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Home My WebLink AboutFour Corners Citgo - 12/31/2021Ci Town of Mansfield TOioi (?f'If-fan1IJ` eh- - Board o-le(.0h 6Park Row Mansfield, MA 02048 'LI .p PERMIT NUMBER: _ pp fY✓-ir'' f 1 �?�'�j3' �'..j' C'db l'f'..Y'. c)1)ar O e) 5a "1%l5 Mere 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: v\ CcNU-s L�u , 7cJ\r,Vi LOCATION OF SALE OF TOBACCO PRODUCTS: q SUGA�A ry`9�t I TELEPHONE AT LOCATION: OWNER OF BUSINESS:�c'_1r1�� ADDRESS OF OWNER: L` o `A y1\,e— IM ox+',SM K- , 0 �-c) L TELEPHONE OF OWNER: yJ �Z'�177 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. �(Anok , �o. iL k� C\ e.,r - , Li\ CA S t-e.b1 e �r , ,/1�c,^5�� I�`> iin 11 , G rU Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation o D-V 4L\ * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3T NUMBER:71 -D 7 FEDERAL ID/SS NUMBER: — SIGNATURE: _ )' pw- DATE: A check mark signifies your understanding and agreement. I understand and agree that: PF//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 0 e 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 hoto ID for anyone less than 27 years of age. must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. 3i Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in [1icensed smoking bars, for onsite consumption only. Unflavored E-cigarettes with nicotine content over 35 mg/per ml can only be sold in adult -only retail tobacco . stores and licensed smoking bars. Cp/Flavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite /consumption only. Self-service tobacco product and/or nicotine delivery product displays from which the customer may select ��roducts are prohibited. If The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. I may not distribute any free samples of tobacco products or nicotine delivery products (e.g. e-cigarettes) and I may not accept any means, instruments or devices that allow for the redemption of tobacco products for free or /cigarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue. Tobacco vending machines are prohibited. L(�jNon-residential Roll -Your -Own machines are prohibited. VBlunt 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 opy of which will be placed on file, that he/she has read the regulation and applicable state laws. I� must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". II ust provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts / epartment of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license). C9/ I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". I , J�must display signs provided by the Board of Health that discloses referral information about cessation. F 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 1/ �� ' Date � (/� yam,` Print Name 1r�5�/1�' `✓` t Commonwealth of Massachusetts Letter ID: L1478178368 Date: September 2, 2020 t R 2 Depulmenl of Revenue Notice Geoffrey E. Snyder, Commissioner Account ID: CRL-I 1981294-009 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO IlbiPli�hhli�uil�it��t�il�tilldnii�lluliitit�id��l�tidt SUBEI LAXMI INC CITGO 4 CORNER CONVENIENCE 4 S MAIN ST MANSFIELD MA 02048-2516 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 P�,,atttcE� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T ,q, Retailer License for Sale of Cigars and Smoking Tobacco t,,.vroYB� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. SUBH LAXMI INC Account ID: CRL-11981294-009 CITGO 4 CORNER CONVENIENCE License Number: 739616768 4 S MAIN ST MANSFIELD MA 02048-2516 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, 2020 Expiration Date: September 30, 2022 55smtUr�.�,, Commonwealth of Massachusetts Deparof evenue �`j'li� i ,�,, Geoffrey Et Snyder,, Commissioner \1: �; °t'N ova mass.gov/dor o 91 Letter 7D: L0511350336 Notice Date: September 3, 2020 Account TD: CGL-11981294-006 RETAILER LICENSE FOR SALE OF CIGARETTES Ih�lllll�l��'��I"Il�ll��ll�lh�l�dh��hlllp'11�1�Ill�ld�tl SUBH LAXMI INC CITGO 4 CORNER CONVENIENCE 4 S MAIN ST MANSFIELD MA 02048-2516 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3). 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 8 cnc sr±u`<> MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 1 Retailer License for Sale of Cigarettes l,Ra r oea� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. SUBH LAXMI INC Account ID: CGL-11981294-006 CITGO 4 CORNER CONVENIENCE License Number: 1447208960 4 S MAIN ST MANSFIELD MA 02048-2516 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revolted for failure to comply with state laws and regulations. Effective Date: October 1, 2020 Expiration Date: September 30, 2022 �..•� SUBHLAI OR •T CERTIFICATE OF LIABILITY INSURANCE DATE(MM/4Q/Y1'1'1'I 10/29/2020 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(tes) 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 508-947-1818 J.K. Olivier( Ins. Agency 64 East Grove St. Middleboro, MA 02346 Kenneth W-Olivier( Rogiff Kenneth W. Olivier( P .... Na : 508-947-1818 __PAX =' N°)' E'r' RE . INSURERS "FORDING COVERAGE NAICk INSURER A t Union Mutual Fire Ins, Co. 25860 1NSURFLD dba`C Inc, ba Fouurr Corners Citgo INSURER$: Me' Retail Merchants We Oroup 23612 INSURER C; INSURER 0: 4 South Main St Mansfield, MA 02046 INSURER E : INSURER F L111JFifI�A CLIVEKAUtt) t.'