HomeMy WebLinkAboutMansfield Gas Co. (W. Samrout Corp., Inc.) - 12/31/2020Town of Xfan,�flelcl.- Board of lkedth
PERMIT NUMBER:
— j 5c)'P'
Town of Mansfield
0 Park Rove
Mansfield;' V(Af
�1#p�
rlpplieution for the Stile o;70bacco 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: W (A.tS & `D r:AcfMfcy A CC t�.
LOCATION OF SALE OF TOBACCO PRODUCTS: �j t-�., (�Mt __..
TELEPHONE AT LOCATION: SG�,- 3 3-1 ^3 1 .tq
OWNER OF BUSINESS: W ra\4 ---JCLrv'roa ADDRESS OF OWNER: Sc t, c er*r,,k \-�- j �O)Clacr ' ry\.
TELEPHONE OF OWNER: �S63-%(Oct-�IC1-�
FAX NUMBER:
If a corporation or partnership, give name, title, and home address of officors or partner.
COt Ful-LAlon, WaIIb S��rnre�-1 1'cPs,i,.a,�i, c�n�tal. 51,
(Au"vi _ \4M)A-S;Cuyxro-4f rft—J-1_ 3cX>c enFrul
Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training
documentation 1 (r jj�� ryry ��-({�� {tom ��/ L V /� /�
T �Cwe 'I'KPm �e 1 , e �Iee Au Lutc f %1 �I'�e 1 (",�1hq TC
34ure v son" _ r _ U U l
Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License.
FEE: $150.00
CT-3T NUMBER: rlYAb")-.3 -.4 .(
FEDERAL ID1SS NUMBER: OLQ 86s)")- I
SIGNATURE
DATE:
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.
:�--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 1D for anyone less than 27 years of age.
E—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 dearettes in packages of fewer than 20 cigarettes is prohibited.
ze 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 device; 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.
c/f acco vending machines are prohibited.
Non-residential Roll -Your -Own machines are prohibited.
hunt wraps are prohibited.
1I Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or
thirty days.
;imay 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.
il�l most prominently display a ropy of the "Permit to Sell Tobacco and Nicotine Delivery Devices".
r--i mist 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).
'imust display Department of Public Health signs stating, 'Sale of tobacco to Minors is prohibited".
must display signs provided by the Board of Health that discloses referral information about cessation.
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,
SignatureDate
Print Name�_(d_I-1�_„_-i�
TAX CERTIFICATION FORM
I certify tinder the penalties of perjury that 1, to my best knowledge and
Belief, have filed all state tax returns and paid all state taxes required
tinder law.
lllctlia Samrw'K�y'•�rC
-- --- (tls -- Lirnt i --- - -----
Siyflahtre o[ kulidvival ar Co
Ntmre BY: Corporate Officer (Nltmda1,11y, q Applicable)
___aLka_h51771 _
"Social Security No. (bolo aanp) or Fedetap
Cdetttifleatimt Noniber
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security ru inber vvill 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 then non -filing or
delinquency will be subject to license suspension or revocation. This
request is made tinder the authmily of Massachusetts General Law
Chapter 62C, section 49A.
C^L'srrswleilq�Lteaklnh:Srott'x rmmml, rood Eihhli,l o,ls. ilmli TAX CERTIFICATION FORM.dw
The Commonwealth of'Mosaochusefts
-0 �r
Department of Indust ial Accidents
Office of Investigations
1 J
600 Washington Streel
r
Boston, AIA 02111
evivie-nuiss. ovVia
g
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leefbiy
Bus€ness/Organization Ntauc:--W(Aki v�
City/State/Zip:_ �(A€` Ao tdi5 j_ _ �I'hon it:SCy�v �3 1 �' '
Are you an employer? Check the appropriate box:
Business Type (required);
S- elan
LC] F am a employer with $ _ employees (fldl maV
m pail -tune)•*
6. E] RestauranUffiwEating Establishment
2,E] T ant it sole proprietor 01'parhlerhip and have no
7, ❑ OtTice and/or Sales (incl. real estate, into, etc.)
employees working for me in lily capaeit}'.
S- F]Noniemfif
[No workers' comp. insurance required]
3.0 We are a corporation and its officers have exercised
`t. Enieviaumlont
their right of exemption per e.1i2,§ f(`!), and wo have
100 mmaltaeturuig
no employees. [No worker,' comp. insuruice :'cyuiredr"
11 f] Health Care
,f n We are a non-profit organization, staffed by voltaneers,
f
with no employees. [No workers' comp. insurance req.]
+ 2.❑ Other_ -
%Any zPPncmddat dlW1 s tux Hl m,rFl also fill out We sntma helot:',how5nq,,air sorkns' eenrpanaate,n Ix,hcy h,ferrmt[en.
