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HomeMy WebLinkAboutCumberland Farms #0187 - 12/31/2021-*q�a--75�9 -1�5 Town of Mansfield - Board of Health PERMIT NUMBER: Town of Mansfield 6 Park Row Mansfield, MA 02048; 4 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 AffectinX 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: Cumberland Farms #0187 LOCATION OF SALE OF TOBACCO PRODUCTS: 30 Chancy St. Mansfield Ma.02048 TELEPHONE AT LOCATION: 508-261-7857 OWNER OF BUSINESS: ADDRESS OF OWNER: Cumberland Farms, Inc. 165 Flanders Rd. TELEPHONE OF OWNER: 508-270-1504 15- 1 EMAILADDRESS: LSalvucci@cumberiandfarms.com If a corporation or partnership, give name, title, and home address of officers or partner. Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation Cumberland Farms supplies an online training for all employees through the HR Dept. * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE:$150.00 CT-3T NUMBER: FEDERAL ID/SS NUMBER: 04-2843586 SIGNATURE: Z-C4ma� 11! Ga .aeC c! DATE: 11 /30/2020 SR.LICENSING COORDINATOR A check mark signifies your understanding and agreement. i understand and agree that: U 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. W 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. 1� I must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in licensed smoking bars, for onsite consumption only. I)t 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. U Flavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite consumption only. jo Self-service tobacco product and/or nicotine delivery product displays from which the customer may select products are prohibited. Q The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. IR 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. X Tobacco vending machines are prohibited. 1� Non-residential Roll -Your -Own machines are prohibited. Q Blunt wraps are prohibited. Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. IX 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. *1 1 must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". 9( I must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts Department of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license). ® I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". 1� I must display signs provided by the Board of Health that discloses referral information about cessation. �X 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 Nicotinelivery Products" and agree to abide by it. Date 11 /30/2020 Name Laura Salvucci Retail License Coordinator y.'trr,rf Commonwealth of Massachusetts Letter ID: 1,0993642048 I -R'"-, Departmcnl of Rcvcnue Notice Dale: July 17, 2020 �' i�i� ,ri Geoffrey E. Snyder, Commissioner Account to: EDL-10031037-534 p rF.yr e4Q' nwss.govldor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS '�II��II�'I'IIIII�IIII�"'II'I�Ir�r��IIIIt111dI��Il�tlt�lr�l�llr CUMBERLAND FARMS INC CUMBERLAND FARMS 03531 165 FLANDERS RD WESTBOROUGHMA 01581-1032 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. DETACH HERE s"`"°s�>a MASSACHUSETTS DEPARTMENT OF REVENUE y Retailer License for Sale of Electronic Nicotine Delivery Systems YSF �,F ��- This license must be posted and visible at all times. The sale of Nr Of' tobacco products to anyone under 21 years of age is prohibited. CUMBERLAND FARMS INC Account ID: EDL-10031037-534 CUMBERLAND FARMS #0187 Location ID: 10031037-1211 30 CHAUNCY ST STE 2 License Number: 322430976 MANSFIELD MA 02048-1958 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: July 17, 2020 Expiration Date: September 30, 2022 5�s?�krT Commonwealth of Massachusetts Letter I D: L0070481472 Department of Revenue Notice Date September 4, 2020 GcotTrey N. Snyder, Commissioner Account ID; CGL,1003I037486 %E\T OFP mass.govldor RETAILER LICENSE FOR SALE OF CIGARETTES id'dplyllhrlttlr�IIIIL'I�ILlllldlrrll�'ll+url��l�bl�p CUMBERLAND FARMS INC CUMBERLAND FARMS #0176 CUMBERLAND 165 FLANDERS RD WESTBOROUGH MA 01581-1032 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 F°yys`�°SFT^r MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes t�ENrU4 �� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. CUMBERLAND FARMS INC Account ID: COL-10031037.486 CUMBERLAND FARMS #0187 Location ID: 10031037-0481 30 CHAUNCY ST License Number: 1130964992 MANSFIELD MA 02048-1958 ®r 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 A o® CERTIFICATE OF LIABILITY INSURANCE DATE(M 04/0DN 1/2020Y Y) 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(fes) must have ADDITIONAL INSURED provisions or be endorsed. It 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 Ann Risk Services central, Inc. Chicago IL Office CONTACT PHONE (g66) 283-7122 FAX (800) 363-010$ UfC. No. Ext): 200 East Randolph Chicago IL 60601 USA E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC