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HomeMy WebLinkAboutMansfield Service Inc. - 12/31/2020arses ,�.=k glg6 —�q5, cel 'a Town'of Mansfield - Board of HealthTown of 6 Pak RoMvansfield Mansfield, MA 02048 a ( IDIIEC 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. A NAME OF BUSINESS: LOCATION OF SALE OF TOBACCO PRODUCTS: S(' TELEPHONE AT LOCATION: 11150L� — j ,n ifa K9 OWNER OF BUSINESS: q� �q//©�Cr ADDRESSOFOWNER: �d J( rJ�?� Farm V7 A, of7s TELEPHONE OF OWNER: FAX NUMBER: If a corporation or partnership, name, title, and home address of officers or partner. /give E /-i..fT.] k 4ao V �..1� 19GCP�v1 f _Srswt'e d7' / 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: 171-30 6 9X0 FEDERAL ID/SS NUMBER: q � —S Z3 1 �:_M SIGNATURE:�� IJ` 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 or Corporate Name By: Corporate Officer (Mai datory, if Applicable) 7L( -3z3 t(<S�Sq' **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:\Users\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.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: #: S2E- .Uq --90V/ Are you an employer? Check theappropriatebox: 1 KI am a employer with employees (full and/ Bus Type (required): 5. Retail $ or part-time).* 6. Restaurant/Bar/Eating 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] 3.0 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]* 4. ❑ We a non-profit organization, staffed by volunteers, 1 LF] Health Care are with no employees. [No workers' comp. insurance req.] 12.❑ Other *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 #l. I am an employer that is Insurance Company Narr Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. insurancefor my employees. Belotp is the policy information. CIA t77i8 �e���lsrassr� , Attach a copy of the workers' compensation policy declaration page (showing the policy number V_Zd 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. 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 #: wvw.mass.gov/dia A check mark signifies your understanding and agreement. I understand and agree that: It is against the law to sell any tobacco product and/or nicotine delivery product (e.g. e-cigarettes) to anyone less than 21 years of age, regardless of how old the person looks. Anyone selling tobacco products and/or nicotine delivery products must conclusively establish the customer's age as over 21 years old, by means of government-issued photographic ID. Anyone selling tobacco products and/or nicotine delivery products must check and verify official government photo ID for anyone less than 27 years of age. /1 must consent to unannounced, periodic inspections and compliance checks of the permitted retail ./e ablishment. f-service tobacco product and/or nicotine delivery product displays from which the customer may select products are prohibited. M-1-`The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. gyp/ 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. Non-residential Roll-Your-Own machines are prohibited. Blunt wraps are prohibited. _V Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or t arty 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 Zcypy of which will be placed on file, that he/she has read the regulation and applicable state laws. ust 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 d24Qepartment of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license). 1 ust display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". I ust display signs provided by the Board of Health that discloses referral information about cessation. If I sell nicotine delivery devices (e.g. e-cigarettes) I must display signs stating that sale of nicotine delivery devices to anyone below the minimum legal sales age is prohibited and that the used of e-cigarettes at indoor establishments is prohibited by local law. I have received, read and understand the Board of Health regulation "Regulation Affecting Smoking and the Sale, Vending, and Distribution of Tobacco and Nicotine Delivery Products" and agree to abide by it. Signature Print Na �� c ✓ �� Date �2 ? v Nam rk/Wf /i /I/l// Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05 005882 VUAU ITilr WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (GS60UB-97011-87-6-19 ) RENEWAL OF (GS60UB-9701L87-6-18) INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY 1. INSURED: MANSFIELD SERVICE INC 189 CHAUNCY STREET MANSFIELD MA 02048-1355 Insured is A CORPORATION NCCI CO CODE: 10456 PRODUCER: R D MURPHY INS AGENCY 75 HANCOCK ST BRAINTREE MA 02185 Other work places and identification numbers are shown In the schedule(s) attached. 