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Home My WebLink AboutMansfield Xtra Mart - 12/31/20205,2m153 vt+ Town of Mansfield - Board of Health PERMIT NUMBER: Tc 6_ Application for the Sale of Tobacco Products ot�$Aansfteld RJ& r, field, MA'�I'OZQ48 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: Mansfield Xtra Mart LOCATION OF SALE OF TOBACCO PRODUCTS: 905 South Main Street, Mansfield MA TELEPHONE AT LOCATION: 508-261-2812 OWNER OF BUSINESS: ADDRESS OF OWNER: Drake Petroleum Company Inc. 800 South Street, Suite 500, Waltham MA 02453 TELEPHONE OF OWNER: 781-398-4342 FAX NUMBER: 781-398-7217 If a corporation or partnership, give name, title, and home address of officers or partner. see attached Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation see attache - * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 p 2 1 CT-3T NUMBER: 4n00 83Rh6q 331gan FEDERAL ID/SS NUMBER: 04-2236089 Drake Petroleum Company Inc. � y SIGNATURE:By: Andrew£Sllfka, EVP DATE: ( l (� A check mark signifies your understanding and agreement. I understand and agree that: 0 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. RI 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. ® Tobacco vending machines are prohibited. X Non-residential Roll -Your -Own machines are prohibited. ® Blunt wraps are prohibited. X 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. X 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). W 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. IN 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. Drake PetroleumComp any Inc. Signature - `°- Date (� I Print Name Andrew Slifka, EVP 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. Drake Petroleum Company Inc. Signature of Individual or Corporate Name 04-223-6089 "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatony, if Applicable) Andrew Slifka, EVP *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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Global Montello Group Corp. CORPORATE OFFICERS Name & Address Title Eric Slifka Director, President and Chief 9 Clark Road Executive Officer Wellesley, MA 02481 Andrew Slifka Executive Vice President 14 Lehigh Road Wellesley, MA 02482 Edward J. Faneuil Secretary, Executive Vice 100 Belvidere Street, Unit 5H President and General Counsel Boston, MA 02199 Matthew Spencer Chief Accounting Officer 17 Parkerville Road Southborough, MA 01772 Daphne Foster Chief Financial Officer 27 Fairgreen Place Brookline, MA 02467 Mark Romaine Chief Operating Officer 155 Hawthorne Road Braintree, MA 02184 ycn�ot4rh. Commonwealth of Massachusetts Letter to: L0739248768 10, Department of Revenue Notice Date: September 24, 2018 Christopher C. Herding, Commissioner Account to: CRL-11154405.072 rtNro54 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO dh�lll�lll i�llt�Ill��toljlllllldllll�lth�'��I"I�'�I�il' DRAKE PETROLEUM CO INC MILLHURY XTRA MART 15 NE INDUSTRIAL RD BRANFORD CT 06405-2844 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 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, 830 a.m. to 4:30 p.m. DETACH HERE 6 �yASP rr� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T e,iy, Retailer License for Sale of Cigars and Smoking Tobacco i V� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. DRAKE PETROLEUM CO INC Account ID: CRL-11154405-072 MANSFIELD XTRA MART Location ID: 11154405-0204 905 S MAIN ST License Number: 486008832 MANSFIELD MA 02048-3149 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 Commonwealth of Massachusetts Letter to: L1283046528 OriX' 21' 7jS�i Department of Revenue Notice Date: Septembor 20,2018 Christopher C. Handles, Commissioner Account ID: CaG11154405-069 rdMpt'w mesasov/don RETAILER LICENSE FOR SALE OF CIGARETTES diIII III nIIIIII IIII I]IIII lllIII III IIIIIII IIII DRAYR PETROLEUM CO INC MILLBURY XTRA MART 15 NE INDUSTRIAL RD BRANFORD CT 06405-2844 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 -tree in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE SA`s4�' MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T o 7 Retailer License for Sale of Cigarettes °E'nrros �a.Sv This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. DRAKE PETROLEUM CO INC Account ID: CGL-11154405-069 MANSFIELD XTRA MART Location 1 ): 11154405-0203 905 S MAIN ST License Number: 2048337920 MANSFIELD MA 02048-3149 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 The Commonwealth of Massachusetts Department oflndnstrialAccidents / ` Office o/'Investigations Lafayette Citdi Center 2Aventie de Lafayette, Boston, MA 02111-1750 9�9'�,�i ,. w n,w.ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Drake Petroleum Company, Inc. Address: 800 South Street, Suite 500 City/State/Zip: Waltham, MA 02453 Phone #: (781) 894-8800 Are you an employer? Check the appropriate box: Business Type (required): 1.9 1 am a employer with employees (full and/ 5. [gRetail 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. ❑ 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]** 11 HealthCare 4. ❑ We arc a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] •❑ 12.N Other VAk1LGLP..Jif.