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HomeMy WebLinkAboutCanoe River C. G. (Starlin, Inc) - 12/31/2020*1 00 01- iso, D Town of Mar #ielcl - Board PERMIT NUMBER: To*n of Mansfield 6 Park Row Mansfield, MA 02048 Application fi f• 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: �Cakes �fYu�1 LOCATION OF SALE OF TOBACCO PRODUCTS: _ 3 '� J1 I i �n S) 2n S ie Ld) TELEPHONE AT LOCATION: OWNER OF BUSINESS: _j lL'uP✓I 6vr s a Jva3p urnt �iSj �^ 6Fy /a-vy Caf ✓ v%I ADDRESS OF OWNER: 1 j S _^ i) ---- TELEPHONE __TELEPHONE OF OWNER:_ 0 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. _ STevoh ii*?ns-q v 5� / kiwda Jri�ttil'lnels jor ��cr a%mY Qr-%•nne C--xriY-dV etS 57 _-S®cT'a Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation A * Provide a copy of current Department of Revenue CT 3T Retail Excise Unit License. FEE: $150.00 Q CT -3T NUMBER: C �' ~ �� 5 CJ ^ 007 FEDERAL ID/SS NUMBER: 01 �� 7 6� /If SIGNATURE: DATE: November 26, 2019 Amy Donovan -Palmer, MPH, RS Health Agent Dear Amy, This letter is to inform you that all my employees that sell cigarettes have watched the 20 -minute online course for tobacco training, as of November 26, 2019. They were also trained verbally and shown the proper signage when they were hired. Sincerely, Lauren Gonsalves Office Manager Canoe River Campground 508-339-6462 �ypCAr(pF, Commonwealth of Massachusetts ?pdy�'=)) �'.h Department of Revenue ,� f�' '� Christopher C. Harding, Commissioner � S*1cSlI�* +'PnT pp4 ntass.gov/dor Letter ID: LI253347968 Notice Date: September 4, 2018 Account ID: CGL -11353826-007 RETAILER LICENSE FOR SALE OF CIGARETTES tlphlldllltll�mlrldhlll�hrPhwrdl4�p�ullhdlPlll STARLIN INC CANOE RIVER CAMPGROUND GENERAL ST oWON 137 MILL ST MANSFIELD MA 02048-3268 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 a��s6! s��jW MASSACHUSETTS DEPARTMENT OF REVENUE Form CT -3T Retailer License for Sale of Cigarettes �n r of This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. STARLIN INC Account ID: CGL -11353826-007 CANOE RIVER CAMPGROUND GENERAL STORE License Number: 1635936256 137 MILL ST MANSFIELD MA 02048-3268 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 revolted for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30, 2020 Nome Account IfVb rce.o1.k v iB hiplo 3.1aIt Tobacco License Multiple List 1 Lrr Filing lD 'License Type 'Status CGL11353826007 Application CT -RL Acco Approved OGL11353826007 License CT -RL Cigaret6Valid 2 Rows STARLIN INC ! 04-2375571; Cigarette License' Biennial CANOE RIVER CAMPGROUND GENERALSTORE CGL -11353826-007 Balance: $0.00 License Type Retailer Submissions Correspondence Names and Addro&ses Refunds Tobacco License Period List Tutorials i,o I Want To Manage payments Close my tax account File a dispute MaassTsu ,CONNECT .Period !License Type 'Status Tax'. Penalty; Interest. Credits Balance'. 30 -Sep -2020 License List Pay 50.00 0.00 0.00 50.00 0.00 30 -Sep -2018 License List Pay 50.00 0.00 0.00 50.00 0.00 30 -Sep -20'16 No License Pay 0.00 0.00 0.00 0.00 0.00 A check mark signifies your understanding and agreement. l 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. 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. The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. 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. Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty 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 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". 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). I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". I 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 0V aYI CO YLS:'1 /V eS Date CANON, RIM CAMPFgOUND 137 Mill Street, Mansfield, MA 02048 Tobacco Sales Policy OBJECT2✓VE: That all store employees follow all laws and procedures of this policy',related to the sale of tobacco products. A tobacco product is any product co.taining or made from tobacco or nicotine. It can be smoked, chewed, absorbed, dissolved, inhaled, snorted, sniffed, or ingested. i These law$ are designed to make regulated tobacco products less accessible and less attractive to youth. It is our responsibility as a retailer and members of the community to prevent the sale of tobacco to anyone under the age of twenty-on� (21). PROCEDURES: •3 This policy will be reviewed with all new employees before they can operate a cash register and sell tobacco products. •A All store employees will watch the MHOA online training video. They will watch it on an annual basis prior to previous year expiration. :• Alltore employees