2. The policy period Is from 11-25-19 to 11-25-20 12:01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ Bodily Injury by Disease: $ Bodily Injury by Disease: $ 100000 Each Accident 500000 Policy Limit 100000 Each Employee, C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 068 D. This policy Includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required Information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 11-05-19 WC OFFICE: RMD HTFD 05G PRODUCER: R D MURPHY INS AGENCY 75TSC ST ASSIGN: MA O v Ev m j1 A O125f," ° O r rmo ,. =o; m to fr� Are you taking the necessary steps to prevent underage tobacco use? Check photo I.D. of everyone under age 27 who attempts to purchase smokeless tobacco. is 4 Only sell smokeless tobacco to customers age land older.* 0 Do NOT give away free samples of smokeless tobacco unless in a "qualified adult -only facility" < - and in limited quantities.*** ,tllt.ttt� Do NOT break open smokeless tobacco packages to sell products in smaller amounts. Do NOT sell smokeless tobacco I without a health warning label. PROVIDED BY THE FDA CENTER FOR TOBACCO PRODUCTS This flyer provides a snapshot of some of the requirements for smoketess tobacco. See our website www.fda.gov/tobacco for a fait list of requirements that may apply to you. *Retailers must also follow state or local tobacco laws, even if they are more restrictive, For example, in some states the minimum age is 19, "The sale of cigarettes, cigarette tobacco, and smokeless tobacco through vending machines and self-service displays is allowed in adult -only facilities where no person younger than 18 is permitted to enter. Please note that tobacco product vending machines are banned in some slates. *"*See Guidance for Industry: Compliance with Regulations Restricting the Sale and Dislobulion of Cigarettes and Smokeless Tobacco To Protect Children and Adolescents - August 2013. � Only sell smokeless tobacco in x� \ a direct, face-to-face exchange.** 9, ,c Do NOT give away free samples of smokeless tobacco unless in a "qualified adult -only facility" < - and in limited quantities.*** ,tllt.ttt� Do NOT break open smokeless tobacco packages to sell products in smaller amounts. Do NOT sell smokeless tobacco I without a health warning label. PROVIDED BY THE FDA CENTER FOR TOBACCO PRODUCTS This flyer provides a snapshot of some of the requirements for smoketess tobacco. See our website www.fda.gov/tobacco for a fait list of requirements that may apply to you. *Retailers must also follow state or local tobacco laws, even if they are more restrictive, For example, in some states the minimum age is 19, "The sale of cigarettes, cigarette tobacco, and smokeless tobacco through vending machines and self-service displays is allowed in adult -only facilities where no person younger than 18 is permitted to enter. Please note that tobacco product vending machines are banned in some slates. *"*See Guidance for Industry: Compliance with Regulations Restricting the Sale and Dislobulion of Cigarettes and Smokeless Tobacco To Protect Children and Adolescents - August 2013. �,> U PP � � `: i} Y• ! s ,_.; A xa if 3 t � t }� ..`iN, ti; M 1, V ,i' t i' r� i <:� (i �., tf !� 1 v ,,� S tai d%..�3 (including e -cigarettes, vape pens, e -hookahs, e -cigars, personal vaporizers, and electronic pipes.) Are you taking the necessary steps to prevent underage tobacco use? Check photo I.D. of everyone under age 27 who attempts to purchase ENDS. Only sell ENDS to customers age and older.* Do NOT give away free samples of ENDS, including their components and parts. Do NOT sell e -cigarettes in a vending machine unless in an adult -only facility.** PROVIDED BY THE FDA CENTER FOR TOBACCO PRODUCTS Examples of ENDS include e -cigarettes, vape pens, e -hookahs, e -cigars, personal vaporizers, and electronic pipes. This flyer provides a snapshot of some of the new requirements for ENDS. See our website www,fda.gov/tobacco for a full list of requirements that may apply to you. 