�(L'�Q`'tbt\ *Any applicant that checks box 01 vast also fill out the section below showing their workers' compensation policy information. **It the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such in organization should check box 01, I ani am employer that is providing workers' compensation insurance for Iny employees. Below is tire policy information. Insurance Company Name: Liberty Mutual Insurance Corp Insurer's Address: 173 Berkeley Street City/State/Zip: Boston, MA 02116 Policy # or Self=ins. Lic. # Wr ,j - i4N - IJi t, co&io o J,q Expiration Date: 10/1/20 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under § 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 STOP WORK ORDER and a fine of up to $250.00 it 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 eVi ldfy, ender the pains and penalties ofpeijimy that the informurtion provided above is brae and correct. Official rise only. Do not iw•ite in this area, to be completed by city or lown official. City at, Town: Issuing Authority (check one): 1.❑Board of Health 2.0 Building Department 50 Selectmen's Office 6. ❑Other Contact Person Permit/License 10City/Town Clerk 4.❑Licensing Board Phone wnmsnmss.gov/dia AC"RO CERTIFICATE OF LIABILITY INSURANCE 11.� 10/l/2020 Dnre lMmloorcvvv) 1 10/1/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements). PRODUCER Lockton insurance Brokers, LLC 777 S. Figueroa Street, 52nd Fl. CA License NOF 15767 Los Angeles CA 90017 (213)689-0065 44E' CT PHONE IAIX No tU - •muL 00 Io INSUREINS1 AFFORDING COVERAGE _NAICII INSURER A: Liberty Mutual Fire insurance Company, 23035 INSURED Drake Petroleum Company, Inc. 1370629 Global Partners, LP INSURER 6: Liberty InsUra too Cor or tiott 42404 INSURER C: INSURERD: 800 Seth]] Street Waltham MA 02454 _ INSURER E : INSURER F : COVERAGES GLOPA01 CERTIFICATE NUMBER: 15683144 REVISION NUMBER: XXXXXXX THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ITR TYPE OF INSURANCE ADOL SUBR POLICY NUMBER POLICY EFF POLICY EXY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX PREMISES flEa.courronpid MED EXP(My ono Person) S XXXXXXX $ XXXXXXX GEN'L PERSONAL a AOV INJURY $XXXXXXX _ AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOG OTHER; GENERAL AGGREGATE $ XXXXXXX PRODUCTS - COMPIOP AGO It XXXXXXX_ $ A AUTOMORRELIABILITY X ANYAUTO OWNED SCHEOULEO - AUTOS ONLYHAUTOS X AHIRED MON-OWNED UTOS ONLY AUTOS ONLY N N AS2-691-460066-039 10/1/2019 10/1/2020 EOMaD�1dinall GLE MIT $ 1000000 BODILY INJURY (Per poison) S xxxxxxx BODILY INJURY (Per accident) $ XXXXXXX --- PROPERTY _ — $XXXXXXX $ 1,000 UMBRELLALIAB EXCESS LIAB OCCUR CLAIMS -MADE NOTAPPLICABLE EACH OCCURRENCE _ $ XXXXXXX AGGREGATE S XXXXXXX DEO RETENTION$ S XXXXXXX B WORKERS COMPENSATION WORKERS COMP NATION YIN AND NE ANY OFFICEOPRIETEREXC NDE09ECUTFN (Mandatory In NH) USCRIPTION OF ... deecdbe underOPERATIONS below DE NIA N WA7-69D-460066-019 10/1/2019 IO/1/2020 PER 07H- X E E E.L. EACH ACCIDENT _ $ j D00000 E.L. DISEASE - EA EMPLOYEE S itD00000 E.L. QI9FA$E-POLICY LIMIT $ 1120(l),61020 DD ODD DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORB 101, Additional Remarksschedule, may be attacbedll moraspaco is required) CERTIFICATE HOLDER CANCELLATION See Attachment 15683144 Commonwealth of Massachusetts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Department of Industrial Accidents THE BATE THEREOF, ACCORDANCCEION WITH THE POLICY PROVISIONIS. CE WILL DE DELIVERED IN Office of Investigations 600 Washington Street Boston MA 2111 AUTHORIZED REPA 01 88.201 nCOD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Y el! '/ �" Employee Agreement for Tobacco Sales The purpose of this agreement is to inform till enrp(oyees involved in customer transactions of the requirement to comply with the Food and Drug Adnthtlslration (FDA) Regulations as well as applicable state and local laws governing the prevention of tobacco styles to minors. I have met with my manager and reviewed the training videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of my job, as well as the imposition of fine. I also understand that, although FDA Regulations require employees to ID anyone under the age of 27 attempting to purchase tobacco products, Global Montello Group Corp. requires employees to ID all persons who appear to be under the age of 40 who attempt to purchase tobacco products. I agree to the following rules about the sale of tobacco products: ❑ I will not sell any tobacco products to any person under the minimum age imposed by the laws applicable to the store in which I am N,,orking ("Minimum Age"). ❑ I will request a valid government-issu-, rd photo ID that includes a date of birth for anyone who appears to be under the age of 40 who