HomeMy WebLinkAboutShaw's #431 - 12/31/2020Town of Mansfield - Board
NOV
of Health
""Town of Mansfield
8 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: �`��r t� v�I 5 —* 4 i
LOCATION OF SALE OF TOBACCO PRODUCTS: H� T
TELEPHONE AT LOCATION: —
OWNER OF BUSINESS: r b/7 W S S1A � r (Y�LA r �< 2 { �y i tit t
ADDRESS OF OWNER:Gi
TELEPHONE OF OWNER:
FAX NUMBER: (a'-� L cf — 14t,/ .
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: $150.00 q
CT -3T NUMBER:
FEDERAL ID/SS NUMBER: 0q— i � a �H a c'
s
SIGNATURE:t�"�� ° ,•� ,�( ,
DATE: i., f
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.
iT 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.
Ff 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.
E I must consent to unannounced, periodic inspections and compliance checks of the permitted retail
establishment.
°E"_ elf -service tobacco product and/or nicotine delivery product displays from which the customer may select
products are prohibited.
R3 The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited.
PrI 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.
-Pr Tobacco vending machines are prohibited.
,E Non-residential Roll -Your -Own machines are prohibited.
Er Blunt wraps are prohibited.
[a' Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or
thirty days.
[i l 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.
F7 r I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices".
Pr 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).
H' II must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited".
Ite I must display signs provided by the Board of Health that discloses referral information about cessation.
N5 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.
1 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.
t,
jp�(g r�
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Signature �6A `.` ,� tom.. Date I
Print Name Tiffany Corcoran
Supervisor Tax
6gnGFltte�� Commonwealth of Massachusetts Letter ID: L1530344064
m Department of Notice DaSeptember 17,
b 1 M Christopher C. Harding, Commissioner
�EYr ow`` mass.gov/dor Account Date:
CGL-1154665 2018 2018
RETAILER LICENSE FOR SALE OF CIGARETTES
n1l'1111161u III IIII 111111111111.1lllnrrIIII III I'll lllIIIII
TAX DEPT
SHAWS SUPERMARKET INC
SHAMS SUPERMARKETS INC STORE NO 2
PO BOX 29096 MS # 6531
PHOENIX A7 85038-9096
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
mass.gov/masstaxconnect 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
SPt%HUSt, 'aMASSACHUSETTS DEPARTMENT OF REVENUE Form CT -3T
m Retailer License for Sale of Cigarettes
fitsroF� This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
SHAMS SUPERMARKET INC Account ED: CGL -11546651-107
SHAW'S #431 Location ED: 11546651-0221
390 WEST ST STE 1 License Number: 129953792
MANSFIELD MA 02048-1170
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: October 1, 2018 Expiration Date: September 30, 2020
AGE SENSITIVE SALES POLICY AND ACKNOWLEDGMENT SIGN -OFF FORM
TO: Store Management [Store Director, Asst. Store Director, Customer Service Manager (CSM), Asst.
Customer Service Manager (ACSM), Relief Managers and Keyholders], Checkers, Service Desk,
Customer Service Representatives (CSRs), Pharmacists, Pharmacy Technicians, Starbuck's Baristas
RE: Alcohol, Imitation Alcohol, CBD, Tobacco, Fireworks, Dextromethorphan (DXM/cough medicine), and
Lottery
MASSACHUSETTS (TOBACCO AGE 21) - Updated 4/22/19
*This signoff is NOT for stores 602, 619, 1420, 2491, 2565, 2576, 2583, 3581 & 4471.
Alcohol / CBD Tobacco Fire- DXM Lottery (sale
PO�;CY Imitation products products works & payouts)
alcohol
It is illegal and/or against company policy to 21 21 21 n/a 18 18
sell to any person under the ase of:
Checker must be a minimum age (see right) 18 18
to sell certain age sensitive items. If under Checker Checker n/a n/a n/a n/a
the age requirement, checker MUST call <18 may <18 may
CSR/Store Management for assistance. not not touch
touch CBD
alcohol products
Date of Birth (DOB) prompt will appear for: Yes Yes Yes No Yes No
Restricted Hours of Sales n/a n/a n/a n/a n/a n/a
ALL AGE SENSITIVE SALES
r Valid picture ID is required for age sensitive sales as noted above.
•+ SELF SCAN Stores: All age verification sales require supervisor intervention. Age verification must be
handled at the actual Self -Scan and not from the RAP station. Age verification CANNOT be performed
at the RAP station.
The following forms of ID are considered "valid" and may be accepted. The ID must not be expired.
® MA State Driver's License
• MA does not recognize out-of-state licenses as per se valid IDs. Therefore, you must refer to
the ID Checking Guide if unfamiliar with an out-of-state license to ensure authenticity. Call
CSM/ACSMs or Store Management for assistance if ID is at all questionable.
