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Home My WebLink AboutDollar General #20417 - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Retail Establishment In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. DG RETAIL, LLC Whose place of business is: DOLLAR GENERAL STORE #20417 65 COPELAND DRIVE Permit Expires December 31, 2019 License Number: RF-17 Food Fee: $125.00 Milk & Cream BOARD OF HEALTH MichaeCHealey, Chairman Permit for the Sale of Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: DOLLAR GENERAL STORE #20417 65 COPELAND DRIVE License Number RF-17 Permit Expires December 31, 2019 BOARD OF HEALTH Michael.9-lealey, Chairman x Jan -Dec , own of Mansfield Health Department '0417 2 12/31/19 ,/ � C 6 Palk Row (508) 261-7366 � _.,._ Mansfield, MA 02048 -_ FOR BOARD OF HEALTH USE ONLY Permit # Issued 0iZi1-N7��>/;:IMSMITUlC112111111' a _''_[d_werk (Application must be submitted at least 30 days before the planned opening date) Establishment Name: Dollar General Store(# 20417 Establishment Address: 65 Copeland Drive, Mansfield, MA 02048 (Bristol County) Establishment Mailing Address (if different): 100 Mission Ridge, Attn: Tax Licensing, Goodlettsville, TN 37072 Establishment Telephone No: To be determined Applicant Name & Title: DG Retail, LLC Applicant Address: 100 Mission Ridge, Attn: Tax Licensing, Goodlettsville, TN 37072 Applicant Telephone No.:(615) 855-4000 24 Hour Emergency No.: (615) 393-4555 Applicant Email:tax-beerandwinelicense@dollargeneral.com Joe Vega -District Manager Owner Name & Title (If different from applicant): n/a Owner Address: see above Owner telephone number: Owner email: 'S—F) d�y Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 0 An Association partner. O A Corporation Name Title Address 0 An Individual Jason -Reiser, Executive Vice President 2512 Belmont Blvd 0 A Partnership Nashville, TN 37212 (Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Not yet assigned - Store Manager Address: Telephone No: 24 Hour Emergency No: / FAX: l!/ Vendor #361026 E-mail: Invoice #2019200704BL12 $ 385 00 Alt E-Mail: Batch #16748 District Or Regional Supervisor (if applicable) Name & Title: Joe Vega Address: Telephone No: (615) 393-4555 24 Hour Emer ency No: (615) 393-4555 FAX: �"�-��`_ E-mail: Jvega@dollargeneral.com C °' Separate Payments _ — u �- Plea rse return check to: /- 5g60 4z� Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: N/A DAYS/HOURS: M-Sun 8AM - 9PM Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. N/A Person Trained in Anti -Choking Procedures (If 25 Seats or more): N/A Location: [ Permanent Location Establishment Type: Q Caterer $35.00 Q Mobile Mobile Start Date: EX Retail ( 9,100 Sq. Ft) $125 M Milk & Crearnal o 00 Mobile End Date: Q Food Service up to INCLUDING i� Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.75.00 NO PHF PREPARED ON SITE $100.00 Length of Permit: g Q Food Service up to 101 -200 $250.00 Man tore-Frozen-DesscrteI ream 25.00/freezer (10 freezer doors) EX Annual E] Food Service up to 201 + $300.00 "''--- -6 o _-'.--- ❑ Pushcart $50� 0 Pushcarts: Residential Kitchen $100.00 R�, Seasonal Seasonal Dates: i] Supermarkets $400 E Tobacco Products $150.00 ❑Retail Snack Food $50.00 R� Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Do itions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non-potentally hazardous food(no fime/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no lurtherprocessing) 0 Sale of Commercially Pre -Packaged Non-PHFs E] PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service 0 Delivery of Packaged PHFs ---- Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours _... Use of Process Requiring di Variance and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale contact alternative, time as a public health control) Q Offers Raw Or Undercooked Food Of Preparation of Non-PHFs X Other Food Operations Juice Manufactured and Packaged for Retail Sale Animal Origin 'All food pre -packaged and ready for ❑ Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities retail sales - no preparation or served Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date foods or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application E] waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code. t Signature of Applicant: UaWn Keen Sr. Licensing Speclallst _4._Jy-tA1 /T_IEAn Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: 36-4577242 Signature of Individual or Corporate Name: TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 36-4577242 (FEIN) "Social Security No. (Voluntary) or Federal Identification Nnaiber *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:AUsers\sleiteADesktopASeotCs DocumentsTood Establishments-'tempATAX CERTIFICATION FORNLdoc The Commomvealth of Massachusetts Department of IndustrialAccidents Office of fi vestigations 600 Washington Street Boston, MA 02111 Ulf tviviv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: DG Retail, LLC Address: 100 Mission Ridge, Attn: Tax Licensing City/State/Zip: Goodlettsville TN 37072 Phone #: (615) 855-4000 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with 1,000+ employees (fill and/ 5. ❑ Retail or part-time).* 6. ❑ Restamant/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. [No workers' comp. insurance required] 8. ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their fight of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* I1.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.j 12.® Other Retail - General Merchandise *Any applicant that checks box N 1 must also till out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # I. I ant an employer that is providing ivorkers' conipensafion insurancefor my employees. Below is the policy information. Insurance Company Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. See attached Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, taider the pains and penalties of perjury that the information provided above is trite and correct. Of frcial use only. Do not rurite in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.orass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written" An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to you situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give its a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or I-877-MASSAFE Fax # 617-727-7749 www.uiass.gov/dia Fm'm Revised 5-26-OS CERTIFICATE OF LIABILITY INSURANCE page 1 of 1 02/09/20 BI 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(ies) 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 endorsement(s). PRODUCER CONTACT Willis of Tennessee, Inc. c/o 26 Century Blvd. P.O. Box 305191 PHONE FAX 877-945-7378 888-467-2378 E-MAIL certificates WllliS. coal INSURER(S)AFFORDING COVERAGE NAIC# Nashville, TN 37230-5191 INSURERA: ACE American Insurance Company 22667-001 INSURED INSURERB: Berkshire Hathaway Specialty Insurance Cc 22276-001 Dollar General Corporation 6 Its Subsidiaries & Affiliates INSURER C: ACE Fire Underwri teas Insurance Company 20702-001 INSURER D: 100 Mission Ridge Goodlettsville, TN 37072 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 26085707 REVISION NUMBER: 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. INSR TVPEOFINSURANCE On SUB In POLICYNUMBEft POLICY EFF POLICY EXP LIMITS A X COMMERCIALGENERALLIABILITY CLAIMS -MADE X OCCUR XSL G27874678 2 /10/2018 2/10/2019 EACHOCCURRENCE S 500,000 ppqqWWW"a oTcTurence) S 500,000 X MED EXP(Anyone person) S SIR $750,000 PERSONAL&ADVINJURY S 500,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE S 20,000,000 PRODUCTS-COMP/OPAGG S 2 OOO OOO X POLICY ECT PRO- ElLOC S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accded S BODILY INJURY(Per person) S ANYAUTO BODILY INJURY(Peramident) S OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON.OWNED AUTOS ONLY AUTOSONLV PROPERTYDAMAGE (Peraaitlent) S S E X UMBRELLALIAB X OCCUR 47-UMO-303309-02 2 /10/2018 2/10/2019 EACHOCCURRENCE S 5,000,000 AGGREGATE S 5,000,000 EXCESS LIAR I I CLAIMS -MADE DED I IRETENTIONS S A C A WORKERS COMPENSATION ANY EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE O mostoryin yn HNH)) EXCLUDED? Mandat Dyes, RI PTION OFF DESCRI PTION OF OPERATIONS below NIA WLR C64625809 SCF C64625810 WCU C64625834 /10/2018 /10/2018 /10/2018 2/10/2019: 2/10/2019 2/10/2019 $ I f=11 TH E.L. EACH ACCIDENT S 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DIS EASE -POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space is required) DOLGENCORP of TX, Inc. is a non -subscriber to the Workers' Compensation System in the State of Texas and as such is not afforded benefits by the Workers' Compensation policies referenced herein in Texas only. Covers all cities/counties within the following states: AZ, CO, IL, KS, MA, MN, NH, UT, VT, ME, ND and OR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DG Retail LLC 100 Mission Ridge Goodlettsville, TN 37072 1-11.a174Y71 m..T •9T acon7 ro.-r 9G'naF7m n1gRR-9015 ACORn CORPORATION. All rights reserved ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 \ , Boston, MA 02114-2017 www,mass.gov/dia Workers' Compensation Insurance Affidavit; General Business. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Business/Organization: DG Retail, LLC dba Dollar General Store Address: 100 Mission Ridge City: Goodlettsville State: TN Zip; 37072 Are you an employer? Check the appropriate box: Phone n: 615-855-4000 1. 1 am an employer with 6-10 employees (full and/or part time)' 2. 1 am a sole proprietor or partnership and have no employees working for me in any capacity. (No workers' comp. Insurance required] 8. We are a corporation and Its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required]+ ❑ 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. Insurance required) -A nv annlirant that rhark, hnx lit meet Type I V I S. Retail ❑ 6. Restaurant/Bar/Eating Establishment El7. Office and/or Sales (incl. real estate, auto, etc.) 1 18. Non-profit u9. Entertainment ❑10. Manufacturing 7 11. Heath Care —1 I i12. Other aolicv Information. tit the corporate officers have exempted themselves, but the corporation has other employees, a workers compensation policy is required and such an organization should check box 01, I am an employer that Is providing workers' compensation Insurance formy employees. Below is the policy and Job site Information. Insurance Company Name: ACE American Insurance Com Address: CO 26 Century Blvd. PO Box 305191 State: TN Policy If or Self -ins. Lic. #: Zip: 37230 WLR C64625809 Phone g: City, Nashville 