attempts to purchase tobacco products. ❑ If there is any doubt about the person's age, I will not make the sale, ❑ I will not knowingly sell tobacco to any adult for use by individuals under the Minimum Age. If I think this is happening, I WILL NOT make the sale. ❑ I will not accept a note (or any other implied permission) from any person under the Minimum Age to purchase a tobacco product for themselves or anyone else, In any of the above -referenced situations, management agrees to support my judgment and decision not to make the sale. 1 understand that failure to comply with the terms of this agreement could lead to action by my employer, the FDA and/or state regulators that may jeopardize my employment and may involve the imposition of fines and/or legal action against me or my employer. Employee's Signature 4 — S rc Manager's Signature Date / /tJ17A Date (This agreement will be maintained in your personnel file as pm1 of your permanent employee record.) Rev. August 2019 FDA Toba'eco Carding, Employee Compliance Form This document musl be rend and signed by all employees for their personnel files 1. Federal law requires states to have a minimum age of 18 years to purchase tobacco (many state and local laws have increased the minimum ago to an age that is older than 18). The FDA requires retailers to check the photo ID of everyone under the age of 27 attempting to purchase any tobacco product. Tobacco products include e-cigarettes and other electronic nicotine delivery systems (ENDS). 2. The ID must include photo and date of birth. 3. 'the FDA will enforce this regulation by contracting with state agencies. The FDA will enforce this regulation by contracting with state agencies. They will form inspection teams made up of an adult commissioned official and a 15-16 year old who, together, will conduct undercover buy inspections at retail locations. The teenager will attempt to purchase a tobacco product while the adult observes the date, time & whether the sale was made. Violations will be sent to the FDA who will issue a warning ietter and/or fine. I'll(,, FDA Itas the authority to impose fines up to $15,000 for each violation. Community activists, anti -tobacco groups and parents will be watchdogs in enforcing the regulations: o They will be sending volunteers to s!.age tobacco purchases, o They ,vill be using adults under 27 to test the carding regulations. o They will report directly to the FDA. o . They may be handing out leaflets tostore personnel. Fk7rat you must do to obide by the regulations and conduct yotaself professlonallyr a. Card anyone who looks under 40. b. If a customer objects, hand them a tear sheet from the counter, point to our signage or calla manager immediately for assistance. c. If anyone from the media begins askino you any questions, call the manager irranediately. Do not answer the questions, Anything you say is considered "on the record" and could appear in the newspaper, on the television, or over the radio. d. If any anti -tobacco groups, connrourriy activists, parent groups etc., enter the store, call a manager immediately. Do not answer' arty questions. If they are handing out loailets, acceptthem and give them directly to managemciit. e. Always be polite, courteous, and professional. We do not expect you to engage in any discussions or arguments. Management will deal With this. I understand that failure to comply viith the ternas of this form could lead to action by my employer and/or the FDA that may jeopardize nay employment and may involve legal action against me and/or my employer, t jes�s� NC A-6&-Q Employee Print Employee Signature Date Rev. August M19 Employee Agr-ement for Tobacco Sales The purpose of this agreement is to inform all employees involvedhi customer transactions of the requirement to comply with the Food and Drug Administration (FDA) Regulations as well as tippticable state and locril laws governing t:ie prevention of tobacco sales to mirrors. I have met with my manager and reviewed the training videos regarding the sale oftobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of myjob, as well as the imposition of a tine. I also understand that, although FDA Regulations require employees to ID anvone under the age of 27 attempting to purchase tobacco products, Global Montello Group Corp. requires employees to ID all persons who appear, to be under the age of 40 who attempt to purchase tobacco products. I agree to the following rules about the sale of tobacco products: ❑ I will not sell any tobacco products to any person under the minimum age imposed by the laws applicable to the store in which I am_ c-orking ("Minimum Age"). ❑ I will request a valid governm--tit-issu it rthoto ID that includes a date of birth for anyone who appears to be under the age c(40 who attempts to purchase tobacco products. ❑ If there is any doubt about the person's ai;e,.I will not make, the sale. ❑ I