HomeMy WebLinkAboutCanaan Fuels - 12/31/2020�5 s _t50`
Town of Mansfield - Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
• 4 y`011
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:
LOCATION OF SALE OF TOBACCO PRODUCTS:
TELEPHONE AT LOCATION:
OWNER OF BUSINESS:
ADDRESS OF OWNER:
TELEPHONE OF OWNER: iY ' � fc a --
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: L c-,
FEDERAL IDISS NUMBER: ` / 3Z 4
SIGNATURE:
DATE: - -- 1
Town of Mansfield
6 Park Bout, iWansfzeld, Alassaclmsetts 02048
Health Department
Any Donovan -Palmer, MPH, BS, HeaAb Agent
October 16, 2019
Tobacco and Nicotine Delivery Products Sales permit holders:
Your current tobacco sales permit in Mansfield will expire on December 31, 2019.
To renew your permit, please submit the following documents and payment to the Health Department NO
LATER THAN NOVEMBER 27, 2019. Please note that ALL of these documents must be submitted each year
for the filing to be complete. Incomplete filings will be returned and no permit will be issued.
1. Tobacco and Nicotine Delivery Products Sales Permit Application (Attached)
2. Tax Certification Form (Attached)
3. Workers' Compensation Insurance Affidavit: General Business. (Attached)
4. Workers' Compensation policy declaration page
5. Copy of current Department of Revenue CT -3T Retail Excise Unit License
6. Written Standard Operating Procedure on how 21+ age restriction is enforced in your
establishment, including training protocols for employees per local regulations
7. Copies of employee signed statements that the employee understands and will uphold the
regulations (example enclosed)
The Health Department is communicating with permit holders mainly through email. Please be sure to
include a valid email address for all positions. If there are any changes in contact information (i.e. new
PIC, new email address), the Health Department must be notified within 10 business days.
As a Tobacco and Nicotine Delivery Product Sales establishment, the following fee applies:
• ,;$150 Tobacco and Nicotine Delivery Product Sales Permit . `
The Plastics Waste Reduction bylaw is now fully in effect. According to this by-law, no retail establishment
shall provide thin-film, single -use plastic check-out bags. Check-out bags can only be a 100% recyclable
paper bag containing at least 40% post -consumer recycled content or a reusable check-out bag.
Please contact the Health Department if I can be of any further assistance.
Sincerely,
��11'vuq ��6,u��O�JwR11.
Amy Donovan -Palmer, MPH, RS
Health Agent
Phone (508)269-7366 Fax (508)269-7425 Email adpalmez@manifieldma.com
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.
�1/ 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.
yl -'Anyone selling tobacco products and/or nicotine delivery products must check and verify official government
/photo ID for anyone less than 27 years of age.
I must consent to unannounced, periodic inspections and compliance checks of the permitted retail
establishment.
Self-service tobacco product and/or nicotine delivery product displays from which the customer may select
products are prohibited.
Y" The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited.
1 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.
'p '_Tobacco vending machines are prohibited.
zP"Non-residential Roll -Your -Own machines are prohibited.
) Blunt wraps are prohibited.
7� Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or
thirty days.
1 I/'I may not allow any employee to sell tobacco products or nicotine delivery products (e.g. e -cigarettes) until such
l 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.
I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices".
1QAII must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts
Department of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license).
I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited".
p/' ll must 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 Name
Date 1,9 .c I`(
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)
"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:\Use&sleite\Desktop\Scott's Documents\Food EstabUslnnents- Temp\TAX CERTIFICATION FORM.doc
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Department of Industrial Accidents
Offtee of Investigations
600 Washington Street
Boston, MA 02111
www. tnass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name: a rh r i
Address:
� ( S
City/State/Zip: 0 ry `t,
Phone #: > C,
Are yo an employer? Check the appropriate box:
Iram
Busines Type (required):
1.❑
a employer with employees (full and/
5. Retail
2. ❑
or part-time).*
I
6. ❑ Restaurant/Bar/Eating Establishment
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
3.❑
[No workers' comp. insurance required]
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
4.❑
no employees. [No workers' comp. insurance required]*
We are a non-profit by
11.❑ Health Care
organization, staffed volunteers,
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 #I.
I out an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:i 3 tt i f (e_� y' 75
Insurer's
City/State/Zip:
v1i
G 31
Policy # or Self -ins. Lic. # 6 ] ` c1C Q - -r �)G Expiration Date: 0.:2—\H - 2- C,, n
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penal ' perlur;Ialh0-lbe4nfgrmadon provided above is true and correct.