will read the applicable Board of Health regulations and state and federal laws. •S A v4lid form of identification will be required as proof of age for all tobajcco purchases. No expired identification will be accepted. ❖ All $tore employees will check the photo ID of everyone under age 27 wh attempts to purchase tobacco products. Photos must be visually matched to the customer purchasing, and the birth date checked against the digital calendar supplied by This is Our Watch. IDs should be dhecked for any kind of tampering. Acc eptable forms of ID are: Val d Massachusetts and Out of State License Val d Massachusetts State ID or Liquor Card Val d US Passport I I have read and understand the Mansfield Board of Health Regulations, which prohibits the sale of tobacco and nicotine delivery products to anyone under the alge of twenty-one (21) years. I also understand that if I fail to follow sto ' policy and local, state, and federal 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 form of ID, I will not make the sale. I will not accept a note from an adult giving permission to a person under the age of 21 to buy tobacco products. In turn, management agrees to support my judgment not to make the sale in any of the cases described above. Failure to follow this policy may result in disciplinary action up to and including termination. Employee Signature Date Store Operator Signature Date This forrA will be maintained in your personnel file as a part of your permanent employee record. CANOE RIVER CAMPGROUND 137 Mill Street, Mansfield, MA 02048 Tobacco Sales Policy OBJECTIVE: That all store employees follow all laws and procedures of this policy related to the sale of tobacco products. A tobacco product is any product containing or made from tobacco or nicotine. It can be smoked, chewed, absorbed, dissolved, inhaled, snorted, sniffed, or ingested. These laws are designed to make regulated tobacco products less accessible and less attractive to youth, It is our responsibility as a retailer and members of the community to prevent the sale of tobacco to anyone under the age of twenty-one (21). PROCEDURES: ❖ This policy will be reviewed with all new employees before they can operate a cash register and sell tobacco products. ❖ All store employees will watch the MHOA online training video. They will watch it on an annual basis prior to previous year expiration. B• All store employees will read the applicable Board of Health regulations and state and federal laws. A valid form of identification will be required as proof of age for all tobacco purchases. No expired identification will be accepted. •3 All store employees will check the photo ID of everyone under age 27 who attempts to purchase tobacco products. Photos must be visually matched to the customer purchasing, and the birth date checked against the digital calendar supplied by This is Our Watch. IDs should be checked for any kind of tampering. Acceptable forms of ID are: Valid Massachusetts and Out of State License Valid Massachusetts State ID or Liquor Card Valid US Passport I have read and understand the Mansfield Board of Health Regulations, which prohibits the sale of tobacco and nicotine delivery products to anyone under the age of twenty-one (21) years. I also understand that if I fail to follow store policy and local, state, and federal 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 form of ID, I will not make the sale. I will not accept a note from an adult giving permission to a person under the age of 21 to buy tobacco products. In turn, management agrees to support my judgment not to make the sale in any of the cases described above. Failure to follow this policy may result in disciplinary action up to and including termination. Employee Signature Store Operator Signature Date Date This form will be maintained in your personnel file as a part of your permanent employee record. CANOE RIVER CAMPGROUND 137 Mill Street, Mansfield, MA 02048 Tobacco Sales Policy OBJECT VE: That all store employees follow all laws and procedures of this policy related to the sale of tobacco products. A tobacco product is any product cc ntaining or made from tobacco or nicotine. It can be smoked, chewed, a sorbed, dissolved, inhaled, snorted, sniffed, or ingested. These law are designed to make regulated tobacco products less accessible and less aftractive to youth. It is our responsibility as a retailer and members of the community to prevent the sale of tobacco to anyone under the age of twenty -on (21). PROCEDI RES: ❖ This policy will be reviewed with all new employees before they can opeiate a cash register and sell tobacco products. ❖ All Store employees will watch the MHOA online training video. They will watch it on an annual basis prior to previous year expiration. All store employees will read the applicable Board of Health regulations and state and federal laws. :• A valid form of identification will be required as proof of age for all tobacco purchases. No expired identification will be accepted. .