-elf the emporate .them hate exeaapted them eW_s, bnl the wc}r>mtiou hos ob,er c+uj luyeej, A u.rAvrG w,npursanun Puliay u mquimd m+d each m,
oramuzatton should Check bor:31. _
tour ml employer [tut Is prordtlbtg rrorkec{ congrensatlou itunranre Jbr nq� eleplapees. Below is the paaey hrformallon•
Insumuce Company
cli
City/StaWzip:
Policy;! or Self -ins. Lic
.Attach a copy of the wm'kers' compensatiou pat icy declaration page (ihowiug W e policy mmther mul expiration date)•
Paihire to secure cocerege as required under Section ?SA of NIG1. c. 152 call land io the iniposition of criminal Pei nflict of a
fine np to S1,500.00 aad/or one-year imprisomuent, as well as civil penalties iit the form of a STOP 1VOR.h ORDER end a fine
of up to $250.00 it day against the violator. Be advised that it copy of this statcnlenl may be forwarded to the OtTiee of
Investigations of the DIA for insurance coverage verification.
1 do hereby cerij/i; udder tie palms and penalties ofperjurr that the 7nJhrma ion provided ahovve is rrae and correct.
Signature:_
Offlelat use only. Do not noire in this area, to be completed by city at teen official.
City or Town:
Poroltt%Lirensc
Issuing Authority (circle ono):
L Board of Health 2, Building Department 3. Cityrrown Cleric 4. Licensing Board 5, Selectmen's Office
6. Other
Information and Instructions
Massachusetts Cienennl Laos chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this stamle, an employer is defined is `...every person in the service of another under any contract of hire,
express or implied, oral or writ ca."
An employer is defined as ".in individual, partnership, association, corporation or other legal entity. or ally two or more
of the foregohtg engaged in a joint enterprise, anti including the legal represeutal ives of a deceased employer, or the
receiver or trustee of all individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling horse having not more than three apartments and who resides therein, or Cite occupant of the
dwelling house of another who employs persons to do maintenance, construction or mash work on such dwelling )house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be nth employer"
MGL chapter 152. §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct balidhngs in the cmmnonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally. MGL chapter 152, §2507) states "Neither the commonwealth nor any of its political subdivisions shall
ender into any contract for the performance of public work until acceptable- evidence of compliouce with the insurance
requirements of this chapter have been presented to the conuacling authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and Phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited liability Partnerships CUT) with tie employees other than lire members
or partners, are not required to carry workers' compensation iusnrance. if an LLC or LLP does have employees, a policy
is required, Be advised that flits affidavit may be submitted to the Department of hhdustrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date tire affidavit. The affidavit should be returner) to the city or town
that the application for the pennir or license is being requested, not the Department of Industrial Accidents. Should you
have may questions regmding the law or if you are required do obtain a workers' compensation policy. please call the
Department at the number listed below. Self -insured conpmues should enter thheir self-insurance license number tut the
Appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and to legibly. The Department has provided a space at the bottom
(if tire affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition. an applicant that
must submitmultiple permit, license applications in any given year, need only subunit one, affidavit indicating current
policy information (if necessary). A copy of the affidavit itat has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for finum pemtts or licenses. A new affidavit
most be filled out each year. where a home owner or citizen is obtaining a license or permit not related to any business
or connnemial venture (i.e. a dog license or permit to bunt leaves etc.) said person is NOT required to complete this
affidavit -
The Office of hwestigations would like to thank you in advance for your cooperation and should you have ally questions,
please do not hesitate to give us a salt
The Departments address, telephone and fax another:
The Commonwealth of Massachusetts
Department of Industrial Accidwits
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-977-MASSAFF,
Fax # 617-727-7749
hawwanass,govldia
Fam rlecised 5-26-05
Age -Restricted Products Policy & Procedures: Tobacco
LOCATION
Every Employee at this location has the legal and morel 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 and procedures of this policy
related to the sale of tobacco products including: cigarettes, smokeless tobacco,
loose tobacco, pipe tobacco, rolling papers, cigars, e-cigarettes, vape and lighters.
The minimum age to purchase tobacco products is twenty one (21) years 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 twenty one (21),
PROCEDURES:
1, This policy will be reviewed with all new Employees before they can
operate a cash register and sell tobacco.products.
2. All store Employees to take computer based training and successfully pass
with 100% prior to starting on a register. This certification to be updated
on an annual basis prior to previous year expiration.
3. A valid form of identification will be required for all tobacco purchases
regardless of age or frequency of customer visits.
Acceptable 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
scanted 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 oil 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.