will not knowingly sell tobacco to any adult for- use by individuals under the Minimum Age, If I think this is happening, I WILL, NOT make the sale, ❑ I will not accept a note (or any other implied permission) from any person under the Alinimum Age to purchase a tobacco product for themselves or anyone else. In any of the above -referenced situations, management agrees to support myjudgment and decision not to make the sale. I understand that failure to comply with the terms of this agreement could lead to action byany employer, the FDA and/or state regulators that may jeopardize my employment and may involve the imposition of fines and/or legal action against me o• my employer. Employee's Date /i S re Manager's Signatw•e Date / (ibis agreement will be maintained in your personnel file as part ofyour permanent employee record.) Rev. August 2019 FDA Tobacco Carding- Employee Compliance ]Form This document must be read and signed by all employees fir their personnel files 1. Federal law requires states to have a minimum age of 18 years to purchase tobacco (many state and local laws have increased the minimum age to an age that is older than 18). The FDA requires retailers to check the photo ID of everyone under the age of 27 attempting to purchase any tobacco product. Tobacco products include e-cigarettes and other electronic nicotine delivery systems (ENDS). 2. The ID must include photo and date of birth. 3. The FDA will enforce this regulation by contracting with state agencies. The FDA will enforce this regulation by contracting with state agencies. They will form inspection teams made up of an adult commissioned official and a 15-16 year old who, together, will conduct undercover buy inspections at retail locations, The teenager will attempt to purchase a tobacco product while the adult observes the date, time & whether the sale was made, Violations will be sent to the FDA who will issue a warning letter and/or fine. The FDA has the authority to impose fines up to $15,000 for each violation. 4. Community activists, anti -tobacco groups and parents will be watchdogs in enforcing tile regulations. o They will be sending vohtirteersto stage tobacco purchases. o They will be using adults under 27 to test the carding regulations, o They will reportdirectly to.the FDA. _ o They may be handing oubleaflets to store personnel. What you nrrlst do to abide by the regtdaIons and cony/ucl,potrrselfl,)rofessionallp. a. Card anyone who looks under 40, b. tf a customer objects, hand them a tear sheet from the counter, point to our signage or call a manager immediately for assistance. c. If anyone from the media begins asking you any questions, call the manager immediately. Do not answer the questions. Anything you say is considered "on the record" and could appear in the newspaper, on the television, or over the radio. d. if any anti -tobacco groups, community activists, parent group; etc., enter the store, call a manager immediately. Do not answer anytluestions. If they are handing out leaflets, acceptthen and give them directly to management: e. Always be polite, courteous, and professional. We do not expect you to engage in any discussions or arg?rments. Management will deal with (his. 1 understand that failure to comply with the term^ of this form could Ica( to action by my employer and/or the FDA that may jeopardize nay employm ant and may involve legal action against ale and/oar illy employer. _ r� o,S mploy I'rmt-'� oyee Signature Date Rev. August 2019 Employee Agreement for Tobacco Sales The purpose o"this agr cement is to inform all employees involved in cerstomer transactions of file requirement to emnp(v with fire Food and plrug Administration (FDA) Regulations as weil as applicable state and local laws governing tl^e prevention cf tobacco sales to minors. I have met with my manager and reviewed the training videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of my job, as well as the imposition of a fine. I also understand that, although FDA Regulations require employees to 1D anyone under the age of 27 attempting to purchase tobacco products, Global Montello Group Corp. requires employees to ID all persons who appear to be under the age of 40 who attempt to purchase tobacco products. t agree to the following rules about the sale of tobacco products: 4/1-will grI will not sell any tebaeco products to stay person under the mininmrc., ag_e iorposed by the laws - applicable to the store in which I am trnr ing ("Minimum Age"). W'Yl will request a va1Sd govern ntoil t-issil p oto ID that includes a date of birth for anyone who appears to be under the age of 40 who Att^tnpts to purchase tobacco products. ,,,Y�lf there is any doubt about tke person';; a e, I will not make the sale. W1 I will not knowingly sell tobacco to any adult fm• use by individuals under the Minimum �ge. If I think this is happening, I WILL tm,r make the sale. GY I