'Retailers must also follow state or local tobacco laws, even if they are more restrictive. For example, in some states the minimum age is 19, **An adult -only facility is one in which minors are neither present nor permitted to enter at any time. v nn v 0 aci E \ )D .) ~\ `\ .wv . i 1 �!} 4 ' � - 3 t i. e ,nn"I'llU11 �<.zH a La E 0 � Y i a W F A tl :^'ES iC.) ug G i 11 \4zr@ \()\ ( \\\\ \ \\\\ \ \\\\z\\ /00 1 u_=t\222 ƒ $/35(6\} LLJ ©�\/\5\ 4//=2 \4zr@ .;C 3, l 3 t,1, ri,,%.� �? *, "ur Are you taking the necessary steps to prevent underage tobacco use? Check photo I.D. of everyone under age 27 who attempts to purchase cigarettes, cigarette tobacco, or RYO tobacco. Do NOT give away free samples of cigarettes, cigarette tobacco, or RYO tobacco, including any of their components or parts. Do NOT sell cigarette packages containing fewer than 20 cigarettes or single cigarettes, known as "loosies." PROVIDED BY THE FDA CENTER FOR TOBACCO PRODUCTS This flyer provides a snapshot of some of the requirements for cigarettes, cigarette tobacco, and RYO tobacco. See our website www.fda.gov/tobar.co for a full fist of requirements that may apply to you. 'Retailers must also follow state or local tobacco laws, even if they are more restrictive. For example, in some states the minimum age is 19. `*The sate of cigarettes, cigarette tobacco, and smokeless tobacco through vending machines and self-service displays is allowed in adult -only facilities where no person younger than 18 is permitted to enter. Please note that tobacco product vending machines are banned in some states. `*'Menthol and tobacco flavored cigarettes, cigarette tobacco, and RYO tobacco are permiteed to be sold. Only sell cigarettes, cigarette tobacco, or RYO tobacco to customers age iQ and older.* Lf ori t -= Only sell cigarettes, cigarette tobacco, u and RYO tobacco in a direct, face-to-face Y exchange.** ` Do NOT sell flavored cigarettes, cigarette tobacco, or RYO tobacco.*** r' r, t. Do NOT give away free samples of cigarettes, cigarette tobacco, or RYO tobacco, including any of their components or parts. Do NOT sell cigarette packages containing fewer than 20 cigarettes or single cigarettes, known as "loosies." PROVIDED BY THE FDA CENTER FOR TOBACCO PRODUCTS This flyer provides a snapshot of some of the requirements for cigarettes, cigarette tobacco, and RYO tobacco. See our website www.fda.gov/tobar.co for a full fist of requirements that may apply to you. 'Retailers must also follow state or local tobacco laws, even if they are more restrictive. For example, in some states the minimum age is 19. `*The sate of cigarettes, cigarette tobacco, and smokeless tobacco through vending machines and self-service displays is allowed in adult -only facilities where no person younger than 18 is permitted to enter. Please note that tobacco product vending machines are banned in some states. `*'Menthol and tobacco flavored cigarettes, cigarette tobacco, and RYO tobacco are permiteed to be sold. 9 ski l y}� d 1 ,L I) Are you taking the necessary steps to prevent underage tobacco use? Check photo I.D. of everyone under age 27 who attempts to purchase cigars. Only sell cigars to customers age 10 and older.* /,t Do NOT give away free samples of cigars, including any of their components or parts. Do NOT sell cigars in a vending machine unless in an adult -only facility.** PROVIDED BY THE FDA CENTER FOR TOBACCO PRODUCTS This flyer provides a snapshot of some of the new requirements for cigars. See our website www.fda.gov/tobacco for a full list of requirements that may apply to you. *Retailers must also follow state or local tobacco laws, even if they are more restrictive, For example, in some states the minimum age is 19. **An adult -only facility is one in which minors are neither present nor permitted to enter at any time. b.I_i <.....t,,tenaaoi,. n 13 t t 1 ti 11 i t t Iy iS#i`'t IT'S UP TO US TO KEEP MINORS SAFE. CHECK I.D. Customers must show valid photo I.D. and be old enough to purchase any tobacco product.