• Shaw's reserves the right to deny a sale on an out-of-state license
® MAID
® Military ID (with date of birth)
® MA Registry of Motor Vehicle Liquor ID Card
® US Passport
® US Passport Card
Page 1 of 6
Ask customer to remove ID from wallet for verification.
® Verify that the picture on the ID matches the customer standing in front of you.
® Verify that the ID does not look like it has been altered or tampered.
NEVER ask a customer for their Date of Birth (DOB); you must always obtain DOB from a valid ID.
The DOB from the valid ID of the purchaser must be properly entered into the POS system to verify age
(MMDDYY). It is against company policy to enter an invalid DOB or a verbally provided DOB.
'+ If you have ANY doubts regarding the authenticity of a license or other form of ID or, for whatever
reason, are uncertain as to whether or not to process a sale, call Checkout/Store Management for
assistance.
-0 If a customer is unable to produce a valid ID you must call Checkout/Store Management for
assistance. Sale is pending Management approval. See below.
-0 If the customer does not present a valid ID and the sale is denied, politely apologize to the customer
and let them know why we cannot honor the sale (state the law/policy). If necessary, offer to get a
member of Store Management.
» Limited Exceptions for Customers without valid ID
® DENYING (CSM/ACSM/Store Management)
• CSM/AGSMs/Store Management are authorized to DENY an age sensitive sale where the
customer cannot produce valid ID.
® APPROVING (CSR)
■ CSRs have limited authority. A CSR is not authorized to approve an age sensitive sale where the
customer cannot provide a valid ID. The CSR must call for CSM/ACSM/Store Management to
make the decision.
® APPROVING (CSM/ACSM/Store Management)
CSM/ACSM/Store Management is authorized to approve an age sensitive sale where the
customer cannot provide a valid ID ONLY IF the customer appears to be over the legal age for
the item being purchased. Refer to the chart above for legal age requirements.
» Checkout/Store Management must ensure that age sensitive policies are strictly adhered to
30 Additional rules/bylaws may apply. If so, the rules/bylaws will be communicated to you separately.
ALCOHOL SALES
Checkers must be 18 years of age or older to scan/touch alcoholic products. If you are under the age
of 18, you must call a CSR to scan and bag the alcohol.
'+ Valid ID must be verified and customer(s) must be at least 21 years of age to purchase alcohol.
3* For a transaction that includes alcohol, all individuals with the purchaser must provide valid ID. If
anyone within the group does not have an ID (excluding children of the purchaser), CSM/ACSM/Store
Management must be called to approve/deny sale.
If a customer appears to be intoxicated or who you suspect may be purchasing alcohol for a minor, you
MUST call Store Management for assistance. NEVER accuse the customer of being intoxicated. He/she
may have a medical condition that impairs their speech or motor abilities.
Page 2 of 6
CSM/ACSM and Store Management may approve or deny the sale of alcohol based on strict
compliance with MA state laws and Shaw's policies. CSRs should immediately call for CSM/ACSM/
Store Management at any time when the validity of an ID is questionable, or a transaction is
questionable.
LOTTERY TRANSACTIONS
Customer must be at least 18 years of age to conduct a lottery transaction (purchase or redemption of
a lottery ticket).
Request/verify valid picture ID from a person who appears to be 30 or under prior to transaction.
System will not prompt for DOB for lottery sales.
If a person who appears to be 30 or under attempts to conduct a lottery transaction at a Lottery
Vending Machine, the remote disabler must be used to disable the machine. The customer must
produce a valid picture ID to prove age before the transaction can be completed. If the person cannot
produce a valid ID or is under the age of 18, the transaction must be denied.
Additional
ADDITIONAL AGE VERIFICATION PROCEDURES
'+ Age can be hard to determine. Ask for ID from customers in accordance with store policy as noted
above. Don't guess.
• Don't let things like dressing maturely, facial hair, gray hair or balding be the final determinant.
Sometimes an underage person will act nervous and not make eye -contact.
'+ Does the person buying alcohol or tobacco look old enough, but have young friends lurking nearby?
This could be a second -party sale. Making a second -party sale is just as serious as selling directly to an
underage customer.
ADDITIONAL ID VERIFICATION PROCEDURES
Hold the ID in your hand; check the front and back, look for the bar code and/or magnetic strip.
Is the ID the right size?
'+ Check the lamination. Are the edges tight? Does it appear to be glued over? Do the letters/numbers
appear altered?
Match the person to the photo.
Check height, weight, and eye color (when printed on the ID). Weight can fluctuate, but not height or
eye color. You may also ask secondary questions, such as "what is your address?"
Reference the ID Checking Guide if necessary to verify ID.
TOBACCO SALES
Tobacco products are defined by federal law as cigarettes and smokeless tobacco. Shaw's/Star Market
stores only sell cigarettes.
