HomeMy WebLinkAboutMansfield Deli - 12/31/2020dSL
Town of Mansfield - Board of Health
PERMIT NUMBER:
NO
�.
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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 Salei 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:
TELEPHONE AT LOCATION:
OWNER OF BUSINESS:
ADDRESS OF OWNER:
TELEPHONE OF OWNER:
FAX NUMBER:
�Z4— J7I— d)L-r)
rcrk6)-63>'_
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: `GL 9 (01
FEDERAL ID/SS NUMBER: LOU 1-tJ- �� v
SIGNATURE:
r
DATE: 1+ ZJ
A check mark signifies your understanding and agreement. I understand and agree that:
Q Itis 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.
@/I must consent to unannounced, periodic inspections and compliance checks of the permitted retail
establishment.
1�Self-service tobacco product and/or nicotine delivery product displays from which the customer may select
products are prohibited.
0/The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited.
,9 ! 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.
dd' Tobacco vending machines are prohibited.
U -/Non-residential Roll -Your -Own machines are prohibited.
Blunt wraps are prohibited.
21-�Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or.
thirty days.
❑ ,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.
�Cy 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).
I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited".
GII
E/ II must display signs provided by the Board of Health that discloses referral information about cessation.
GY 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 _�i� . / Date ' Z d 15
Print Name 3
Age -Restricted Products Policy & Procedures: Tobacco
Mansfield Deli
72 Pratt Street, Mansfield MA
Employees of this business have the duty and responsibility to ensure that
age -restricted items are not sold or otherwise distributed to minors.
TOBACCO PRODUCT SALES POLICY
Objective: That each employee of the Mansfield Deli will comply with all
applicable laws and procedures restricting the sale of tobacco products to
anyone under the minimum age of twenty on (21) years of age. These
products shall include but are not limited to: cigarettes, smokeless tobacco,
loose tobacco, pipe tobacco, rolling papers, cigars, e -cigarettes, vape and
lighters.
Protocol:
1. This policy and procedure shall be reviewed with and acknowledged
by each employee before engaging with customers and /or
completing any sales transactions.
2. Each employee shall complete the on line computer training program
or its equivalent with a score of 100% before engaging with
customers and/or engaging in any sales transactions.
I A valid form of identification is required for each and every tobacco
related transaction, with no exceptions, accommodations and/or
considerations.
4. Acceptable forms of identification must be active and current; they
are as follows:
a. Valid Massachusetts Driver's License
b. Valid Massachusetts State Identification Card
c. Valid US Passport
d. Valid Out of State Driver's License
5. No expired form of identification is acceptable under any
circumstances.
6. The photo appearing on the identification shall be visually compared
to the customer and the likeness matched, without reservation, to the
customer.
7. If a driver's license is relied upon for identification, it is to be scanned
into the cash register / point of sale system. If an identification card
or US Passport are relied upon, the date of birth reflected on the
identification must be manually entered into the system.
8. If it is suspected that an individual is purchasing tobacco products
for anyone under the minimum age of twenty-one (21), a valid form
of identification will be required from all persons present at the time
of and prior to concluding the transaction.
Age -Restricted Products Policy & Procedures: Tobacco
Mansfield Deli
72 Pratt Street, Mansfield MA
Employees of this business have the duty and responsibility to ensure that
age -restricted items are not sold or otherwise distributed to minors.
TOBACCO PRODUCT SALES POLICY
Objective: That each employee of the Mansfield Deli will comply with all
applicable laws and procedures restricting the sale of tobacco products to
anyone under the minimum age of twenty on (21) years of age. These
products shall include but are not limited to: cigarettes, smokeless tobacco,
loose tobacco, pipe tobacco, rolling papers, cigars, e -cigarettes, vape and
lighters.
Protocol:
1. This policy and procedure shall be reviewed with and acknowledged
by each employee before engaging with customers and /or
completing any sales transactions.
2. Each employee shall complete the on line computer training program
or its equivalent with a score of 100% before engaging with
customers and/or engaging in any sales transactions.
3. A valid form of identification is required for each and every tobacco
related transaction, with no exceptions, accommodations and/or
considerations.
4. Acceptable forms of identification must be active and current; they
are as follows:
a. Valid Massachusetts Driver's License
b. Valid Massachusetts State Identification Card
c. Valid US Passport
d. Valid Out of State Driver's License
5. No expired form of identification is acceptable under any
circumstances.
6. The photo appearing on the identification shall be visually compared
to the customer and the likeness matched, without reservation, to the
customer.
7. If a driver's license is relied upon for identification, it is to be scanned
into the cash register / point of sale system. If an identification card
or US Passport are relied upon, the date of birth reflected on the
identification must be manually entered into the system.
8. If it is suspected that an individual is purchasing tobacco products
for anyone under the minimum age of twenty-one (21), a valid form
of identification will be required from all persons present at the time
of and prior to concluding the transaction.