. rrrl.ra,cn --- - - 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 A TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR X Business Owners INVDL UBR POLJCY NUMBER BOP0173545 ROLICY EFF 07/14/2020 POLICY EXP 07/14/2021 LIMITS EACH OCCURRENCE S 1,000,000 WEWESDER T Dn $ 500,000 Anon MED EXP e rson 10,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: X POLICY ❑ JECT LOC PRODUCTS -COMPIOP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ BODILY INJURY Par Rarmwj S ANY AUTO BODILY INJURY Peracddant OWNS ONLY SCHEDULED AUTO�q� EEpp AUTOS AUTOS ONLY AUT AUTOOSONLY PeOr EacRident AMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATE $ EXCESS LIAB CLAIMS4AADE X I STE'A OTH- S B NIA 014005033710120 01/01/2020 01/01/2021 DED RETENTION$ WORKERSCOMPENSAnON AND EMPLOYERS' LIABILITY ANY PROPRIETOERIPARTNERIEXECUTIVE Y� O FFICERtMMEbery n NE' EXCLUDED? fl EL EACH ACCIDENT 100,000 $ EL DISEASE, EA EMPLOYE 100,000 S E.L. DISEASE-POLICYLIMIT S 500,000 If yyees, descdhe under DESCRIRTION OFOPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, nay be attached If more space is requlred) Town of Mansfield 6 Park Row Mansfield, MA02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE ACORD 25(2016103) v,aeq-cv,.�.....••-•- �•••-•-• •-•• The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ^'>> www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address: L l Sd (Jk)v\ Yr on, J\ Sir I)-,01VU-CPhone#: � lT--337-4M Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time). * 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. 3.eo workers' comp. insurance required] We area 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. rNo workers' comp. insurance req.] Busines Type (required): 5. Enietail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment lo.❑ Manufacturing 1 L❑ Health Care, 12.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I ant an employer that is providing workers'compensation insurance for, ' my employees. Below is the policy information. Insurance Company Name: � l�/1 p� t �Tjpe �my Insurer's Address: GL " ` ,k, F a /C- S�- */ " ``&& u� ✓v � cro (' City/State/Zip: Ak)AC'XXV, Policy # or Self -ins. Lie. # N�)o eo 1 --73 gL-k Expiration Date: U �—2-0 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 a 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�rtify, under thepains and penalties ofpeijury that the information provided above is true and correct C;�atrrP 1l. ITI�G'—ems/ Date: �V-2%—Zi� Phone #: 7QD � 7 Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: PermitlLicense # 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.mass.gowma TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) *"Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Usem\sleite\Desktop\Scott's Dacu ents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Age -Restricted Products Policy & Procedures: Tobacco LOCATION Every Employee at this location has the legal and moral responsibility to control the sale and distribution of age -restricted items to ensure these items do not get sold to minors!! TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all laws and procedures of this policy related to the sale of tobacco products including: cigarettes, smokeless tobacco, loose tobacco, pipe tobacco, rolling papers, cigars, e-cigarettes, vape and .lighters. The minimum age to purchase tobacco products is twenty one (21) years of age. It is our responsibi#ity as a retailer and members of the community to prevent the sale of tobacco to anyone under the age of twenty one (21). PROCEDURES: 1. This policy will be reviewed with all new Employees before they can operate a cash register and sell tobacco products. 2. All store Employees to take computer based training and successfully pass with 100% prior to starting on a register. This certification to be updated on an annual basis prior to previous year expiration. 3. A valid form of identification will be required for all tobacco purchases regardless of age or frequency of customer visits. Acceptable forms of id are as follows: Valid Massachusetts License Valid Massachusetts state id Valid US passport Valid Out of State License No expired identification will be accepted. scanned into the register. Driver's License is to be scanned into the register system. All other identification from the acceptable list will require manual entry of the date of birth listed on the documentation. 