Employees may not open standard -sized cigarette packages and sell cigarettes in lesser quantities.
E.g., you cannot open a standard pack of cigarettes (20 cigarettes per pack) to sell 5 cigarettes.
• Employees cannot alter or remove the warning labels on tobacco products.
Employees cannot offer consumers free samples of tobacco products.
Page 3 of 6
Employees cannot accept coupons, proofs -of -purchase or similar items received from the purchase of
tobacco products in exchange for any gift or item.
Employees cannot offer a gift or other item in connection with the sale of tobacco products. E.g., a
free Marlboro shirt with the purchase of a carton of Marlboros.
YOUTH & TOBACCO
Each day in the United States, 3,800 children or young adults under 18 years of age smoke their first
cigarette, and an estimated 1,000 children or young adults become daily cigarette smokers. Many of
these children or young adults will become addicted before they are old enough to understand the
risks and will ultimately die too young of tobacco -related diseases.
The FDA is working to protect the health of America's children and ultimately reduce the burden of
illness and death caused by tobacco use. Prevention efforts must focus on young adults.
Nearly 9 out of 10 smokers started smoking by age 18 and 99% started by age 26. Progression from
occasional to daily smoking almost always occurs by age 26.
LOTTERY TRANSACTIONS
Service Desk: If a person who appears to be 30 or under attempts to conduct a lottery transaction at
the Service Desk, the Service Desk Employee must ask for a valid picture ID. The customer must
produce a valid picture ID to prove age before the transaction can be completed. If the person cannot
produce a valid ID or is under the age of 18, the transaction must be denied.
+ Lottery Vending Machine: The location of the Lottery Vending Machine is subject to the approval of
the Massachusetts State Lottery Commission. Please note that the machine should be located within
eyesight of store personnel at all times. It should not be located close to children's rides, children's
vending machines, or video games. If Store Management believes that there is an issue with the
location of the machine, Store Management is responsible for contacting their appropriate Customer
Service Specialist (CSS).
The Lottery Vending Machine must remain operational/powered on throughout the entire time the
store is open (unless it is down for service). For stores that have the Lottery Vending Machines located
in the Service Desk area and for 24 hour locations, limited exceptions apply. See the sections below
entitled Service Desk Area and 24 Hour Locations.
The remote disabler for the Lottery Vending Machine must be functional at all times. If the remote
disabler is not functioning properly, contact a member of Store Management. Store Management is
responsible for immediately disabling the machine and contacting their appropriate Customer
Satisfaction Specialist.
» If a person who appears to be 30 or under attempts to conduct a lottery transaction at the Lottery
Vending Machine, the remote disabler must be used to disable the machine. The customer must
produce a valid picture ID to prove age before the transaction can be completed. If the person cannot
produce a valid ID or is under the age of 18, the transaction must be denied.
Checkout Department: For Lottery Vending Machines located in the Checkout Department, the CSR or
the Employee who is actively running the Checkout Department must maintain the remote disabler on
their set of keys. If a person who appears to be 30 or under attempts to conduct a lottery transaction
at the machine, the CSR or Employee is responsible for disabling the machine and asking for a valid
picture ID.
Page 4 of 6
+ All Cashiers are responsible for notifying the CSR or the Employee who is actively running the Checkout
Department if they observe a customer who appears to be 30 or under attempting to conduct a lottery
transaction at the Lottery Vending Machine.
-� The Checkout lane closest to the Lottery Vending Machine must remain open at all times.
'+ Service Desk Area: For Lottery Vending Machines located in and visible to the Service Desk area, the
Service Desk clerk must maintain the remote disabler on their set of keys at all times when the Service
Desk is open. If a person who appears to be 30 or under attempts to conduct a lottery transaction at
the machine, the Service Desk clerk is responsible for disabling the machine and asking for valid picture
ID.
When the Service Desk is closed but the store is open, a Lottery Vending Machine in the Service Desk
area should remain powered on but disabled from use unless assistance from a Keyholder is obtained.
The remote disabler must be transferred to a Keyholder until the Service Desk re -opens. The
Keyholder is responsible for enabling the machine upon the request of a customer determined to be of
legal age (either because the customer appears to be over 30 or has produced a valid picture ID). The
Keyholder is also responsible for disabling the machine upon completion of the customer's transaction.
CBD AWARENESS
It is Shaw's policy that all customers must be 21 to purchase CBD products.
• It is Shaw's policy, that checkers must be 18 years of age or older to scan/touch CBD products. If you
are under the age of 18, you must call a CSR to scan and bag the CBD product.
CBD stands for cannabidiol - the second most common cannabinoid found in a cannabis plant.