will not accept a note (or airy other b"plied permission) from any person under the Minimum Age to prs•chuse n tobacco peoduct for themselves or anyone else. In any of the above-retorcnced situations, management agrees to support my judgment and decision not to make the sale. I understand that fuiInre to Comply with the terms of this agreement could lead to action by my cmpl per, the FDA and/or state regulators that mayjeopardize my employment and may invoIvethe i4Lmp ion of fi es atti lega ac 'on against me or my employer. yee's Signature _ t/t �Stor lanager'sSignature Date (This agreement will be maintained in your: personnel 01e.as pfut oryourpermnnent employee record.) Rev. August2019 FDA tobacco Carding: Employee Compliance Fonn This docaament must be read and signed by all enmloyees,%r Their personnel f//es 1, federal law requires states to have a mi mism age of 18 years to purchase tobacco (many state and local laws have increased the minimum al{e to an age that is older than 18). The FDA requires retailers to check the photo ID of everyone under the age of 27 attempting to purchase any tobacco product. Tobacco products include c-cigarettes and other electronic nicotine delivery systems (ENDS). 2, The ID must include photo and date of birth, 3. Tile FDA will enforce this regulation by contracting with state agencies. The FDA will enforce this regulation by contracting with state agencies. They will form inspection teams made up of an adult commissioned official and a 15-16 year old who, together, will conduct undercover bury inspections at retail locations. The teenager will attempt to purchase a tobacco product while the adult observess the date, time & whether the sale was made. Violations will be sent to the FDA who will issue a warning letter and/or fine. The FDA has the authority to impose lines up to $15,000 for each violation. 4. Community activists, anti -tobacco groups and parents will be watchdogs in enforcing the regulations. o They will be sending volunteers to stage tobacco purchases. o They will be using adults under 27 to test the carding regulations. o They will report directly to the FDA. o They may be handing out leaflets to store personnel, What you im al do to abide by the regidadons and conduct yourself professiotrally: a. Card anyone who looks under 40, b. Ifa customer objects, hand them a tear sheet from the counter, point to our signage or call a manager immediately for assistance. e, If anyone from the media begins asking you any questions, call the manager immediately. Do. not answer the questions, Anvthing you say is considered "on the record" and could appear in the newspaper, oil the television, or over the radio. d. If any anti -tobacco groups, community activists, parent groups etc., enter the store, call a manager immediately. Do not answer any questions, If they are handing out leaflets, acceptthem and give them directly to management. e. Always be polite., courteous, and professional. We do not expect you to engage in any discussions or arguments. Management will deal with this. I understand that failure to comply with the terms of ibis form could lead to action by my employer and/or the FDA that may jeopardize my employm eit and m y inv v At"al action against me and/ormy employer. Employee print En ployee Signature --- Daf¢ Rev. August 2019 The purpose of this agreement is to inform all employees involver! in customer transactions of the requirement to comply with the Food and Drug Adnnirrisn•allort (FDA) Regulations as well as applicable state and local laws governing the prevention of'tohacco sales to minors. I have met with my manager and reviewed the ti'aining videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of myjob, as well as the imposition ofa fine. I also understand that, although FDA Regulations require employees to ID anyone Under the age of 27 attempting to purchase tobacco products, Global Montello Group Corp. requires employees to ID all persons who appear to be under the age of 40 who attempt to purchase tobacco products: 1 agree to the following rules about the sale of tobacco products ❑ I will not sell any tobacco products to am{ person under the minimum age imposed by the lases applicable to the store in which I am worl-ling ("Minimum Age"). ❑ I will request a valid govern men t-issutul photo ID that includes n date of birch for a.nyoate who appears to be under the age of 40 who`attuntpts to purchase tobacco products. ❑ If there is any doubt:about the person's age, I will not make the sale. ❑ I will not knowingly sell tobacco to any adult for use by individuals under the Minimum Age. If I think this is happening, I WILL No,r make the sale. ❑ I will not accept a note (or any other itiplied permission) from any person under the Minimum Age to purchase a tobacco product for themselves or anyone else. In any of the above -referenced situations, management agrees to Support