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
fall to follow store policy and local and irate laws about the sale of tobacco or nicotine delivery products to
.
any person under the legal age, I could lose my job or be fined.
agree to the following r uies about the sale of tobacco products:
I will not sell any tobacco products, Including cigarettes, cigars, chewing tobacco, bldis, or any other form
of tobacco, or any nicotine delivery product to any person under the age of Rl. 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 myjudgment not to make the sale in any of the cases described
above.
Failure to follow this policy may result in disciplinary action up to and including
termination.
Employee Signature
Date
Store Operator Signature Date
(This form will be maintained in your personnel file as a part of your permanent
employee record)
TRAVELERS J WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICYNUMBER: (GHOB-11C96621-3-19)
NEW-10
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
1.
INSURED:
WALID SAMROUT CORPORATION INC
54 CHAUNCY STREET
MANSFIELD MA 02048
Insured Is A CORPORATION
NCCI CO CODE: 13439
PRODUCER:
DOWLING INS AGENCY INC
PO BOX 850962
BRAINTREE MA 02185
Other work places and Identification numbers are shown In the schsdule(s) attached,
2. The policy period Is from 03 -28-19 to o3-2a-20 12:01 A.M. at the Insured's mailing address,
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In
Ram 3.A. The limits of our liability under Part Two are;
Bodily Injury by Accident: $ 100000 Earn Accident
Bodily Injury by Disease: `v 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 068
D. This policy includes these endorsements end schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this poilcy will be determined by our Manuals of Rules, Classifloations, Rates and Rating
Plana. All required Information Is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 05-01-19 HG
OFFICE; ORLANDO INDUS AFF 161
PRODUCER: DOWLING INS AGENCY INC
01330
2.1SNT
ST ASSIGN: MA
TRAVELERS
CLASSIFICATION SCHEDULE:
CLASSIFICATIONS CODE NO
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PACE WC 00 00 01 ( A)
POLICY NUMBER; (CHUB-1K96621-3-19)
PREMIUM BASIS
ESTIMATED
RATES ESTIMATED
TOTAL ANNUAL
PER $100 OF ANNUAL
REMUNERATION
REMUNERATION PREMIUM
SITE EXTENSION OF INFORMATION PAGE - SCHEOULE(S)
SIC -CODE: 55i 1 NAICS: 441110
'---_.._____---_----------- ------------------------`--------------.._-----
STANDARD
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 3750
PREMIUM DISCOUNT NONE
0900-20 EXPENSE CONSTANT 338
'TERRORISM 45
TOTAL ESTIMATED PREMIUM 4133
TAXES AND SURCHARGES 144
DEPOSIT AMOUNT DUE 4277
A/R (WCIP) #
Minimum PrOMIUM: $ 266
DATE OF ISSUE: 05-01-19 HG
OFFICE: ORLANDO INDU5 A" 161
PRODUCER: DOWLING INS AGENCY INC 23FNT
ST ASSIGN: MA
TRAVELERS` WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
EXTENSION OF INFO PAGE -SCHEDULE WC 00 00 01 ( A)
POLICY NUMBER: (CHUB-1K96621-3-19)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
INSURED'S NAME: WALID SAMROUT CORPORATION INC
RATE BUREAU lb; 000000397
PREMIUM BASIS
ESTIMATED RATES
TOTAL ANNUAL PER $100 OF
CLASSIFICATION CODE REMUNERATION REMUNERATION
LOCATION 001 01
FEIN 0428OS171 ENTITY CO 001
WALID SAMROUT CORPORATION INC
54 CHAUNCY STREET
MANSFIELD, MA 02048
SIC CODE: 5511 NAICS: 441110
AUTOMOBILE SERVICE OR REPAIR
CENTER 8 DRIVERS 8380 150612 2.49
13439-MA
ESTIMATED
ANNUAL
PREMIUM
gm
------------- ,..----------------------------------------------- .-----_-------------__--
MERIT RATING/EXPERIENCE MOD: NONE MODIFIED PREMIUM $ NONE
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 3750
EXPENSE CONSTANT(0900) 338
0.0300 TERRORISM (9740) 45
3.83% MA WC SPECIAL FUND AND TRUST. FUND 144
TOTAL ESTIMATED PREMIUM 4277
DEPOSIT AMOUNT DUE 4277
DATE OF ISSUE: 05-01-IS HG ST ASSIGN: MA SCHEDULE NO: 1 OF LAST
W1140
�Gep�
Colilmonwealth or Massachusetts
Department of Revenue
Commissioner
Christopher C. Harding,
�v S
F�y-r pFe
ma55.gOv/dOr
c
Letter ID: L1027466368 L
Notice Date: September 4, 2018
Account ID: CGL-11753998-010'
RETAILER LICENSE FOR SALE OF CIGARETTES
t11111Idyllrl1111111111111111111111141nlltlytllu.�Inllhltl
WALID SAMROUT CORPORATION INC
MANSFIELD GAS SERVICE
H = 54 CHAUNCY ST
MANSFIELD MA 02048-1902
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
3nass gav/masstaxnonnect 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
MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-31
This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
;c
WALID SAMROUT CORPORATION INC Account ID: CGL-11753998-010
MANSFIELD GAS SERVICE License Number: 942073856
54 CHAUNCY ST
MANSFIELD MA 02048-1902
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws
sell at retail at the address shown above. This lict,nse is non -transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
-" -,.:-", October 1, 2018 Expiration Date: September 30, 2020
Age -Restricted Products Policy & Procedures: Tobacco
LOCATION
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 procedures of this policy
related to the sale of tobacco products including: cigarettes, smokeless tobacco,
loose tobacco, pipe tobacco, rolling papers, cigars, e-cigarettes, vape and lighters.