* PHOTO Ensure its really the customer. BIRTH DATE Must be old enough to purchase any tobacco product.' LICENSE EXPIRATION License should not be expired. SECURITY FEATURES Run the magnetic strip or barcode with a scanner if available. PROVIDED BY THE FDA CENTER FOR TOBACCO PRODUCTS *Federal law requires customers to be 1B or older to purchase tobacco products. Retailers must fellow stale or local tobacco laws, even if they are more restrictive. For example, in some states the minimum age is 19. m �t Ell 11 : EIII 100,,-- , , Age -Restricted Products Policy & Procedures: Tobacco LOCATION Every Employee at this location has the legal and moral responsibility to control the sale and distribution of age -restricted items to ensure these items do not get sold to minorsll TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all laws` n,d procedures,of this:policy related to the sale of tobacco products including cigarettes, smokeless tobacco, loose tobacco, pipe tobacco, rolling papers; cigars, e=cigarettes, vapp and lighters. The minimum age to purchase tobacco�prouucts is twenty 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 age11 ;o{ twenty one (21). PROCEDURES: 1. This policy will be.reviewed with all new Employees before they can operate a cash register and sell tobacco products. 2. All store Err�ployees,to take,:cdmputer based training and successfully pass with -10Q% prior to starting on a'register. This certification to be updated on an annuale'basis prioY to previous year expiration. 3 kvalid form &,identificati©n will be required for all tobacco purchases regardIe s of age;or frequency of customer visits. ble forms'df id are as follows: Valid MassadhUsetts 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 acceptablq 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. have read and understand the,Mansfield Board of HealthRegulatlons which prohibits thelsale of tobacco andnicotlne delivery products to anyone underthe age of twenty-one (21) year. I also understand1Wt if I fail to follow store policy and local and -state laws about the sale of,,tobacco,or nicotine delivery products to any person under the legal age, I could lose myjob or be fined, agree to the following rules about the sale;of tobacco products: will not sell any tobacco products, including cigarettes, cigars; chewing tobacco, bidis,:or any otherform < of tobacco, or, any nicotine delivery ,product to;any person under the age of 21. If any person regardless of age attempts to make a tobaccmpurchase without an acceptable] 1 will not make thesale. 1 will not accept a nnYu fenm en.adnlh noun wer.....n..... "!.. . .....r.........l:.. •L.. ....,. �i9� a. L..,. a -L--__ .__-J..u_ 1,143/1 q Employee Signatu'r'e Date /"V,/,f Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) Age -Restricted Products Policy & Procedures: Tobacco LOCATION Every Employee at this location has the legal and moral responsibility to control the sale and distribution of age -restricted items to ensure these items do not get sold to minors!! TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all laws' "i preduF of t olicy related to the sale of tobacco products incl iga7 es, smoklbacco, loose tobacco, pipe tobacco, rolling papers,,cigars riga tes, vq' and lighters. The minimum age to purchase tobacceoprotS is nty onesyears of age. It is our responsibility as a retailer andlin ftters o de community to prevent the sale of tobacco to anyone un r, the age dt i4pNT ty „>n PROCEDURES: r# ”} a:,� 1. This policy will beev►ewed ih alline€mployees before they can operate a cash registee-acsell tobacco products. 2. All store Ert }�loyeesIto tak£ r put& based training and successfully pass witKftoo 0, or to st i g on a'register. This certification to be updated olp"an an�fiCij��srs prroo previous year expiration. IR V;p 3 6=,Avalid form o ,I" - �ftc ion will be required for all tobacco purchases p,gardlgss of age` or frequency of customer visits. ble forms+df id are as follows: Valid Mao--' "'"usetts 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 acceptablq 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 anyoon'underthe age of twenty-one (21) years.'I also understand that if fail to follow store pollcyand 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 of21 to buy tobacco products. In turn, management agrees to support myjudgment not to make the sale in any of the cases described above. , FailureAo follow his policy may result in