Cannabidiol (CBD) is the second major cannabinoid found in cannabis plants like hemp and marijuana
Unlike the other major cannabinoid THC, CBD is non -psychoactive.
METHAMPHETAMINE AWARENESS
Cough, cold, allergy, sinus, and diet pills that contain pseuodoephedrine, ephedrine, and
phenylpropanolamine can only be sold in limited quantities, which will be controlled by the Point of
Sale. These items must be located behind the pharmacy counter and may only be purchased at the
pharmacy. Under no circumstance may an associate sell these items outside of the pharmacy, or in
quantities that exceed the register limits.
It is very important when customers ask about these restrictions that you respond in a positive
manner. Let customers know that we are complying with federal, state, county, and city laws and we
are showing our community concern by limiting the sales of these products. These controls are aimed
at drug traffickers, not cold and allergy sufferers, or dieters. Be sure to apologize for any
inconvenience and get your manager/supervisor involved if a customer becomes upset. Your
manager/supervisor will tell you how to identify a possible problem sale. Refer any suspicious activity
to your manager/supervisor.
Page 5 of 6
AGE SENSITIVE SALES POLICY AND ACKNOWLEDGMENT SIGN -OFF FORM
I have read and understand ALL of the information stated on the AGE SENSITIVE SALES
POLICY AND ACKNOWLEDGMENT SIGN -OFF FORM - MA ONLY - Tobacco Age
21 - Updated 4/22/19. I have been issued a copy of this document. I understand that violations
of any of the policies or procedures stated on this document will result in corrective action - up
to and including termination of employment.
Print
Page 6 of 6
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.
Tiffany Corcoran
SuperyisorTax
Signator of In ' 'dual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
"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:\Usus\sleite\Desk[op\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
UlfDepartment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Shaw's Supermarkets, Inc. D/B/A Shaw's #431
Address: 390 West Street
City/State/Zip: Mansfield, MA 02048 Phone #: 508-339-3987
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. ❑ Restaurant/Bar/Eadng Establishment
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,
8. ❑ 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
10.0Manufacturing
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit by
I1.❑Health Care
organization, staffed 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: ACE American Insurance Company
Insurer's Address: 5600 West 83rd St, 8200 Tower, Ste 1100
City/State/zip: Minneapolis, MN 55437
Policy # or Self -ins. Lic. # WLRC6604287A
Expiration Date: 8/1/2020
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 a 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 ofperjury that the information provided above is true and correct.
I
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 M
www.mass.gov/dia
an
CERTIFICATE OF LIABILITY INSURANCE
DAToiMzezol
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(les) 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 endomement. A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
ADO Risk services Central, Inc.
Minneapolis MN Office
5600 West 83rd Street
8200 Tower, suite 1100
CONTACT
NAME.
LIMBS
(AICNNa.EaO:
(866) 283-7122 C.No,: (800) 363-0105
EMAIL
ADDRESS:
INSURER(S)AFPOROING COVERAGE MAIC#
Minneapolis MN 55437 USA
INSURED
INSURERA: ACE American insurance Company 2266_7
Albertsons Companies. Inc.
Including Safeway Inc., Albertson's LLC
& subsidiaries
INSURER B: ACE Property & Casualty Insurance Co. 20699
INSURERC: Steadfast Insurance Company 26367
250 East Parkcenter Blvd
Boise ID 83706 USA
INSURER O:
INSURERS:
INSURERR
COVERAGES CERTIFICATE NUMBER: 570077666367 REVISION NUMBER:
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. Limits shown are as requested
INSR LTB
TYPE OFINSUPANCE
INSO
WYD
POLICYNUMBER
BlyppOUGYEFF
LVD
LIMBS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS�MADE ❑X OCCUR
XSLG
SIR applies per policy ter
is & condi
ions
CURHENCE 53,000,000
ToTiL'R $3,000,000
S Ea ocwnenceX
(My one person) Excluded
DugglslUabincluded
L&ADV INJURY $3,000,000
GENL AGGREGATE LIMIT APPLIES PER:
AGGREGATE $18,000,000
r(FA.�d.otl
POLICY ❑PELT LOC
TS-COMPIOPAGG 56000000
OTHER:
bli0 Uon 2nCl Uded
A
AuTOA1mBILEUAWLITY
ISA H25301274
08/01/201908/01/2020D
SINGLE LIMIT $5,000,000
m t
BODILY INJURY(Per person)
X ANYAUTO
BODILY INJURY (Pot aWden0
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIREDAUTOS NON -OWNED
ONLY AUTOS ONLY
PROPERTY DAMAGE
Per acddenl
B
X
UMBRELUUAO
E%CESS I,ee
X
OCCUR
CLAIMS-MADESIR
XOOG2794761A004
applies per policy ter
08/01/2019
is & condi
08/01/2020
ions
EACH OCCURRENCE $10,000,000
AGGREGATE $10,000,000
DED I X RETENTION
A
C
WORKERS COMPENSATION AND
EMPLOYERS'LMBILDY
ANYPROPIUSTORIPVTNERIEXECUTIVE YIN
OFFICERJMEMBER EXCLUDED?