in), judgment and decision not to make the sale. 1 understand that failure to comply with the terms of this agreement could lead to action by my employer, the FDA and/or state regulators that may jeopardize my employment and may involve the imposition of tines and/or legal action against me or my employer. Ei loyce's Signature i Manager's Signature Date _ G- Date (This agreement will be maintained in your personnel file: as part of your pemmoent employee record.) Rev, August 2019 FDA Tobacco Carding: Employee Compliance Form This document must be read and signed by all eniplo.vees fir their personnel files 1. Federal law requires states to have a minim:5nl nge. of 18 years to purchase tobacco (many state and local laws haveincreasedthe miniirlum age to an age that is older than 18). The FDA requires retailers to check the photo ID of everyone under the age of 27 attempting to purchase any tobacco product. Tobacco products include,e-cigarettes and other electronic nicotine delivery systems (ENDS), 2. The ID',lost-include photo and date of birth. 3. The FDA will enforce this regulation by contrwAing with state agencies. The FDA will enforce this regulation by contracting with state agencies, They will form inspection teams made up of an adult commissioned official and a 15-16 year old who, together, will conduct undercover: buy inspections at retail locations. The teenager will attempt to purchase a tobacco product while the adult observes the date, time & whether tine sale was made. Violations will be sent to the FDA who will issue a warring letter and/or fine. The FCA has the authority to impose fines up to $15,000 for each violation. 4. Community activists, anti -tobacco groups and i_urents will be watchdogs in enforcing the regulations, o They will be sending volunteers to stage tobacco purchases, o They will be using adults under 27 to test the carding regulations. o They will repot directly to the FDA. . oThey may be handing out leaflets to store personnel. I'VItat yatt tltust do to abide by the regulations and conduct,yotirself professionally: a. Card anyone who looks under 40. b. If a customer objects, hand them a tear sheet from the counter, point to our signage or call a manager immediately for assistance. o. If anyone from the media begins asking you any questions, call the manager immediately. Do not answer the questions. Anything you say is considered 'bn the record" and could appear in the newspaper, oil the television, or over tine radio. d. If any anti -tobacco groups, community activists, parent groups etc„ enter the store, call a manager immediately. Do not answer any questions. If they are handing out leaflets, accept them and give them directly to management, e. Always be polite, courteous, and professional. We do not expect you to engage in any discussions or arguments. Management will deal with this. I understand that failure to comply with the terms of this form could lead to action by illy employer and/or the FDA that may jeopardize my employment and may involve legal action against me and/or my employer. pluyee Frini � Emplo e Signature / Date �( Rev. August 2019 . Employee -Agreenicnt for Tobacco Sates Tire purpose r�ftitis «gree°i.enf is to jq/irnr all enilayees involver/ in ^.uslonrer transactions of the requirement to comply with the Feral rnrd Drug f dnrini.vtration, (FDIi) Regrdrttions as well as applicable state rui/l focal lawsgoverning the prevention o.ftohaceo sales to ririrrors. I have met with nay manager and reviewed the draining videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of my job, as well as the imposition of a tine. I also understand that, although FDA Regulations require employees to ID anyone under the age of 27 attempting to purchase tobacco products, Global N9ontello Group Corp. requires employees to ID all persons who appear to be under the age of 40 who attempt to purchase tobacco products. I agree to tine following rules about the sale of tobacco products: ❑ I m`il not sell any tobacco products to any pc ,son under the min.imurn age imposed by the laws applicable to file store in which I am wo tan ; ("Minimum Age"), ❑ I will request n valid government -issued pho,a Ill that includes a date of birth for anyone who appears to be under the age of 40 who attenrits to purchase tobaeco products, ❑ If there Is any doubt about the person's age, ;; will not make the sale. ❑ I will cot knowingly sell tobacco to any adult for use by individuals under the Minimum Age. if I think this is happening, I WILL NGT rmal,e the sale. ❑ I will not accept a note (o' any other implied permission) from any person under the Minimum Age to purchase a tobacco produe, for themselves or anyone else. In any of the above -referenced situations, management agrees to support myjudgment and decision not to make the sale. 1 understand that failure to connply with the terms of this agreement could lead to action