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Home My WebLink AboutWicked Vaped (Devine Enterprise, Inc.)- 12/31/202041'� Tomi of Mansfield - Board of Health _ 150, G" PERMIT NUMBER: Town of Mansfield - 6 Park ROW Man s elck!)� 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 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: V!hG ChatfQC:SE t hc, DM W0%t1e_c_� LOCATION OF SALE OF TOBACCO PRODUCTS: 2f.(. N. Ma:h S�. U%%F 2 TELEPHONE AT LOCATION: 774e Zgy--(4 - OWNER OF BUSINESS: _ A)--0ZA/CF—____ ADDRESSOFOWNER: j2qLo CAS4MoirSC�pi (W� DZOYB TELEPHONE OF OWNER: 17y-2tti - ('0297 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 *Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $150.00 CT -3T NUMBER: p FEDERAL ID/SS NUMBER: S2' 2S'18"3-77 SIGNATURE: DATE: d s fl1`j--_ Scanned with CamScanner 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 J less than 21 years of age, regardless of how old the person looks. tc 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; Q/ Self-service tobacco product and/or nicotine delivery product displays from which the customer may select products are prohibited. R/ The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. FW` 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. I�/Non-residential Roll -Your -Own machines are prohibited. E -'/Blunt wraps are prohibited, i/ Penalties for violation of the regulation Include monetary fines and/or suspension of this permit for seven or thirty days. L✓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. V�i must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". (3� i must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts Department of Revenue (DOR) , dmy DOR business permit (Attach a copy of each permit/license). GI'r I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". Cil must display signs provided by the Board of Health that discloses referral information about cessation. WIf I sell nicotine delivery devices (e.g. e -cigarettes) I must display signs stating that sale of nicotine delivery devices to anyone below the minimum legal sales age is prohibited and that the used of e -cigarettes at indoor establishments is prohibited by local law. I have received, read and understand the Board of Health regulation `Regulation Affecting Smoking and the Sale, Vending, and Distribution of Tobacco and Nicotine Delivery Products" and agree to abide by it. Signature �� Date kl' -Ltk , t Print Name _J-Os� Scanned with CamScanner 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 or Corporate Name By: Corporate Officer (Mandatory, if Applicable) S2- 259$3?72 "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:\Userslsleite\Dcsktop\Scou's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Scanned with CarnScanner The Cornrnonivealtll oft4/assachitsetts Department oj'Inrhtstrla! Accidents Ofjiee of Investigations 600 ffashington Street ,Roston, AIA 02111 rvxan.nrpss.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibiv Business/Organization Name: Devine Enterprise Inc. DBA Wicked Vaped 266 N. Main St. City/State/Zip: Mansfield, MA 02048 Phone M 7747-284-4964 Are you tin employer? Check the appropriate box: I _v 1 ton a employer with 1 employees (fill and/ or part-time).* 2, F1 1 am a sole proprietor or partnership and have no employees working for the in any capacity,. [No workers' comp. insurance required] 3,n We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp insurance required]' 4,F1 We area non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. Q✓ Retail G. ❑ Restaurant/Bar/Eating Establishment 7, Q Office and/or Sales (incl, real estate, auto, etc.) 8. QNon-profit 9. ❑ Entertainment 10.0 Manufacturing I Ln Health Care 12.[—],Other *Any applicant that checks box #1 most 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 organizntion should check box #1. I am an employer that is providing workers' compensation insurance for illy employees. Below is the policy information. Insurance company Name: The Hartford Fire Insurance Comapny Insurer's City/State/Zip: ani? Park Place. 300 South State St. 7th floor Poli c # or Self -ins. Lic. NY 13202 76 WEG AA6WRF Expiration Date: 09/01/2020 Y 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 MOL 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 rnveaHvationsof the. DIA for insurance coverage verification. 7dohereby certi er the pains and penalties ofpelyiny that the information provided above is it -tie and correct re`�i'---�-- Date 11 24 19 Phone #: 774-219-6297 Official rise 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 1, Other Contact Person: Phone #: www.mass.gov/dia Scanned with CamScanner Wicked Vaped ID Policy & S.O.P. Wicked Vaped located at 266 N. Main St. Mansfield, MA 02048 is a 21+ Adult Only establishment What this means: 1 No person under the age of 21 can enter the shop period. 