(Mantlatoly In NH)
NIA
WLRC6604287A
AOS
EWT008362504
TX
08/01/2019
08/01/2019
09/01/2020
08/01/2020
X PERSTATUTEER
E.LEACHACCIDENT $2,000,000
E.L. OISEASE-EA EMPLOYEE $2,000,000
1T ea,deaaibeunder
DESCRIPTION OF OPERATIONS belowE.L
11
DISEASE.POLICY LIMIT $2,000,000
Ti
1
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, A4dmonal Remadu Schedule, may be allachad Hmom apace Is mqulmd)
Blanket Additional insured for General Liability and Waiver Of subrogation for General Liability status extend to those parties
to whom the Insured has contractually agreed to provide this status. Safeway Inc. is a qualified self -insurer for Workers'
Compensation in the following states: AZ, CA, CO, HI, MT, OR, WA. Albertsons LLC is a qualified self -insurer for Workers'
compensation in the following states: AZ, CA, HI, MT, OR.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEREO IN ACCORDANCE WITH THE
POLICYPROVISIONS.
Albertsons Companies, Inc. AUTHOR1220 REPRESENTATIVE
Including Safeway Inc.
Albertson's LLC & subsidiaries w ��
250 East Parkcenter Blvd. cJ4'No/sa
Boise ID 83706 USA str..i>:r4 na.
91988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Officer Listing
Shaw's Supermarkets, Inc.
FEIN: 04-1123420
Star Markets Company, Inc.
FEIN: 04-3243710
Name
Title
Address
Ownership
Michelle Larson
President
750 W. Center St., West Bridgewater, MA 02379
0%
Laura A. Donald
Group Vice President, Corporate Law & Assistant Secretary
1015 EI Curtola Blvd., Walnut Creek, CA 94595
0%
Robert A. Gordon
Executive Vice President, General Counsel & Secretary
24 Robert Rd., Orinda, CA 94563
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Gary Morton
Vice President, Treasurer & Assistant Secretary
2000 Canal St., Boise, ID 83705
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CERTIFICATE OF AUTHORITY AND
LIMITED POWER OF ATTORNEY
I, Robert A. Gordon, Executive Vice President, General Counsel &
Secretary of Shaw's Supermarkets, Inc., a Massachusetts corporation
("Company"), by authority granted to me under a standing resolution duly
adopted by the Board of Directors on April 19, 2017, hereby delegate authority
and grant a limited power of attorney to the persons listed in Exhibit A (as
such Exhibit A may be updated from time to time) for and on behalf of
Shaw's Supermarkets, Inc. to execute the following:
Licenses? permits, 'WIC contracts, lottery contracts, tax and fee
returns, sales/use returns, fuel returns, property renditions,
applications for fictitious business names.
Notwithstanding this Certificate of Authority and .Limited Power of
Attorney, the persons listed in Exhibit. A (as such Exhibit A may be
updated from -time to time) remain subject to, and must comply with, any
applicable approval and procedural requirements set: forth in the Company's
policies on legal review, approval and signing .of agreements, as such policy may
be amended from time to time.
This Certificate of Authority and Limited Power of Attorney shall
continue in effect for the individuals named in Exhibit A (as such Exhibit. A
may be updated from time to time) for so long as such individuals remain in
their present positions (or any more senior positions of authority) and maintain
responsibility for the tasks or functions described herein, unless earlier
modified or rescinded in writing.
Dated:. 3-13-1
Robert A. Gordon
Executive Vice President, General Counsel &
Secretary
I, Laura A. Donald, hereby certify that I am the Group Vice President,
Corporate Law & Assistant Secretary of the Company; that the approval
adopted by the. Board of Directors of the Company on April 19, 2017 is still,
on this day, in full force and effect; that Robert A. Gordon is Executive Vice
President, General Counsel & Secretary of the Company; and that Robert A.
Gordon has full right and authority to execute the above Certificate of
Authority and Limited Power of Attorney.
Dated: W
La4fra A. Donald
Group Vice President, Corporate Law
& Assistant Secretary
Updated July 12, 2019, supersedes March 13, 2018 version.
Exhibit A
Certificate of Authoritv and limited Power of Attorney
(Shaw's Suliermarkets, Inc. — NASC Documents
Name
Title
Steve Barna
Mana er Tax
Jana Bohlman
Director Tax
William Carter
Manalzer Tax
Tiffany Corcoran
Su ervisox Tax
Joe Vaiente
Sr. Director Financial Reporting
Devin Whyte
Manager Tax
Jeff Wilson
Supervisor Tax
S h Olnn1 S V l l cm 5 `Y+ c, I d
AGE SENSITIVE SALES POLICY AND ACKNOWLEDGMENT SIGN -OFF FORM
TO: Store Management [Store Director, Asst. Store Director, Customer Service Manager (CSM), Asst.