disciplinary action up to and including terminati Employee Signature Date 2, Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) Age -Restricted Products Policy & Procedures: Tobacco LOCATION Every Employee at this location has -the legal and moral responsibility to control the sale and distribution of age-restrigted items to ensure these items do not get sold to minorsll TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all law's Oho procedu*,of thw olicy related to the sale of tobacco products incl igaees, smoklesbacco, loose tobacco, pipe tobacco, rolling papers; igars,'p�igar es, v ele and lighters. The minimum age to purchase tobacca�procjt$ is twenty onrx` O years of age. It is our responsibility as a retailer andtibers ofM he community to prevent the sale of tobacco to anyone under the age" t4rity At -(21). PROCEDURES: I. This policy will be reviewed nth all ne}iEmployees before they can operate a cash reg�terd sell tobacco products. 2. All store E*loyees o to �n3pute"r based training and successfully pass with�Q� % p'ior to st�g on a`�egister. This certification to be updated o oan an U (haJ prio o previous year expiration. 3lrt'A valid for ofienjfatln will be required for all tobacco purchases `hegardless of age<or frequency of customer visits. Acceptable forms of id are as follows: Valid 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 a'll members of the party. I have read and understand the Mansfield Board of Health:Regulations which prohibits thelsale of tobacco and` nicotine'delivery products to anyonQ under•the•age of twenty-one (2t.) years, I also understand that if I fail to follow store policy.and local andstate laws about the sale of tobacco or nicotine delivery products to any person underthe legal age, I could lose my job or be fined. I agree to the following rules about thesale 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 anyperson regardless of age attempts to make a tobacco purchase withogt an acceptable, I will not make the sale. I will notaccept a note from an adult giving permission toa person under the.age of to buy tobacco.products. in turn, management agrees to support my judgment notto make the sale in any of the cases described above. ; Failure,to follow this policy may result in disciplinary action up to and including term) na/t� ion /l' ` ••YEN �, _ Z. Employee Signature Date St re Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) Age -Restricted Products Policy & Procedures: Tobacco LOCATION Every Employee at this location has the legal and moral responsibility to control the sale and distribution of age -restricted items to ensure these items do not get sold to minors!! TOBACCO PRODUCT SALES POLICY a r'� Objective: That all store Employees follow all laws eirtd procedurof tholicy related to the sale of tobacco products incly�ga�es, smok�'bacco, loose tobacco pipe tobacco rolling i . p p g papers, cigars, t, iga ties, vapp and lighters. The minimum age to purchase tobacco�prodits is twenty onesO years of age. It is our responsibility as a retailer and'An"O kers o he community to prevent the sale of tobacco to anyone under the age of tW t onei 21 . PROCEDURES: F rn 1. This policy will be feviewed With all n'ew�€mployees before they can operate a cash re�ter� sell LP t.co products. 2. All store Em loyees o ta� put& based training and successfully pass with;,rs ,9%prior to st�rtiTlg on a register. This certification to be updated .on an ari'"l�i�q is prion previous year expiration. t 3 "A valid form of eht fi �t on will be required for all tobacco purchases rpgardl ss of age�,or frequency of customer visits. Valid id are as follows: 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 ,a members of the party. I have read and understand the Mansfield. Board of Health Rggu[ations which prohibits the:sale of tobacco and nicotine deliveryproducts to anyone under the age'oftwenty-one (21) years. I also understand that if I fail to follow store policy and local and state laws about the sale of tobacco or.nicotine delivery products to any person under the legal age, I could lose myjob or be fined. I agree to the following rules about,thesale of tobacco products:' I wilfnot 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 Imake the sale: I will not accept