2 No sales can be made to anyone under the age of 21 in this shop 3 Parents can not bring anyone under the age of 21 into the shop (this includes babies, they are under 21) 4 We do not allow parents to buy products for anyone under the age of 21 if we know that is what they are doing. How can you achieve this? Card everyone that comes through the door. Match the photo to the person presenting the ID. If you have questions about an ID you can use the FDA ID scanner on the iPad before helping the customer. Repercussions of any underage sale will result in immediate termination Acceptable ID consists of the following: Valid State ID Valid Drivers License Valid out of state Drivers license Valid US Passports We do not accept: Any expired ID Any expired license Any paper license or Permit or temp ID's By signing is for you acknowledge you have read and understan the tobacco 21+ policy. 1t / 7r,tt/ 2f/ rS Employee Date Employer Date Wicked Vaped ID Policy & S.O.P Wicked Vaped located at 266 N. Main St. Mansfield, MA 02048 is a 21+ Adult Only establishment What this means: 1 No person under the age of 21 can enter the shop period. 2 No sales can be made to anyone under the age of 21 in this shop 3 Parents can not bring anyone under the age of 21 into the shop (this includes babies, they are under 21) 4 We do not allow parents to buy products for anyone under the age of 21 if we know that is what they are doing. How can you achieve this? Card everyone that comes through the door. Match the photo to the person presenting the ID. If you have questions about an ID you can use the FDA ID scanner on the iPad before helping the customer. Repercussions of any underage sale will result in immediate termination Acceptable ID consists of the following: Valid State ID Valid Drivers License Valid out of state Drivers license Valid US Passports We do not accept: Any expired ID Any expired license Any paper license or Permit or temp ID's By signing this for you acknowledge you have read and understand a tobacco 21+policy. Employo Date Employer Date ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMID WY) �i 11/25/2019 THIS CERTIFICATE IS ISSUED ASA 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(ies) 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 endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Calco Commercial Insurance CONTACT y NAME; Name MOVBeS an 13907 Ventura Blvd. Suite 106 Sherman Oaks, CA 91423 PH I (AIM.. (877)225-2699 AX No: (866)521.0617 npDRESS, nane@calcocommercialinsurance.com License #: OG67946 INSURERS AFFORDING COVERAGE NAIC# INSURERp: LIQ d's of London y INSURED Devine Enterprises, Inc. 266 N Main Street Unit 2 Mansfield, MA 02048 INSURER a: INSURER C: INSURER D: INSURER E: INSURER F: )t CI—AIMS—MADE D OCCUR COVERAGES CERTIFICATE NUMBER- nnn099d9.A71QA nctecln.r.ui..nve. 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 CONTRACTOR 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. INSR LTR TYPE OF ADDL SO Saar POLICYNUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDNWY LIMITS A )t COMMERCIAL GENERAL LIABILITY y VI1975 08/22/2019 08/22/2020 EACH OCCURRENCE $ 250,000 )t CI—AIMS—MADE D OCCUR PREM SES Ea o rrenm $ 100 000 MED EXP (Any one person) $ 5 000 — PERSONAL B ADV INJURY $ 260,000 GEN'L AGGREGATE 11MIT APPLIES PER: GENERAL AGGREGATE $ 250000 xOLICY❑ JET LOC PRODUCTS -COMPIOPAGE $ 250,000 $ OTHER: AUTOMOBILE LIABILITY COMBINE —SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BOOILYINJURY(Peraccidenp $ AUTOS ONLY AUTOS HIRED NON -OWNED AUTOSONLY AUT08ONLY PROPERT/DAMAGE $ Pcu.mdent S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMSMADE AGGREGATE $ OED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITYYIN I STATUTE ER E.L.EACH ACCI$ ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ NIA EL. DISEASE -CA EMPLOYE $ (Mandatory in NH) if yes, describe under E.L. DISEASE -POLICY LIMIT $ N OF OPERATIONS below r DESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (ACONO 101, Additional Remarks Schedule, may be attached If more space Is required) Location: 266 N Main Street Unit 2 Mansfield MA 02048 CERTIFICATE HOLDER CANCELLATION (01988-2015-ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by NLM on November 25, 2019 at 09:42AM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPREEWNTATIVE NLM (01988-2015-ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by NLM on November 25, 2019 at 09:42AM