Age -Restricted Products Policy & Procedures: Tobacco
Mansfield Deli
72 Pratt Street, Mansfield MA
Employees of this business have the duty and responsibility to ensure that
age -restricted items are not sold or otherwise distributed to minors.
TOBACCO PRODUCT SALES POLICY
Objective: That each employee of the Mansfield Deli will comply with all
applicable laws and procedures restricting the sale of tobacco products to
anyone under the minimum age of twenty on (21) years of age. These
products shall include but are not limited to: cigarettes, smokeless tobacco,
loose tobacco, pipe tobacco, rolling papers, cigars, e -cigarettes, vape and
lighters.
Protocol:
1. This policy and procedure shall be reviewed with and acknowledged
by each employee before engaging with customers and /or
completing any sales transactions.
2. Each employee shall complete the on line computer training program
or its equivalent with a score of 100% before engaging with
customers and/or engaging in any sales transactions.
3. A valid form of identification is required for each and every tobacco
related transaction, with no exceptions, accommodations and/or
considerations.
4. Acceptable forms of identification must be active and current; they
are as follows:
a. Valid Massachusetts Driver's License
b. Valid Massachusetts State Identification Card
c. Valid US Passport
d. Valid Out of State Driver's License
5. No expired form of identification is acceptable under any
circumstances.
6. The photo appearing on the identification shall be visually compared
to the customer and the likeness matched, without reservation, to the
customer.
7. If a driver's license is relied upon for identification, it is to be scanned
into the cash register / point of sale system. If an identification card
or US Passport are relied upon, the date of birth reflected on the
identification must be manually entered into the system.
8. If it is suspected that an individual is purchasing tobacco products
for anyone under the minimum age of twenty-one (21), a valid form
of identification will be required from all persons present at the time
of and prior to concluding the transaction.
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 governing 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:.
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 the sale
in any of the cases described above.
Failure to follow this policy may result in disciplinary action up to and
including termination.
Store Operator Signature
Date
Date
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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 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
L
i•4; .t (l ie; 4 Jr%liUj
Printed Name Date
12 '-2 C
Store Operator Signature Date
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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 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
Store Operator Signature
9 C6 Al 1� Lo /� __ e N'
Printed Name
14/5//'�1
MR.
L0�
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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 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
Store Operator Signature
Senv)a 4smussen 1a�a�1
Printed Name Date
2-�_7C
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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 the sale
in any of the cases described above.
Failure to follow this policy may result in disciplinary action up to and
including termination.
1
Employee Signature
Store Operator Signature
a� 4 IFt t/� ai�h..i 1 �'�..L�.,.� -. �1 t✓ t �... � �.
V
Printed Name Date
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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 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
Store Ope for Signature
�Y'3vdcxn ChmitlinSK� Iz�3�zoi�
Printed Name Date
Date
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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 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
Store Operator Signature
(IOR V D D Rt�Fiv
Printed Name Date
l z -2---/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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 the sale
in any of the cases described above.
Failure to follow this policy may result in disciplinary action up to and
including termination.
JULk MOD
Lij
Employee Signature Printed Name
7
Store Operator Signature
11�
MC
ice-)--/'
Date
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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 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
-;) O�� �__
Store Operator Signature
Printed Name Date
–�_ S —(
Date
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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 the sale
in any of the cases described above.
Failure to follow this policy may result in disciplinary action up to and
including termination.
Io l e�
Employee nature
Store Ope ator Signature
Printed Name
Date
!2,-'�-(/1�
Date
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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 the sale
in any of the cases described above.
Failure to follow this policy may result in disciplinary action up to and
including termination.
kQ (*eq L_A/�l
I�
Signature Printed Name Date
/L -17(f
Store Operator Signature Date
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 governing 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:
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 age of 21. If any person regardless of age
attempts to make a tobacco purchase without and acceptable form of
identification, 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 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 Printed Name Date
Store Operator Signature
Date
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.
Signature of Individual drCorporate Name
i -W41 -,�-
"Social Security No. (Voluntanj) or Federal
Identification Number
By: Corporate Officer (Mandatonj, 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.
CAUsers\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information MANSEVID WE, QI LU Please Print Legibly
Business/Organization Nam epyp 7 p��ATT �S'TR "Tryry
l6 tj¢An I y ,1
_v b 6 - A
City/State/Zip:
Phone #: 5vx 3 2-55%
Are you an employer? Check the appropriate box: Business Type (required):
1.❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6.❑RestaurantBar/EatingEstablishment
2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
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] * I .❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
--E ny applicant mal CnCCKS box Ht must also nu 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 #1.
I am an employer that isproviding workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: 'N— t sq,) P - n Q
Insurer's Address: U P V)t pg \ L _N -2 9') '1, f `c 2
City/State/Zip:
M
13ti6-�—
Policy # or Self -ins. Lic. # 0Y K10– TY H f L• 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 cern �under the ai� andpenalties ofperjury that Ute information provided above is true and correct
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
L67 5
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