• All store employees will check the photo ID of everyone under age 27 who attempts to purchase tobacco products. Photos must be visually matched to the customer purchasing and the birth date checked against the digital calendar supplied by This is Our Watch. IDs should be che�ked for any kind of tampering, Acceptable forms of ID are: Vali d Massachusetts and Out of State License Valid Massachusetts State ID or Liquor Card Valid US Passport I have read and understand the Mansfield Board of Health Regulations, which prohibits the sale of tobacco and nicotine delivery products to anyone under the age of twenty-one (21) years. I also understand that if I fail to follow store policy and local, state, and federal laws about the sale of tobacco o�j nicotine delivery products to any person under the legal age, I could loselmy 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 pioduct to any person under the age of 21. If any person regardless of age attempts to make a tobacco purchase without an acceptable form of ID, I will not make the sale. I will not accept a note from an adult giving permission to a person under the age of 21 to buy tobacco products. In turn, management agrees to support my judgment not to make the sale in any of the cases described above. Failure to follow this policy may result in disciplinary action up to and including termination. _`a--------- ------as1 ------ Employee Signature Q!z%te _CZl_y«a_1%t!r ----- Store Operator Signature Date ----Z52-4f)-j--------- Date This form will be maintained in your personnel file as a part of your permanent employee record. CANOE RIM CAMPGROUND 137 Mill Street, Mansfield, MA 02048 Tobacco Sales Policy OBJECTIVE: That all store employees follow all laws and procedures of this policy related to the sale of tobacco products. A tobacco product is any product containing or made from tobacco or nicotine. It can be smoked, chewed, absorbed, dissolved, inhaled, snorted, sniffed, or ingested. These laws are designed to make regulated tobacco products less accessible and less attractive to youth. It is our responsibility as a retailer and members of the community to prevent the sale of tobacco to anyone under the age of twenty-one (21). PROCEDURES: ❖ This policy will be reviewed with all new employees before they can operate a cash register and sell tobacco products. ❖ All store employees will watch the MHOA online training video. They will watch it on an annual basis prior to previous year expiration. All store employees will read the applicable Board of Health regulations and state and federal laws. •3 A valid form of identification will be required as proof of age for all tobacco purchases. No expired identification will be accepted. •3 All store employees will check the photo ID of everyone under age 27 who attempts to purchase tobacco products. Photos must be visually matched to the customer purchasing, and the birth date checked against the digital calendar supplied by This is Our Watch. IDs should be checked for any kind of tampering. Acceptable forms of ID are: Valid Massachusetts and Out of State License Valid Massachusetts State ID or Liquor Card Valid US Passport I have read and understand the Mansfield Board of Health Regulations, which prohibits the sale of tobacco and nicotine delivery products to anyone under the age of twenty-one (2 1) years. I also understand that if I fail to follow store policy and local, state, and federal laws about the sale of tobacco or nicotine delivery products to any person under the legal age,1 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 form of ID, I will not make the sale. I will not accept a note from an adult giving permission to a person under the age of 21 to buy tobacco products. In turn, management agrees to support my judgment not to make the sale in any of the cases described above. Failure to follow this policy may result in disciplinary action up to and including termination. Employee ' ature Store Operator Signature ----1 a-=_ S Date is -s -i9 Date This form will be maintained in your personnel file as a part of your permanent employee record.