Customer Service Manager (ACSM), Relief Managers and Keyholders], Checkers, Service Desk,
Customer Service Representatives (CSRs), Pharmacists, Pharmacy Technicians, Starbuck's Baristas
RE: Alcohol, Imitation Alcohol, CBD, Tobacco, Fireworks, Dextromethorphan (DXM/cough medicine), and
Lottery
MASSACHUSETTS (TOBACCO AGE 21) - Updated 4/22/19
*This sianoff is NOT for stores 602 619 1420, 2491, 2565, 2576, 2583, 3581 & 4471.
Alcohol / CBD Tobacco4n/an/a
Lottery (sale
Imitation products products& payouts)
PUIICy alcohol
it is illegal and/or against company policy to 21 21 21 18
sell to any person under the age of:
Checker must be a minimum age (see right) 18 18
to sell certain age sensitive items. If under Checker Checker n/a n/a
the age requirement, checker MUST call <18 may <18 may
CSR/Store Management for assistance. not not touch
touch CBD
alcohol products
Date of Birth (DOB) prompt will appear for: Yes Yes Yes No Yes No
Restricted Hours of Sales n/a n/a n/a n/a n/a n/a
ALL AGE SENSITIVE SALES
Valid picture ID is required for age sensitive sales as noted above.
• SELF SCAN Stores: All age verification sales require supervisor intervention. Age verification must be
handled at the actual Self -Scan and not from the RAP station. Age verification CANNOT be performed
at the RAP station.
The following forms of ID are considered "valid" and may be accepted. The ID must not be expired.
® MA State Driver's License
■ MA does not recognize out-of-state licenses as per se valid IDs. Therefore, you must refer to
the ID Checking Guide if unfamiliar with an out-of-state license to ensure authenticity. Call
CSM/ACSMs or Store Management for assistance if ID is at all questionable.
■ Shaw's reserves the right to deny a sale on an out-of-state license
® MA ID
• Military ID (with date of birth)
® MA Registry of Motor Vehicle Liquor ID Card
® US Passport
® US Passport Card
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� Ask customer to remove ID from wallet for verification.
{J Verify that the picture on the ID matches the customer standing in front of you.
® Verify that the ID does not look like it has been altered or tampered.
)► NEVER ask a customer for their Date of Birth (DOB); you must always obtain DOB from a valid ID.
�► The DOB from the valid ID of the purchaser must be properly entered into the POS system to verify age
(MMDDYY). It is against company policy to enter an invalid DOB or a verbally provided DOB.
» If you have ANY doubts regarding the authenticity of a license or other form of ID or, for whatever
reason, are uncertain as to whether or not to process a sale, call Checkout/Store Management for
assistance.
�► If a customer is unable to produce a valid ID you must can Checkout/Store Management for
assistance. Sale is pending Management approval. See below.
�► If the customer does not present a valid ID and the sale is denied, politely apologize to the customer
and let them know why we cannot honor the sale (state the law/policy). If necessary, offer to get a
member of Store Management.
�+ Limited Exceptions for Customers without valid ID
® DENYING (CSM/ACSM/Store Management)
• CSM/ACSMs/Store Management are authorized to DENY an age sensitive sale where the
customer cannot produce valid ID.
® APPROVING (CSR)
■ CSRs have limited authority. A CSR is not authorized to approve an age sensitive sale where the
customer cannot provide a valid ID. The CSR must call for CSM/ACSM/Store Management to
make the decision.
® APPROVING (CSM/ACSM/Store Management)
CSM/ACSM/Store Management is authorized to approve an age sensitive sale where the
customer cannot provide a valid ID ONLY IFthe customer appears to be over the legal age for
the item being purchased. Refer to the chart above for legal age requirements.
» Checkout/Store Management must ensure that age sensitive policies are strictly adhered to
vo Additional rules/bylaws may apply. If so, the rules/bylaws will be communicated to you separately.
ALCOHOL SALES
r Checkers must be 18 years of age or older to scan/touch alcoholic products. If you are under the age
of 18, you must call a CSR to scan and bag the alcohol.
Valid ID must be verified and customer(s) must beat least 21 years of age to purchase alcohol.
For a transaction that includes alcohol, all individuals with the purchaser must provide valid ID. If
anyone within the group does not have an ID (excluding children of the purchaser), CSM/ACSM/Store
Management must be called to approve/deny sale.