a note from arr;adult, giving permission to a person under the.age of 21 to buy tobacco.products. In turn, management agrees to support myjudgment not to make the sale in any of the cases described above. a Failure,to follow this policy may result in disciplinary action up to and including terminatibn.' Employee Signature Date Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) Tobacco Retailer Employee Training Agreement I understand that Mansfield Service Inc. Located in Mansfield MA prohibits the sale of tobacco products and paraphernalia to persons under 21 years of age. I have reviewed the information regarding the sale of tobacco products and paraphernalia to persons under 21 years of age and understand that if I make an illegal sale of tobacco products or paraphernalia to a minor, I could lose any job, receive a fine and cost my employer a fine or loss of license to sell tobacco products. 1 agree to the following rules and company policy about the sale of tobacco products: • I will not sell tobacco products or paraphernalia (pipes, cigarette papers, etc.) to any person under the age of 21. • If the person appears to be under age 27, 1 will ask for identification, look at it and detennine their age. If there is any doubt about the person's age, I will NOT snake the sale. • I will not knowingly sell tobacco to any adult for use by individuals under the legal age. If I think this is happening, I will NOT make the sale. • I understand that access to all tobacco products is restricted to store employees only. • I have received training concerning state and local laws as well as store policy regarding the sale of tobacco. This Company will NOT sell tobacco products or smoking paraphernalia to anyone under the age of 21. I have received training in tobacco sales from my employer. I understand and agree to the statements on the previous page. Employee's name printed, signature, and date Employee's name printed, signature and date Employee's name printed, signature, and date Employee's name printed, signature, and date Employee's name printer!, signature, and date Employee's name printed, signature, and (late Employee's name printed, signature, and date Employee's name printed, signature, and (late Employee's name printer!, signature, and date Employee's name printed, signature, and date Employee's name printer!, ,signature, and date Store manager's signature and date Store manager'ssignature and date Store manager's signature and date Store numager's signature and date Store manager's signature and date Store manager's signature and date Store nurnager's signature and (late .Store manager's signature and date Store manager's signature and date Store manager's signature and (late Store manager's signature and (date (This agreement will be kept on stom premises at all times and must be presented for relew, �rhen requested by persons performing tobacco sales compliance checks.) Mansfield Service, Inc. CASHIER STORE TRAINING CHECKLIST All Mansfield Service, Inc. Store employees will receive detailed and thorough training . The training Checklist will serve as a tool to ensure that each employee is trained in all key areas within their responsibilities. COMPLETE PAPERWORK/Form 1-9 /MA Form W-4 GENERAL POLICIES REVIEW CUSTOMER SERVICE EXPECTATIONS AND REVIEW CUSTOMER SERVICE EXTENDED AND REVIEW SAFETY : ROBBERY REVIEW SAFETY: HOUSEKEEPING and WORK PLACE PRACTICES SAFETY : INJURIES, INCIDENTS and REPORTING SAFETY: SHIFT RESPONSIBILITIES SALES AND REGISTER PROCEDURES/PRACTICAL APPLICATION SHIFT CHECKOUT CASH AND INVENTORY CONTROL FOOD AND BEVERAGE SERVICE EQUIPMENT GENERAL CLEANING AVAILABILITY OF PRODUCT: FRONTING, FACING AND STOCKING ENGLISH PROFICIENCY CONFIRMATION FIRST DAY TRAINING (AM) GENERAL POLICIES & TRAINING OVERVIEW 1. Class C Operation training & Certificate 2. Emergency procedures 3. fire, Spill, Observable Leak 4. Retail Site Contact List SECOND DAY TRAINING (AM) Store Operations overview L Tom of Store 2. Bars Program 3. Tardiness and absenteeism policy/Loitering Policy 4. Authorized personnel only lin store restricted areas) 5. Power Outages Policy 6. Personal visitors at store: personal visitors not allowed at the store 7. CompanyTowing Policy 8. Cell phone use policy 9. Video Surveiiance