877-945-7378 Expiration Date: 2/10/19 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date, Failure to secure coverage as required under MGL. c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties In the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ✓❑ I do hereby certify under the pains and penalties of perjury that the information provided above Is true and correct, and that clicking this checkbox and ping my name In the field below will act as my signature <. Name: " '' T S'"r'� Date. t W'i l d(J /C) Phone h: 615-855-4000 emau; tax-beerandwinelicense@dollargeneral.com Town of Mansfield - Board of Health PERMIT NUMBER: Town of Mansfield 6 Park Row Mansfield, MA 02048 Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. As a provision of this permit, all employees who sell tobacco or nicotine delivery products have read the applicable BOH regulations and have signed a statement that the employee understands and upholds the regulation. 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: Dollar General Store 0417 LOCATION OF SALE OF TOBACCO PRODUCTS: 65 Copeland Drive TELEPHONE AT LOCATION: y 016 To be determined OWNER OF BUSINESS: DG Retail LLC ADDRESS OF OWNER: 100 Mission Ridge, Attn: Tax Licensing, Goodlettsville, TN 37072 TELEPHONE OF OWNER: (615)855-4000 EMAIL ADDRESS: tax-beerandwinelicense@dollargeneral.com If a corporation or partnership, give name, title, and home address of officers or partner. Jason Reiser, Executive Vice President, 2512 Belmont Blvd., Nashville, TN 37212 * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: i 50.00 Vendor#361026 tf� CT-3T NUMBER: �1°p"!� is 1 `��Ln Invoice #201920417TOBCITY21 Batch #16784 $ 150.00 / FEDERAL ID/SS NUMBER: 36-4577242 Separate Payments: SIGNATURE ; ., }� „, J Please return check to: DATE: /oZ—/n/ /T `-1gISSS y5ncentrfi Commonwealth of Massachusetts Department Department Revenue �� of j� Christopher C. Harding, Commissioner A r't�p,�o+� mnss.gov/der Letter ID: L1962854016 IN Notice Date: December 19, 2018 Account ID: CGL-10527826-005 RETAILER LICENSE FOR SALE OF CIGARETTES 1111Pphru19a1idnnlnldhllPd11P1i1intnt,h11111111111 DO RETAIL LLC DOLLAR GENERAL STORE # 13774 ti B 100 MISSION RDG .; GOODLETTSVILLETN 37072-2171 Attached below is your Retailer License for Sale of Cigarettes (Font 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 P,,nt4H1uF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T " Retailer License for Sale of Cigarettes- � �1 a y 1 !rE'Kr Ova This license must be posted and visible at all times. The sate of tobacco products to anyone under 18 years of age is prohibited. DG RETAIL LLC Account ID: CGL-10527826-005 DOLLAR GENERAL STORE #20417 Location ID: 10527826-0180 65 COPELAND DR License Number: 427710464 MANSFIELD MA 02048-1220 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: December 19, 2018 Expiration Date: September 30, 2020 s`ctgtrF, Commomvealth of Mass:rchusc'Us � � Letter ID: LI520645760 oo Yi:��iL Department of Revenue Notice Date: December 18, 2018 St l'lry Christopher C. Harding, Commissioner Account ID: CRL-10527826-033 2.�-r pew nmss.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO III III III'IIIIII tlldllIII III III 1:luPnlltill [[IIIIII u]]II:I DO RETAIL LLC DOLLAR GENERAL STORE # 13774 100 MISSION RDG GOODLETTSVILLE TN 37072-2171 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, 8:30 a.m. to 4:30 p.m. DETACH HERE 6 �sa;\Us, ^ MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Ir Retailer License for Sale of Cigars and Smoking Tobacco 1 v�t��t ��o`� This license must be posted and visible at all times. The sale of tobacco products to anyone colder 18 years of age is prolfibited. DG RETAIL LLC Account ID: CRL-10527826-033 DOLLAR GENERAL STORE #20417 Location ID: 10527826-0181 65 COPELAND DR License Number: 2093459456 MANSFIELD MA 02048-1220 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: December 18, 2018 Expiration Date: September 30,2020 snengts eCommonwealth of Massachusetts Depm hunt of Revenue b 111� Christopher C. Harding Commissioner mass.gov/dor pro Letter ID: L0446903936 Notice Date: December 18, 2018 Account ID: SLS-10527826-058 SALES AND USE TAX REGISTRATION CERTIFICATE �111�1p�111111h�Pu11h1dhm�II��IIrlilolittlPtllt�n111 DG RETAIL LLC DOLLAR GENERAL STORE #20417 100 MISSION RDG GOODLETTSVILLETN 37072-2171 Attached below is your Sales and Use Tax Registration Certificate (Form ST-1). Cut along the dotted line and display at your place of business. You must report any change of name or address to Its so that a revised ST-1 can be issued. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this certificate. DETACH HERE y`ssr'SaTT MASSACHUSETTS DEPARTMENT OF REVENUE Form ST-I Gn . � Sales and Use Tax Registration Certificate 9y I t. This registration must be posted and visible at all times. DG RETAIL LLC Account ID: SLS- 10527826-05 8 DOLLAR GENERAL STORE #20417 Certificate Number: 482846720 65 COPELAND DR MANSFIELD MA 02048-1220 This certifies that the taxpayer named above is registered under Chapters 62C, 64H and 641 of the Massachusetts General Laws to sell tangible personal property at retail or for resale at the address shown above. This registration is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: January 31, 2019