If a customer appears to be intoxicated or who you suspect maybe purchasing alcohol for a minor, you
MUST call Store Management for assistance. NEVER accuse the customer of being intoxicated. He/she
may have a medical condition that impairs their speech or motor abilities.
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'+ CSM/ACSM and Store Management may approve or deny the sale of alcohol based on strict
compliance with MA state laws and Shaw's policies. CSRs should immediately call for CSM/ACSM/
Store Management at any time when the validity of an ID is questionable, or a transaction is
questionable.
LOTTERY TRANSACTIONS
Customer must beat least 18 years of age to conduct a lottery transaction (purchase or redemption of
a lottery ticket).
'+ Request/verify valid picture ID from a person who appears to be 30 or under prior to transaction.
» System will not prompt for DOB for lottery sales.
If a person who appears to be 30 or under attempts to conduct a lottery transaction at a Lottery
Vending Machine, the remote disabler must be used to disable the machine. The customer must
produce a valid picture ID to prove age before the transaction can be completed. If the person cannot
produce a valid ID or is under the age of 18, the transaction must be denied.
ADDITIONAL AGE VERIFICATION PROCEDURES
» Age can be hard to determine. Ask for ID from customers in accordance with store policy as noted
above. Don't guess.
'+ Don't let things like dressing maturely, facial hair, gray hair or balding be the final determinant.
'+ Sometimes an underage person will act nervous and not make eye -contact.
Does the person buying alcohol or tobacco look old enough, but have young friends lurking nearby?
This could be a second -party sale. Making a second -party sale is just as serious as selling directly to an
underage customer.
ADDITIONAL ID VERIFICATION PROCEDURES
- Hold the ID in your hand; check the front and back, look for the bar code and/or magnetic strip.
r Is the ID the right size?
Check the lamination. Are the edges tight? Does it appear to be glued over? Do the letters/numbers
appear altered?
Match the person to the photo.
Check height, weight, and eye color (when printed on the ID). Weight can fluctuate, but not height or
eye color. You may also ask secondary questions, such as "what is your address?"
» Reference the ID Checking Guide if necessary to verify ID.
TOBACCO SALES
• Tobacco products are defined by federal law as cigarettes and smokeless tobacco. Shaw's/Star Market
stores only sell cigarettes.
- Employees may not open standard -sized cigarette packages and sell cigarettes in lesser quantities.
E.g., you cannot open a standard pack of cigarettes (20 cigarettes per pack) to sell 5 cigarettes.
• Employees cannot alter or remove the warning labels on tobacco products.
+ Employees cannot offer consumers free samples of tobacco products.
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Employees cannot accept coupons, proofs -of -purchase or similar items received from the purchase of
tobacco products in exchange for any gift or item.
'+ 'Employees cannot offer a gift or other item in connection with the sale of tobacco products. E.g., a
free Marlboro shirt with the purchase of a carton of Marlboros.
YOUTH & TOBACCO
Each day in the United States, 3,800 children or young adults under 18 years of age smoke their first
cigarette, and an estimated 1,000 children or young adults become daily cigarette smokers. Many of
these children or young adults will become addicted before they are old enough to understand the
risks and will ultimately die too young of tobacco -related diseases.
'+ The FDA is working to protect the health of America's children and ultimately reduce the burden of
illness and death caused by tobacco use. Prevention efforts must focus on young adults.
• Nearly 9 out of 10 smokers started smoking by age 18 and 99% started by age 26. Progression from
occasional to daily smoking almost always occurs by age 26.
LOTTERY TRANSACTIONS
Service Desk: If a person who appears to be 30 or under attempts to conduct a lottery transaction at
the Service Desk, the Service Desk Employee must ask for a valid picture ID. The customer must
produce a valid picture ID to prove age before the transaction can be completed. If the person cannot
produce a valid ID or is under the age of 18, the transaction must be denied.
Lottery Vending Machine: The location of the Lottery Vending Machine is subject to the approval of
the Massachusetts State Lottery Commission. Please note that the machine should be located within
eyesight of store personnel at all times. It should not be located close to children's rides, children's
vending machines, or video games. If Store Management believes that there is an issue with the
location of the machine, Store Management is responsible for contacting their appropriate Customer
Service Specialist (CSS).
The Lottery Vending Machine must remain operational/powered on throughout the entire time the
store is open (unless it is down for service). For stores that have the Lottery Vending Machines located
in the Service Desk area and for 24 hour locations, limited exceptions apply. See the sections below
entitled Service Desk Area and 24 Hour Locations.
The remote disabler for the Lottery Vending Machine must be functional at all times. If the remote
disabler is not functioning properly, contact a member of Store Management. Store Management is
responsible for immediately disabling the machine and contacting their appropriate Customer
Satisfaction Specialist.