The minimum age to purchase tobacco products is twenty one (21) years of age.
It is our responsibility as a retailer and members of the community to preventthe
sale of tobacco to anyone under the age of twenty one (21).
PROCEDURES:
1. This policy will be reviewed with all new Employees beforethey can
operate a cash register and sell tobacco products.
2. All store Employees to take computer based training and successfully pass
with 100% priorto starting on a register. This certification to be updated
on an annual basis prior to previous year expiration.
3. A valid form of identification will be required for all tobacco purchases
regardless of age or frequency of customer visits.
Acceptable 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 from all members of the
party.
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 agreeto the following rules about the sale of tobacco products:
I will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis, or any otherform
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. I will notaccept
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.
Failure to follow this policy may result in disciplinary action up to and including
termination.
Em loyee Signature__--- — -
Store Operator Signature
Date
--h=a-S=W--—
Date
(This form will be maintained in your personnel file as a partof your permanent
employee record)
Age -Restricted Products Policy & Procedures: Tobacco
LOCATION
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 minorsll
TOBACCO PRODUCT SALES POLICY
Objective: That all store Employees follow all laws and procedures of this policy
related to the sale of tobacco products including: cigarettes, smokeless tobacco,
loose tobacco, pipe tobacco, rolling papers, cigars, e-cigarettes, vape and lighters.
The minimum age to purchase tobacco products is twenty one (21) years of age.
It is our responsibility as a retailer and members of the community to preventthe
sale of tobacco to anyone under the age of twenty one (21).
PROCEDURES:
1. This policy will be reviewed with all new Employees before they can
operate a cash register and sell tobacco products.
2. All store Employees to take computer based training and successfully pass
with 100% prior to starting on a register. This certification to be updated
on an annual basis priorto previous year expiration.
3. A valid form of identification will be required for all tobacco purchases
regardless of age or frequency of customer visits.
Acceptable 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 from all members of the
party.
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, orany otherform _
of tobacco, orany nicotine delivery product to any person underthe age of 21. If any person regardless of
age attempts to make a tobacco purchase without an acceptable, 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.
In turn, management agrees to support my judgment not to make the sale in any of the cases described
above.
Failure to follow this policy may result in disciplinary action up to and including
termination.
�L'tt� l'V • � i /Y �V Vn, � l i
I =2s
Employee
employee record)
Age -Restricted Products Policy & Procedures: Tobacco
LOCATION
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 and procedures of this policy
related to the sale of tobacco products including: cigarettes, smokeless tobacco,
loose tobacco, pipe tobacco, rolling papers, cigars, e-cigarettes, vape and lighters.
The minimum age to purchase tobacco products is twenty one (21) years of age.
It is our responsibility as a retailer and members of the community to preventthe
sale of tobacco to anyone under the age of twenty one (21).
PROCEDURES:
1. This policy will be reviewed with all new Employees before they can
operate a cash register and sell tobacco products.
2. All store Employees to take computer based training and successfully pass
with 100% priorto starting on a register. This certification to be updated
on an annual basis prior to previous year expiration.
3. A valid form of identification will be required for all tobacco purchases
regardless of age or frequency of customer visits.
Acceptable forms of id areas 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 from all members of the
party.
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 1 =
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 anytobacco products, including cigarettes, cigars, chewing tobacco, bidis, oranyotherform
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. I will not accept
a note from an adult giving permission to a person underthe 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.
Failure to follow this policy may result in disciplinary action up to and including
termination.
Employee Signature
Date
—44wu6z----- —
Store Operator Signature Date
(This form will be maintained in your personnel file as a part of your permanent
employee record)