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HomeMy WebLinkAboutFour Corners Convenience - 12/31/2020PERMIT NUMBER: 'h Sgh, o"' 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: LAer�_ LOCATION OF SALE OF TOBACCO PRODUCTS: L-1 'ol\ TELEPHONE AT LOCATION: S_Cl�- � 3 7 - 6 l l I OWNER OF BUSINESS: I>\ e I 5 ADDRESS OF OWNER: LA 0� Skt\�)ke _6C. C) TELEPHONE OF OWNER: _09__ clik'i— $\77? FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation eoy�' Ci -C&I �v e(-,, k� (YA e- Ap��'e C' 0/ r\ \ftAlrcr Provide a copy of current Department of Revenue CT-3T Retaii Excise Unit License._ FEE: $150.00 CT-3T NUMBER: 7 5- ,!of FEDERAL ID/SS NUMBER: 4 — U� — �A SIGNATURE: DATE: l() \� 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 I ss than 21 years of age, regardless of how old the person looks. I' 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. Self-service tobacco product and/or nicotine delivery product displays from which the customer may select roducts are prohibited. V/Xphe sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. LR I may not distribute any free samples of tobacco products or nicotine delivery products (e.g. e-cigarettes) and I may not accept any means, instruments or devices that allow for the redemption of tobacco products for free or cigarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue. Tobacco vending machines are prohibited. tll/ Non-residential Roll -Your -Own machines are prohibited. &lunt wraps are prohibited. Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. VI 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. must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". E3 I must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts f j Department of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license). [7 I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". VI must display signs provided by the Board of Health that discloses referral information about cessation. X�I 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 Print Name Date Every Employee at this location has the leEal 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 prevent the sale of tobacco to anyone under the age of twenty one (21). 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 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 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 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 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 Date U 2 2_— t`V Date (This form will be maintained in your personnel file as a part of your permanent employee record) 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. Cur Signature of Individual or Corporate Name (:)�A L, } � &-C) "Social Security No. (Voluntary) or Federal Identification Number 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\Scoh's Documenls\Food Establishments- Temp\TAX CERTIFICATION FORM.doc i ne uommonweatrn of massaenuseas Department of Industrial Accidents %ll 1" Office of Investigations �° 600 Washington Street ,\ f ! ` Boston, MA 02111 r www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: U�h C( 'r Address: (A s c Mt,_� j City/State/Zip: (ns'� /M I/c �cx ( Phone #: AUK - Are you an employer? Check the appropriate box: Business Type (required): Mail 1-ElI am a employer with employees (full and/ 5. 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. g• ❑Non-profit Wo workers' comp. insurance required] ❑ 3.M e 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]* I1.❑ 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 #1 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 #1. I out an employer that is provi fig woyl�rers' compensation insurance for my employees. Below is the policy information. Insurance CompanyName:/ "tit ``'L W L Insurer's Address: City/State/Zip: t 3�CA rn�f'C' DiUva;O �-ACA /cai/ 2,0 ) Policy # or Self -ins. Lic. # Expiration Date: 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, under the pains and penalties of perjury that the information provided above is trite and correct. ___ .__. Harp• Official use only. Do not write in this area, to be completed by city or town ojjicial. 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.masxgov/dm ACORO' vAsucol ��. CERTIFICATE OF LIABILITY INSURANCE DATE 1012212019Y) 10/22/2018 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 pollcy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of tha policy, certain policies may require an endorsement. A statement on this certificate does not confer Alibis to the certificate holder in lieu of such endorsemen s . PRODUCER 508-947-1818 J.K. 011vieri Ins. Agency 64 East Grove St. Middleboro, MA02346 -Xmas: Kenneth W.Olivier! JNAJ9GT Kenneth W. 011vierl PxoxE 508-947-1818 FAX Alc Nd, Eal : No : - AFFORDING COV INSURER A: NGM Insurance Co. C 14788 INSURED Vasud�v �or o ation dba Town �NgawNggrtTh Icylk� t ency Mansfield, I gD248 usuasRB:Technology Insurance Co. — I URER C_ sURERO: NHURER H INSURER F: COVERAGES CERTIFICATFMIIMRPR• - . RcvlelnM N"UnErt 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. I SR TYPE OF INSURANCE ADDL SUS POLICYNUMBER POLICYEFF -11/3012018 POLICYHXP LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS41ADE � OCCUR Business Owners BPF1371Y - 11/30/2019 EACH OCCURRENCES ,000,OOO DAMAGE ORENTED 3 600,00g X NED EXP (Any wear 10,000 PERSONALB AUV INJURY S 1,000,000 EN'LAGGR GATE LIMIT AP KS PER: X POLICV� j LOG OTHER GENERAL NEGATE 2,000,000 PRODUCTS •COMP/OP AGO S 2,000,000 AUTOMOBILE LIABILITY AMYAUTO OWNED SCHEDULED AUTOS ONLY ANNUTNNODWUINEED AUTOS ONLY 2TOWMM COMBIN D SINGLE LIMIT BODILY JURY Per eson BODILY INJURY Pera nl 40PE�YI AMAGE UMBRELLA LIAB EXCESS LIAB OCCUR CWMS49ADE EACHOCCU REN E ACOBEGATE DED I IRMNUONi B ADEPLYNBLBTILQYq A IA ANYPROPRIETORPARTNERIEXECUTNE EXCLUDED? MMw-rryMrN 01E•es, describe ranter RATI N NIA TWC3776493 03/13/2019 03/13/2020 X SPTEARTI FORT H- E.L. EACH ACCIDENT 500000 , 15.1— DISEASE -EA EMPLOYE 1 500,000 8 600,000 p Business Owners Liquor Liability BPF1371Y 11/30/2018 11/30 01019 See Limits Below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Add6lonal Rams**Sohedulo, may bs aNaohad Umcm span is requlnd) Liquor Liability Coverage: 11,000,000 Each Common Cause Limit 2,000,000 Aggregate Limit 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. ACORD 26 (20161031 ©1988-2015 ACORD CORPORATION. All r1Ghts The ACORD name and logo are registered marks of ACORD