equipment : do not touch/change stations 10. Store manuals (location and purpose) 11. Music systems:do not touch: do not change stations 12. Clocking in/out and employee work schedule policy 13. Employee consumption beverage policy 14. Policy for vendors leaving expired product IS, Back door policy 16. Smoke break policy P. 3rd shift open/closed door regarding going outside for any reason CUSTOMER SERVICE : EXPECTATIONS 1. No drawer sharing policy or sharing employee codes 2. Customer service Second Register Policy 3. Review product and know what you sell 4. Detailed customer service expectations )CUSTOMER SERVICE : EXTENDED 1. Review customer greeting culture 2. Review responding to customer needs 3. Review plus selling MODULE 1 CUSTOMER SERVICE MODULE 2 DIVERSITY SECOND DAY TRAINING (PM) SAFETY : ROBBERY REVIEW 1. No heroes policy review 2. Who to call in case of robbery/emergency 3. Review of robbery procedure/before/during and after SAFETY : HOUSEKEEPING and WORK PLACE PRACTICES 1, OSHA Label Training/OSHA SOS training 2. Beertainers/soda containers ice policy 3.Hourly store walk policy... inside and Outside to include pump areas 4. Avoiding slips, trips and falls 5. Lifting/ladder safety 6. UST and veeder Root training 7. Emergency stop button/turning off and on 8. No "Cherry Picking" 9. General safety rules SAFETY: INJURIES, INCIDENTS and REPORTING 1. Customer related incidents and amidents 2. Employee related incidents and accidents 3 Car wash incidents 4. Efuel nonle Incidents 5. Incident reports and employee statement guidelines 6. Damage to Timewise property SAFETY: SHIFT RESPONSIBILITIES 1. Leaving premise during work hours 2. Smoke Break on 3rd Ships 3. Pay Window Hours of Operation _ 4. No Employee Allowed Outside when Doors are Locked MODULE 3 ROBBERY & SAFETY THIRD DAY TRAINING (AM) SALES AND REGISTER PROCEDURES/PRACTICAL APPLICATION 1. Introduction to Ruby/operating proficiency/general operating procedures 2. PtU'S : price look up (deli) 3 Register departments 4. Lotto Machine 5. Lottery Sales 6. Sales dictated bylaws : ID anyone looking 30 and under ]. Methods of payment : Cash Debit Credit Ebt Gift Cards 8. Counterfeit bills 9. ATM'S : Troubleshooting 10. Correcting register mistakes : voids, line item voids/no sale policy 11. Figuring and courrungchange:verbally 12. Gas sales/pre pay protocol/move pumps 13. Car wash sales/car wash voids 14. Epay 15. Proper safe drop procedures 16. Menual,edit card procedures 17. Proper handling of a coupon 18. Heee refund Frtroalon/credil and cash 19aranuat entry of an item 2D. Manual For procedures 1. Cash drawer (how much allowed in drawer) 2. Change fund (processing properly) 3. Lottery ticket counts 4. Equipment readings and reports 5. Lotto and Lottery reports 6. Cash over and shortages and troubleshooting ]. Shift reports: complete, sign and data MODULE 4 LOTTO LOTTERY & PASSPORT CASH AND INVENTORY CONTROL I Drop procedures 2. Sale (shift counting accurately) 3. Vendor check -in/out 4. Credit card charge backs/fraud (responsibility) 5. Personally count cash drawer, safe and lottery tickets . 6, noncoms; ], Discuss with manager any potential problems you may see FOURTH DAY TRAINING (AM) FOOD AND BEVERAGE SERVICE EQUIPMENT L Coffee Make,,Aleaning/timers 2. Drink Dispensers 3lcees/Frozen Drinks 4, Hot Dog Grill / Nacho 5. Proper marking in/out dates of hot dogs 6. Proper temperatures of hot dogs and how to calibrate a thermometer /. Microwave 9, Cappuccino machine 9. Heat and serve 10. Maintaining food service area/stockinl GENERAL CLEANING 1. Duties : responsibility of ALL store employees 2. Restroom$ : check them at least one time per hour 3. Floors : make sure you use your wet floor sign 4. Fast food and drink center S. Sales Counter Area 6. Shelves, gondolas and endcaps ]. Cooler vault: do not turn off cooler fans or prop open cooler doors B. Windows and window ledges 9 Fuel dispensers 10. 