4. If it is suspected that someone is purchasing tobacco for anyone under the age of twenty-one (21) a valid Id will be required from all members of the party. I have read and understand the Mansfield Board of Health Regulations which prohibits the sale of tobacco and nicotine delivery products to anyone under the age of twenty-one (21) years. I also understand that if I fail to follow store policy and local and state laws about the sale of tobacco or nicotine delivery products to any person under the legal age, I could lose my job or be fined. I agree to the following rules about the sale of tobacco products: I will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis, or any other form of tobacco, or any nicotine delivery product to any person under the age of 21. If any person regardless of age attempts to make a tobacco purchase without an acceptable, I will not make the sale. I will not accept a note from an adult giving permission to a person under the age of 21 to buy tobacco products. In turn, management agrees to support my judgment not to make the sale in any of the cases described above. Failure to,follow this policy may result in disciplinary action up to and including termination. J ('UIJy Employee Signature PA Store Operator Signature 2-\a-`L6 Date ( 2-1 r, -?a Date (This form will be maintained in your personnel file as a part of your permanent employee record) M Age -Restricted Products PoNcy & Procedures: Tobacco LOCATION Every Employee at this location has the legal and moral responsibility to control the sale and distribution of age -restricted items to ensure these items do not get sold to minors! I TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all laws and procedures of this policy related to the sale of tobacco products including: cigarettes, smokeless tobacco, loose tobacco, pipe tobacco, rolling papers, cigars, e-cigarettes, vape and .fighters. The minimum age to purchase tobacco products is twenty one (21) years of age. It is our responsibility as a retailer and members of the community to prevent the sale of tobacco to anyone under the age of twenty one (21). PROCEDURES: 1. This policy will be reviewed with all new Employees before they can operate a cash register and sell tobacco products. 2. All store Employees to take computer based training and successfully pass with 100% prior to starting on a register. This certification to be updated on an annual basis prior to previous year expiration. 3. A valid form of identification will be required for all tobacco purchases regardless of age or frequency of customer visits. Acceptable forms of id are as follows: Valid Massachusetts License Valid Massachusetts state id Valid US passport Valid Out of State License No expired identification will be accepted. .. .... r .....-- scanned into the register. Driver's License is to be scanned into the register system. All other identification from the acceptable list will require manual entry of the date of birth listed on the documentation. 4. If it is suspected that someone is purchasing tobacco for anyone under the age of twenty-one (21) a valid Id will be required from all members of the party. I have read and understand the Mansfield Board of Health Regulations which prohibits the sale of tobacco and nicotine delivery products to anyone under the age of twenty-one (21) years. I also understand that if I fail to follow store policy and local and state laws about the sale of tobacco or nicotine delivery products to any person under the legal age, I could lose my job or be fined. I agree to the following rules about the sale of tobacco products: I will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis, or any other form of tobacco, or any nicotine delivery product to any person under the age of 21. If any person regardless of age attempts to make a tobacco purchase without an acceptable, I will not make the sale. I will not accept a note from an adult giving permission to a person under the age of 21 to buy tobacco products. In turn, management agrees to support my judgment not to make the sale in any of the cases described above. Failure to.follow this policy may result in disciplinary action up to and including termination. A -t-Ni Employee Signature Store Operator Signature k't— � 0 --z 4 Date Date (This form will be maintained in your personnel file as a part of your permanent employee record) �51�r�Q� Commonwealth of Massachusetts Letter ID: Ll089417792 vT° ry Department of Revenue Notice Date: May 28, 2020 IN Geoffrey E. Snyder, Commissioner Account to: EDL-11981294-012 '�h'"`77A__...��NNNb'To�a mass.gov/dor '� y LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS ��I�Ihll��u�hl'�III�Ihlll'11'�Ild4thl�r��ltlrl�l��ill�lll SUBx LAXMI INC N ® FOUR CORNER STORE a 4 S MAIN ST ® MANSFIELD MA 02048-2516 Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. 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. FONFEW.� 01616 bs"c sFaT MASSACHUSETTS DEPARTMENT OF REVENUE m �}� Retailer License for Sale of Electronic Nicotine Delivery Systems This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. SUBH LAXMI INC Account ID: EDL-11981294-012 FOUR CORNER STORE License Number: 1261725696 4 S MAIN ST MANSFIELD MA 02048-2516 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems 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: May 28, 2020 Expiration Date: September 30, 2022