Phone #'
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License
— l_ 0
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.mass.gov/dia
Phone
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 ajoint 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 the 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 burn 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
inn Revised 5-26-05
s5trFjA Commonwealth of Massachusetts Letter ID: L0534874752
§ m Department of Revenue Notice Date: October 1, 2018
Christopher C. Harding, Commissioner Account ID: CGL -11310564-006
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�e mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES]
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CANNAN GROUP INC -
CANNAN FUELS
w 157 PRATT ST - - -
MANSFIELD MA 02048-1555 - - -
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ari. wisp ay at your usmes o"ca tori; Ararly time, you can log into your ass -Tax ohne c at
mass.gov/mmstaxconnect to view and re -print a copy of this license. .y
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. '
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�, t DETACH HERE •_. " .
.._.," 'fLJL 1.�;I-YPMNJ�AL LAWS;
CHAPTEI2270; SECTION
TOBACCO SAIES .TO:IVITNORS .::':' ?s ,•
oeyer.sells. a cigarette, chewing. tobacco, snuff or:any tobacco. tri: any yf its.'foriis to
nq person under the age of eighteen: or; not:being his parerifor.guardian, 'gies;a}`;
;este; chewing tobacco, snuff or tobacco..in aiiy..of ts:forins fo;atiy„peison:under<tlie
of'eighteen shall be punished by.a fine of not less thaiY. one hundred dollars fob tTie '4.
t offense, not less than two hundred=dollazs :for aaeaorid;offerise andi nb'Iess :liaii' ';
three hundred dollars for any third or:�ubsequent offense” "
I understand that Massachusetts law prohibits the sale of tobacco products to anyone
under age 18; however in the town/city I am working I am prohibited from selling
tobacco products to anyone under age 21. I understand that r I fail to follow company
policy and town/city law about the sale of tobacco to minors I will lose my job and may
be fined.
I agree to the following rules about the sale of tobacco products:
1. I will not sell any tobacco products, including cigarettes, ing tobacco,
cigars, chew
bidis, or any other. form of tobacco, to any person under the age of ew
21.
2. I will ask for photo identification (I.D.) of any person attempting to buy a tobacco
product. If there is any doubt about the person's age, I will not make the sale
3. I will not accept a note from an adult giving permission to a person under the age
of 21 to buy tobacco products.
In turn, management agrees to support m
PP y judgment not to make the sale in any o f the
cases described above.
L
loyees Prl ame
Employ 4si ature
Location worlting
Date
Regional Manager's signature
Date
(This agreement will be maintained in your personnel file as part of your permanent employee record)
25 Braintree Hill Office Park #409 Braintree, Ma 02184 781-356-1960 783-356-1976(fax)
MASSACHUS + TTS::GE1V]
RAL'..LA VAS''
CHAPTER -47-6 SEGTIOIV:6
TOB
ACCO SALES TO M&
6R
`,.`,Wlioever:sells.a cigarette
chewing. wmg tobacco; sii}iff oi;any;tobacco_ iri: ail` "i''
; anq.persori under the age of eighteen:on�not.beiiig liis parent or. `u- - "..' . for1.ii s`to
cigaiette, chewing tobacco, snuff.or tobacco.in anyg xan Uives:a>' .-
age of'eighteen shall be .of its'form to, any person under the
`' first offense, not -less than two hundred dollars for a second offers Band not ess Hite
three hundred dollars for any thnd.or':�ubse uent: offense: n
q "
I understand that Massachusetts law prohibits the sale of tobacco products to anyone
under age 18; however i.n the town/city I am working I am prohibited from selling
tobacco products to anyone under age 21. I understand that if I fail to follow compan
Policy and town/city law about the sale of tobacco to minors I will lose m ob y
be fined. yJ and may
I agree to the following rules about the sale of tobacco products:
1. I will not sell any tobacco products, including cigarettes
bidis, or any other_ form , cigars, the of tobacco, to any person under the age of 2�g tobacco,
2. I will ask for photo identification (I.D.)
product. of any person attempting to buy a tobacco
If there is any doubt about the person's age, I will not make the sale.
3. I will not accept a note from an adult giving permission to a person under the age
of 21 to buy tobacco products.
In turn, management agrees to support m a
cases described above. Yjudglnent not to make the sale in any of the
�1'1�t 1 1 K�SSc�Y�
Employee's Printed Name
_ Location working
ta�Sav;
Employee's si naure
Date
Regional Manager's signature
Date _
(This agreement will be. maintained in your personnel file as part of your permanent employee record)
25 Braintree Hill Office Park #409 Braintree, Ma 02184 781-356-1960 781-356-1976(fax)
Y