0rives, porches and parking areas 11. Inside and outside t,ash policies 12. Car wash bays 13. Cleaning product use and knowledge 14. Use of PH strips 15. SDS mstatist far cleaning products MODULE S CLEANING & FASTFOOD STANDARDS I In 11.11n, FOURTH DAY TRAINING (PM) AVAILABILITY OF PRODUCT : FRONTING, FACING, STOCKING 1. Windshield service centers 2. Cigarette displays 3. Beer and soda boxes and barrels 4. Fronting and facing; rotating stock 5. Fast food and drink center 6. Rack stock I. Restroom MODULE 6 CASHIER TEST REVIEW NOTES: COMMENTS: I have been trained in all areas covered by the cashier trainingstore checklist and have initialed each accordingly. I fully understand the cashier training I have received. Employee Signature Date Store Manager Date CASHIER TRAINING CLASS ENGLISH PROFICIENCY ACKNOWLEDGEMENT Printed Employee Name Date I have observed the above named employee in my Cashier Training Class for the last two days and I certify that they have Independently spoken to me In English, and answered my questions that were written in English, read the policies and procedures in English, and answered questions that were written in English. In my opinion, the above named employee is able to capably read ,write, speak, and comprehend English. Training Manager Store N I have read, written, and spoken English in my Cashier Training Program with my Manager and I again certify that I can read, write, speak, and comprehend English. Employee Signature Date I Poll tr t i cl 0 `r' cl .c 4u v C,J c CA ti U c lu fj ris ,« 03 CSS � 00 Com! cL t6 tV :r U LAS Commonwealth of Massachusetts Department of Revenue Christopher C. Harding, Commissioner BNr OFQ' mass.gov/dor Letter ID: L2077758080 Notice Data September 4, 2018 Account ID: CGL -11477902-007 RETAILER LICENSE FOR SALE OF CIGARETTES u99rpIIId111ru111 htlllrul11111111ru112111111111111111 MANSFIELD SERVICE INC o MANSFIELD SERVICE INC 189 CHAUNCY ST MANSFIELD MA 02048-1355 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-printa 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 S MASSACHUSETTS DEPARTMENT OF REVENUE Form CT -3T —_---2e�aderZtcense forS�oTCigareftes- "a This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. MANSFIELD SERVICE INC 189 CHAUNCY ST MANSFIELD MA 02048-1355 Account ID: CGL -11477902-007 License Number: 1725306880 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 gSt: urFj� Commonwealth of Massachusetts Letter to: L192443660MINIM 8 h + Department of Revenue Notice Date: September 4, 2018 .y 14 a Christopher C. Harding, Commissioner Account ID: CRL-11477902-010 'pvroF4 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO IIIIa�I11Lllhllllld�purl'I'�IIIII"�III6JI�IddI�iL�L MANSFIELD SERVICE INC o Jim MANSFIELD SERVICE INC m _ 189 CHAUNCY ST MANSFIELD MA 02048-1355 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (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 massrgov/masstaxconnect to view and 7e -print a-copyofthis license. If you have any questions about your license, call us at (617) 887-6367 or toll-free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE MASSACHUSETTS DEPARTMENT OF REVENUE ---RetailerLicense-o—rS ale —of Clgars aso&Smoking-T-0biacco-_- 'FNr oFs` This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. MANSFIELD SERVICE INC 189 CHAUNCY ST MANSFIELD MA 02048-1355 Form CT -3T AccounttD: CRL -11477902-010 License Number: 1099065344 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 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 (Mai datory, if Applicable) I q --6 Z--�; tf�s'q: "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:\Users\sleite\Desktop\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: 1 Are you an employer? Check the appropriate box: 1 I am a employer with J employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 3.❑ 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.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Bus'ne s Type (required): 5. Retail 6. RestaurantBar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other *My 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 worker 'coin enation insurancefor my employees. Below is the policy information. Insurance Company Name: J,i/t-P , / v✓i a, Insurer's Address: City/State/Zip: 0• 07 /8 Policy # or Self -ins. Lic. # (a S 0U 6 .— 27:0 L L -7 _ � — /9 Expiration Date: j% 1%7"C2 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. Ido hereby certify, under the pains and penalties of perjury that the informationprovided 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 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 www.mms.gov/dia Phone