If a person who appears to be 30 or under attempts to conduct a lottery transaction at the Lottery
Vending Machine, the remote disabler must be used to disable the machine. The customer must
produce a valid picture ID to prove age before the transaction can be completed. If the person cannot
produce a valid ID or is under the age of 18, the transaction must be denied.
Checkout Department: For Lottery Vending Machines located in the Checkout Department, the CSR or
the Employee who is actively running the Checkout Department must maintain the remote disabler on
their set of keys. If a person who appears to be 30 or under attempts to conduct a lottery transaction
at the machine, the CSR or Employee is responsible for disabling the machine and asking for a valid
picture ID.
Page 4 of 6
Ail Cashiers are responsible for notifying the CSR or the Employee who is actively running the Checkout
Department if they observe a customer who appears to be 30 or under attempting to conduct a lottery
`transaction at the Lottery Vending Machine.
• The Checkout lane closest to the Lottery Vending Machine must remain open at all times.
'+ Service Desk Area: For Lottery Vending Machines located in and visible to the Service Desk area, the
Service Desk clerk must maintain the remote disabler on their set of keys at all times when the Service
Desk is open. If a person who appears to be 30 or under attempts to conduct a lottery transaction at
the machine, the Service Desk clerk is responsible for disabling the machine and asking for valid picture
ID.
When the Service Desk is closed but the store is open, a Lottery Vending Machine in the Service Desk
area should remain powered on but disabled from use unless assistance from a Keyholder is obtained.
The remote disabler must be transferred to a Keyholder until the Service Desk re -opens. The
Keyholder is responsible for enabling the machine upon the request of a customer determined to be of
legal age (either because the customer appears to be over 30 or has produced a valid picture ID). The
Keyholder is also responsible for disabling the machine upon completion of the customer's transaction.
CBD AWARENESS
It is Shaw's policy that all customers must be 21 to purchase CBD products.
'+ It is Shaw's policy, that checkers must be 18 years of age or older to scan/touch CBD products. if you
are under the age of 18, you must call a CSR to scan and bag the CBD product.
CBD stands for cannabidiol - the second most common cannabinoid found in a cannabis plant.
'+ Cannabidiol (CBD) is the second major cannabinoid found in cannabis plants like hemp and marijuana.
Unlike the other major cannabinoid THC, CBD is non -psychoactive.
METHAMPHETAMINE AWARENESS
• Cough, cold, allergy, sinus, and diet pills that contain pseuodoephedrine, ephedrine, and
phenylpropanolamine can only be sold in limited quantities, which will be controlled by the Point of
Sale. These items must be located behind the pharmacy counter and may only be purchased at the
pharmacy. Under no circumstance may an associate sell these items outside of the pharmacy, or in
quantities that exceed the register limits.
• It is very important when customers ask about these restrictions that you respond in a positive
manner. Let customers know that we are complying with federal, state, county, and city laws and we
are showing our community concern by limiting the sales of these products. These controls are aimed
at drug traffickers, not cold and allergy sufferers, or dieters. Be sure to apologize for any
inconvenience and get your manager/supervisor involved if a customer becomes upset. Your
manager/supervisor will tell you how to identify a possible problem sale. Refer any suspicious activity
to your manager/supervisor.
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AGE SENSITIVE SALES POLICY AND ACKNOWLEDGMENT SIGN -OFF FORM
I have read and understand ALL of the information stated on the AGE SENSITIVE SALES
POLICY AND ACKNOWLEDGMENT SIGN -OFF FORM - MA ONLY - Tobacco Age
21 - Updated 4/22/19. I have been issued a copy of this document. 1 understand that violations
of any of the policies or procedures stated on this document will result in corrective action - tip
to and including termination of employment.
Print
Page 6 of 6
Date
AGE SENSITIVE SALES POLICY AND ACKNOWLEDGMENT SIGN -OFF FORM
I have read and understand ALL of the information stated on the AGE SENSITIVE SALES
POLICY AND ACKNOWLEDGMENT SIGN -OFF FORM - MA ONLY - Tobacco Age
21 - Updated 4/22/19. I have been issued a copy of this document. 1 understand that violations
of any of the policies or procedures stated on this document will result in corrective action - up
to and including termination of employment.
PrintName� p�1 � l_G�-��uc(S✓�'� Signature Date
Page 6 of 6
FT
AGE SENSITIVE SALES POLICY AND ACKNOWLEDGMENT SIGN -OFF FORM
I have read and understand ALL of the information stated on the AGE SENSITIVE SALES
POLICY AND ACKNOWLEDGMENT SIGN -OFF FORM - MA ONLY - Tobacco Age
21 - Updated 4/22/19. I have been issued a copy of this document. I understand that violations
of any of the policies or procedures stated on this document will result in corrective action - up
to and including termination of employment.
Print Name &to c, Sign atAe_ / "d ✓L (/ Date AG/ N/l 01
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