by my employer, the FDA and/or state regulators that mayjeopardize my employment and may involve the imposition of fines and/or legal action against one or illy employer. L'mployee's Signature Datc Sto Manager's Signature Date (This agreen-mit will be. maintained in your.persoiutel file tts _port of your permanent employee record.) Rev. August 2019 Employee Agreem.,Ilrlmt for Tobacco Sales The pmrose of dais agreement is to inform oll employees involved in customer transactions of the requirement to comply with the Food and Drug Administration (FDiy) Regulations as well as applicable state and local !taus governing the prevention of tobacco sales to minors. I have met with my manager and reviewed the training videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of m,yjob, as well as the in;posiHon of a fine. I also understand that, although FDA Regulations require employees to ID anyone under the age of 27 attempting to purchase tobacco products, Global-Nrontello Group Corp. requires employees to ID all persons who appear to be under the age ol'40 who ;lttenspt to purchase tobacco products, I agree to the following rules about (lie sale of tobacco products; Q I wil! not sell any tobacco products ro any p(rsmt under the minimum age imposed by the laws applicable to the store in which I am workir f; ("Minimum Age"), ❑ I will request a valid government -issued photo ID that includes a date of birth for anyone who appears to be under tine age of 40 who attete )ts to purchase tobacco products. ❑ If there is any doubt about the person's age,.' will not.malte the sale. 1 will •,tot knowingly sell tobacco to any adult for use by individuals under the Minimum Age. if I think this is happening, I WILL NLT make the sale. ❑ I will not accept a note,(or any other implied permission) front any person under the Minimum Age to purchase a tobacco produc'. for themselves or anyone else. Io any of the above -referenced situations, management agrees to support my judgment and decision not to make the sale. 1 understand that failure to comply with the terms of this agreement could lead to action by my employer, the FDA and/or state regulators that may jeopardize my employment and may involve the imposition of fines and/or legal action against me or my employe-, o n,gununc _ .. Date nager's Signature ----- Date (This agreemeat will be maintained in your personnel file as pan of your permanent employee record.) Rev. August2019 FDA 'Tobacco Carding: En-'ployee Compliance Form J-his document must be read and signed by all employees for their personnel files 1. Federal law requires states to have a minimum age of 18 years to purchase tobacco (many state and local laws have increased the minimum age .`o r,a age that is older than 18), The FDA requires retailers to check the photo 1D oi'everyone under the age of 27 attempting to Purchase any tobacco product. Tobacco products include e-cigarettes and other electronic nicotine delivery systems (ENDS). 2. The ID must include photo and (late of birth. 3. The FDA will enforce this regulation by contracting with state agencies.. The FDA will enforce this regulation by contracting with state agencies. They will form inspection teams made up of an adult commissioned official and a 15-16 year old who, together, will conduct undercover buy inspections at retail locations. The teenager will attempt to purchase a tobacco product while the adult observes the date, time&whether the sale was made. Violations will be sent to the FDA Who will issue a warning letter and/or tine. The FDA has the authority to impose fines Lip to $15,000 for each violation. 4. Conuuunity activists, anti -tobacco groups and parents will be watchdogs in enforcing the regulations, o They will be sending volunteers to stage tobacco purchases. o They will be using adults under 27 to test the carding regulations. c They will report directly to the FDA. o They may be handing out leaflets to store personnel. Whatyou must do to abicle by the regulations and cenduct yoursey"professtorvally: a. Card anyone who looks under 40, b. If a customer objects, hand them a tear sheet from the counter, point to our signage or call a manager immediately for assistance. c. If anyone from the media begins asking you any questions, call the manager immediately, Do not answer the questions. Anything you say is considered "on the record" and could appear in the newspaper, on tile television; or over the radio: d. if any anti -tobacco groups, community activists, parent groups etc., enter the store, call a manager immediately. Do not answer any questions. If they are handing out leaflets, accept them and give them directly to management, e. Always be polite, courteous, and professional, We do not expect you to engage in any discussions or arguments. Management will deal with this. I understand that failure to comply with the terms of th s form could lead to action by my