE RI 02904-4052 Attached below is your Retailer License for Sale of Cigarettes (Form CT -3T). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at tnass.gov/masstaxcontzect to -view and re -print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll-free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE shit-tus,�,.� IVIASSACHUSETTS DEPARTMENT OF REVENUE - Form CT -3T m�n 2 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. GT RETAIL INC Account IID: CGL -11451273-008 WINES & MORE - MANSFIELD License Number: 489965568 280 SCHOOL ST MANSFIELD MA 02048-1840 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 Bate: October 1, 2018 Expiration Date: September 30, 2020 Retail Store Operations Section: 3.23 Alcohol and Tobacco Service Effective: 05/15/1998 Revised: 08/25/18 It is not the policy of this store to allow for the sale of alcoholic beverages to any one under the legal age of 21 years old. It is the responsibility of the cashier to properly identify the age of patrons who are requesting service. It is the policy of this store that if any individual does not appear to be 40 (Forty) years of age that they are to be asked for proper identification to verify their age. Other shoppers, who accompany purchasers, will also be asked for their ID's. If proper Identification cannot be presented, by all, then no sale will occur. All cashiers will be trained before 30 of employment has expired, by either the S.T.O.P training or T.I.P.S training program, to receive certification of proper alcohol and tobacco service. Any violation of this policy will result in the immediate termination of the employee. All employees acknowledge that they will be responsible for all penalties or fines assessed or incurred as a result of failing to properly check identification and servicing of alcohol to minors. This store is equipped with an ID Checker to verify the authenticity of each ID when it is asked for. All ID's once asked for will be scanned for authenticity. IF the ID is not deemed authentic, NO SALE WILL OCCUR! Furthermore, it is not the policy of this store to allow for the sale of tobacco products to any one under the legal age of 18 years old. It is the responsibility of the cashier to properly identify the age of patrons who are requesting service. It is the policy of this store that if any individual does not appear to be 30 (Thirty) years of age that they are to be asked for proper identification to verify their age. Any violation of this policy will result in the immediate termination of the employee. All employees acknowledge that they will be responsible for all penalties or fines assessed or incurred as a result of failing to properly check identification and servicing of Tobacco to minors. This is the Policy of This Store for Alcohol and Tobbaco service In response to the nationwide concern over the problem of "Underage Drinking" and "Under Age Tobacco Use" the Management of This Store feels that it is important that you be aware of our policies concerning the service of alcohol and tobacco. 1. No person under the age of 21 (Twenty -One) years of age is to be served alcoholic beverages of any kind under any circumstance. Parental approval is not even a reason for doing such. This is the law in both Rhode Island and Massachusetts. No person under the age of 18 (Eighteen) years of age is to be served tobacco of any kind under any circumstance. Some Massachusetts communities are now 21 years of age. Please check with your Store trainer or Manager. 2. It is the responsibility of the cashier, to verb the identification and Date of Birth of all young people. If the in do not look 40 (Forty) years of age, for alcohol or 30 years of age for tobacco, you are to askfor their I.D. Once an I.D. is asked for, no one may over -ride or change that decision. The I.D. must be presented if service is to continue 3. Any individual observed receiving money from a minor will be refused alcoholic beverage or tobacco service. 4. Individuals observed shopping with purchaser will also be carded. Only fourforms ofldentification will be accepted at This Store: State Issued Driver License. This must be current and include photo! Expired licenses are worthless State Issued Identification Card. Must be current and include photo! Armed Services LD. Must be current with photo& date of birth! Passport Must be current with photo & in ENGLISH! Any violations of this policy will be grounds for immediate dismissal. Additionally, the employee agrees to pay for any fines levied as a result of serving a minor. No Exceptions! I have read and fully understand this policy and agree to adhere to it always. Employee Signature: Date{ Preventing Youth Tobacco Sales Employee Agreement 2019 Studies show that Massachusetts's youth under the age of 21 are able to purchase tobacco products in many retail stores, even though it is illegal to sell tobacco products to them. This employee agreement, which you must sign, will ensure that this store does not sell tobacco to minors. I understand Massachusetts's law and the Board of Health Tobacco Control Regu ation a ecting gout Access to Tobacco Products' prohibits the sale of tobacco products to youth under the age of 21 years of age. I understand that my failure to follow store policy, state law and local regulations could result in discipline, including loss of my job or a fine of one hundred ($100.00), two hundred ($200.00), or three hundred ($300.00) dollars and that my employer could lose their permit to sell tobacco products tmlb®f multiple violations. • 1 will not sell any tobacco products to anyone under the age of 21. • If the person appears to be under the age of 27, 1 will ask for ID. I can only accept a valid government -issued photo ID. (like a drivers license, passport, military ID or Liquor ID. If there is any doubt about the persons age I will not make the sale. • 1 will not accept a note from an adult giving permission to a person under the age of 21 to buy tobacco products for them. In any of the above cases, management agrees to support my judgment in not making sales. Employee's Name (Print): Employee's Signature: _ Store Managers Signature Establishment Name: Zip Code: *In accordance with the Board of Heath Tobacco Control Regulations, a copy of this agreement must be kept on file in the establishment permitted to sell tobacco products; it must be available for inspection by the Board of Health and/or their agents during normal business hours 6.12.09 G.N.B.T.C.P.