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Home My WebLink About7-Eleven #37484H - 12/31/2020QV Town of Mansfield 122019 Town of Mansfield Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: Application for the Sine ol'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: 11 ( 3 LOCATION OF SALE OF TOBACCO PRODUCTS: �2 r�i�atU .)A� TELEPHONE AT LOCATION: _ �3 �__ _ S_7�----------- ----- .----..------_____. OWNER OF BUSINESS: ADDRESS OF OWNER: TELEPHONE OF OWNER: FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner, �I -- Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training rinrnmontntinn -____-._—�} �_t_�� Gin * Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $150.00 n la 18 CT -3T NUMBER: �0O—M �Z` Y � 2� FEDERAL ID/SS NUMBER: SIGNATURE: DATE: STATE OF MN LIST OF OFFICERS Joseph M DePinto Pres/CEO Rankin Gasaway SVP/GC/SEC David Seltzer VP/TR Common 0h of Manouhuu0r Lclnr ID: L0202251392 Dopanmom of Rovowo Nulim Ome; Septombor 17, 2018 Christophm C, Huding, Commissioner Account ID: CGL -10196336.110 mm.gov/doe RETAILER LICENSE FOR SALE OF CIGARETTES 7ELEVENINC 7 -ELEVEN 37445H PO BOX 711 DALLAS TX 75221-0711 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 uAN cH°ft>a MASSACHUSETTS DEPARTMENT OF REVENUE Form CT -3T Retailer License for Sale of Cigarettes sm�� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. 7 ELEVEN INC Account ID: CGL -10196336-1 10 7 -ELEVEN 37484H Location ID: 10196336-0772 242 CHAUNCY ST License Number: 2012383232 MANSFIELD MA 02048-1256 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, 20 181, Expiration Date: September 30, 2020 Commonwealth of Map.ch... ft. q� Department of Revenue t}� Christopher C. Harding, commissioner t>F+ mns.gov/dor tAwr ID: 1.1813340800 Notice Date: September 17, 2018 A000unt to: CRL -10196336.113 RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO 111111ttII1t11h1111HIt11tthgHt11aa11IttptltiIII loll' 11111 7ELEVENINC 7 -ELEVEN 37445H PO BOX 711 DALLAS TX 75221-0711 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 moss.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 0 rcxuF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT -3T Retailer License for Sale of Cigars and Smoking Tobacco 'ire far This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. 7 ELEVEN INC Account_ID: CRL -10196336-113 7 -ELEVEN 37484H Location ID: 10196336-0773 242 CHAUNCY ST License Number: 463280128 MANSFIELD MA 02048.1256 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 yrs c.rF�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT -3T Retailer License for Sale of Cigars and Smoking Tobacco 9 G x This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. 7 ELEVEN INC Account ID: CRL -10196336-113 7 -ELEVEN 37484H Location ID: 10196336-0773 242 CHAUNCY ST License Number: 463280128 MANSFIELD MA 02048-1256 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 r SS�'SF�a .SSACHUSETTS DEPARTMENT OF REVENUE o w Retailer License for Sale of Cigarettes Form CT -3T This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. 7 ELEVEN INC Account ID: CGL -10196336-110 7 -ELEVEN 37484H Location ID: 10196336-0772 242 CHAUNCY ST License Number: 2012383232 MANSFIELD MA 02048-1256 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 I, 2018 Expiration Date: September 30, 2020 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. V` 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, s' The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. Xi 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. Ur Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. V 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". ! 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. 1 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. 12? r Signature, ` -"' Date Print Name 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 customers 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. y I must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. f 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 o�!igarettes 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. 1� Blunt wraps are prohibited. Penalties for violation of the regulation include, monetary fines and/or suspension of this permit for seven or f thirty days. tj 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` I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". V 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 I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". !f I must display signs provided by the Board of Health that discloses referral information about cessation. U/IIf 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 _ 7 -L� ii Date J ' - f �/ Print Name A check mark signifies your understanding and agreement. I understand and agree that: sf 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. r 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. jr I must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. v/ Self-service tobacco product and/or nicotine delivery product displays from which the customer may select products are prohibited. 1 The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. t' 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 r cigarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue. t 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. vi 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). must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". Q I must display signs provided by the Board of Health that discloses referral information about cessation. I If I sell nicotine delivery devices (e.g. e -cigarettes) I must display signs stating that sale of nicotine delivery devices to anyone below the minimum legal sales age is prohibited and that the used of e -cigarettes at indoor establishments is prohibited by local law. 1 have received, read and understand the Board of Health regulation "Regulation Affecting Smoking and the Sale, Vending, and Distribution of Tobacco and Nicotine Delivery Products" and agree to abide by it. Signature \ \� s V \ Date ! rX , Print Name d`�1iJi l� A check mark signifies your understanding and agreement. I understand and agree that: ,V 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. tl 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 pjroto ID for anyone less than 27 years of age. /I mus ,consent to unannounced, periodic inspections and compliance checks of the permitted retail estiblishment. Self-service tobacco product and/or nicotine delivery product displays from which the customer may select products are prohibited. 'ti The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. ,1 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 cjgarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue. �Tgbacco vending machines are prohibited. Nos -residential Roil -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 �eopy of which will be placed on file, that he/she has read the regulation and applicable state laws. f 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". Ist 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 Njcottrre1Delivery Products" and agree to abide byjt/ Signature Print Name V r r9� 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. I must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. Vf Self-service tobacco product and/or nicotine delivery product displays from which the customer may select products are prohibited. r J The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. f 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. j Non-residential Roll -Your -Own machines are prohibited. V Blunt wraps are prohibited. V Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or / thirty days. y 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. u 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". J I must display signs provided by the Board of Health that discloses referral information about cessation. fIf 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 I Date^' Ac ck 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 /Anyone less than 21 years of age, regardless of how old the person looks. selling tobacco products and/or nicotine delivery products must conclusively establish the customer's /A/age as over 21 years old, by means of government -issued photographic ID. nyone selling tobacco products and/or nicotine delivery products must check and verify official government Jphoto ID for anyone less than 27 years of age. I must consent to unannounced, periodic inspections and compliance checks of the permitted retail / establishment. JSelf-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 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 I cigarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue. J Tobacco vending machines are prohibited. Non-residential Roll -Your -Own machines are prohibited. /Blunt wraps are prohibited. JPenalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. J1 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/ I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". J 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". J 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 o zul - Date )'* hhhl Print Name --u��0&31 AJI check mark signifies your understanding and agreement. I understand and agree that: t is against the law to sell any tobacco product and/or nicotine delivery product (e.g. e -cigarettes) to anyone ess than 21 years of age, regardless of how old the person looks. C' Anyone selling tobacco products and/or nicotine delivery products must conclusively establish the customer's Jage 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 J photo ID for anyone less than 27 years of age. must consent to unannounced, periodic inspections and compliance checks of the permitted retail /establishment. V/ Self-service tobacco product and/or nicotine delivery product displays from which the customer may select Jproducts 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 1ay not ept any means, instruments or devices that allow for the redemption of tobacco products for free or C,,,garetIe:iat a price belowthe minimum retail price determined by the Massachusetts Department of Revenue. /bacco vending machines are prohibited. /Non-residential Roll -Your -Own machines are prohibited. �t3lunt 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 fife, 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). Y1fMi/I ust display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". ust display signs provided by the Board of Health that discloses referral information about cessation. 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. 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 Print Name