employer mud/or the FDA that ntay jeopardize my cnrplo'yment at;Il, may iriyo1, employer. Icgal'actior against me and/or my 3�n s tJp rn Es Y Employee Print mPloyee Signature Date Rev. August 2019 Employee Agreetm—Nit foi- Tobacco Sales The ptnPose of this agreement is to lnfm•nt all employees involved in customer transactions of the I equirement to comply with the Frtnrl and Drag .rGrtirtisYr rrlion (FDA) /,egtdatiorts as veil as applicablestate aad local laws governing the pretientioa gftobacco sales to minors. I have met with my manager and reviewed the training videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of myjob, as well as the imposition of a fine. I also understand that, although FDA Regulations require employees to ID anyone under the age of 27 attempting to purchase tobacco products, Global Montello Group Corp. requires employees to fD all Persons Who appeal' to be under the age of40 who atteiripttopurchase tobacco products. I agree to the following rules about the sale of loba�,co products: Cl I will not Sell any tobacco products to any person under the mininnun age imposed by the laws applicable to the store in which i am working (`Minimum Age"). ❑ I will t`egµest a valid government -issued photo Ill that includes a date of birth for anyone who appears to be under the age of 40 who attempts to purchase tobacco products. LI If there is any doubt about the person's nge,: will not make the sale. ❑ I will not knowingly sell tobacco to any adult for use by individuals under the Minimum Age. If I think this is happening, I WILL NOT matte the sale, ❑ I will not accept a note (or any other implied permission) from any person under the Miniunutn Age to purchase a tobacco produc,' for themselves or anyone else. In any of the above -referenced situations, management agrees to support my judgment and decision not to make the sale. I understand that failure to comply with the terms of this agreement could lead to action by my employer, the FDA and/or state regulators that may jeopardize my employment and may involve the imposition of fines and/or legal action against Inc or Illy employer. C,mployeeAisnaireq.Dale 12 tore Manager's Signature Date (This agreement will be maintained in your personnel file as part oFyour permanent employee record.) Rev. August 2019 FDA Tobacco Carding: Employee Compliance Form This docuniew nrusv be read and signed by all employees for their personnel files L Federal law requires states to have it mininnum age of 13 years to purchase tobacco (many state and local laws have increased the ninimum age to ,in age that is older than 13). The FDA requires retailers to check the photo ID ofeveryone under the age of27 attempting to purchase any tobacco product. Tobacco products include c-cigarettes and other electronic nicotine delivery systems (ENDS). 2. The To hrhust include photo and date of birth. 3. The FDA will cnt'orce (his regulation by contracJng with state agencies. The FDA will enforce this.regulation by contracting with state agencies. They will form inspection teams made up of an adult commissioned official and a 15-I6 year old who, together, will conduct undercover buy inspections at retail locations. 'File teenager will attempt to purchase a tobacco product while the adult observes the date, time & whether the sale was made. Violations will be sent to the FDA who will issue a warning letter and/or fine. The FDA has the authority to impose Fines up to $15,000 for each violation. 4. Community activists, anti -tobacco groups and parents will be watchdogs in enforcing the regulations. o They will be sending volunteers to stage tobacco purchases. o They will be using adults under 27 to test the carding regulations. o They will report directly to the FDA. o They may be handing out Ieanets to store personnel. What you insist do to abide by the regulatic:rs .end conduct yourself professionally: a. Card anyone who looks under 40. b. It a customer objects, hand them a tear sheet from the counter, point to our signage or call a manager immediately for assistance, c. If anyone fi'om the media begins asking you any questions, call the manager immediately. Do not answer the questions. Anything you say is considered "on the record" and could appear in the newspaper, on the television, or over the radio. d. If any anti -tobacco groups, community activists, parent groups etc., enter the store, call a manager immediately. Do not answer any questions. If they are handing out leaflets, accept them and give them directly to management. c. Always be polite, courteous, and professional. we do not expect you to engage in any discussions or arguments, Management will deal with this. I understand that failure to and/or the FDA that may je Rev. August 2019 ply with the`terms of th;,a l'Ornt could lead to action by lily employer dize nn}+ employnncntaaA may involve legal action against me and/or my mp oyee Signahu'e� / /