N INSURED INSURER A: ACE American Insurance Company 22667 Cumberland Farms, Inc. C/o EG Retail America, LLC 165 Flanders Road INSURER B: Indemnity Insurance Co of North America 43575 INSURERO: Generali-U.S. Branch 11231 Westborough MA 01S81 USA INSURER D: Assicurazioni Generali S.p.A. M1360015 INSUgEfl E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570081256557 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. Limits shown are as requested LTq TYPE OF INSURANCE INSD WVD POLICY NUMBER MMDD,VYV yMADDNYYYI1 LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑X OCCUR GLS 0 7702 EACHOCCURRENCE $1,000,000 PREMISES Ea oce manure)$100,000 MED EXP(Any oneperson) $10,000 PERSONAL &ADV INJURY $1,000,000 GENT AGGREGATE LIMITAPPLIES PER: X POLICY ❑ JEPRO CT ❑ LOG OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS COMP,OPAGG $2,000,006 A AUTOMOBILE LIABILITY X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIBEDAUTOS NON OWNED ONLY AUTOS ONLY ISA H25300014 04/01/202004/01/2021 COMBINED SINGLE LIMIT Ea accident $5,000,000 BODILY INJURY (Per person) BODILY INJURY (Par accident) PROPERTY DAMAGE Per accident UMBRELLALIAe EXCESS LIAB H OCCUR CLAIMS MADE EACH OCCURRENCE AGGREGATE DEDI RETENTION B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR, PARTNER, EXECUTIVE OFFICEWMEMBER EXCLUDED? (Mandatory In NH) It Yee deserts orer DESCRIPTION OF OPERATIONS Isla. NIA WLRC66919171 04/01/2020 04/01 2021 X I PER STATUTE I OTH- ER E.L. EACH ACCIDENT $5,000,000 E.L. DISEASEEAEMPLOYEE $5,000.000 E.L. DISEASEPOLICYLIMIT $5,0001000 DESCRIPTION OF OPERATIONS, LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Screams, may be attached If more space Is required) The insurance afforded by the policies described herein is subject to all terms, exclusions and conditions of such policies. 2 0 U 4= r N U CERTIFICATE HOLDER CANCELLATION Q SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield Six Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD O 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 tinder law. RIICENSING COORDINATOR Signature of Individual or Corporate Name 04-2843586 "Social Security No. (Voluntary) or Federol Identification Nninber n/a By: Corporate Officer (Mandatory, if Applicable) *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\sleile\DesklopAScotVs DooimenlsTood Establishments- TempVFAX CERTIPICAI [ON F01W doc Department oflndustrialAeei(tents + Office of lit vestigation s Lafayette City Center 2 Avenue de Lafayette; Boston, MA 02111-1750 OV3VW.li!(lSS.gOVlCIiC! Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Cumberland Farms Inc., c/o EG Retail America, LLC 165 Flanders Road City/State/Zip: Westborough, MA01581 Phone 617-383-3483 Are you an employer? Check the appropriate box: Business Type (required): LE I am a employer with 3605 employees (full and/ 5. Q Retail 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 10-0 Manufacturing no employees. [No workers' comp_ insurance required]** I I ❑Health Care 4. ❑ We area non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req-] 12.0 Other "Any applicant that checksbox 41 most also fill rut 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 urn are employer that is providing;porkers' compensation insurance for Pity employees. Below is the pollcy infararation. Insurance Company Name: Chubb Global Casualty Insurer's Address: One Financial Center, 22nd Floor City/State/Zip: Boston, MA 02111 Policy 4 or Self -ins. Lie. g SCF C66919213 Expiration Date:04/01/2021 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 tine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties at the form of a STOP WORK ORDER and a fine of up to $250-00 a day against the violator. Be advised drat a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. n certy, rude tl pains cord ties of perjury that the infnrmntion provider) above is true clot correct. ( 03/30/2020 Date: _ Official rise only. Do not write in this area, to be completer) by city or town official, City or Town: Issuing Authority (check one): 1.❑Board of Health 2.❑ Building Department 5.❑Selectmen's Office 6.00ther Permit/License 3.❑ City/Town Clerk 41hicensing Board Contact Person: Phone w, ,v.mass.gov/dm Date of Incorporation: State of Incorporation: Principal Address: Office Telephone: Federal ID No: George Fournier 165 Flanders Road Westborough, Ma. 01581 Caroline Taitelbaum 165 Flanders Road Westborough, Ma. 01581 Nick Unkovic 165 Flanders Road Westborough, Ma. 01581 September 14, 1984 Delaware 165 Flanders Road, Westborough, MA. 01581 508-270-1400 04-2843586 PRINCIPAL OFFICERS President Vice President Secretary rI/ Photos must be vis licenses Scann 1 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 1 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. 1 agree to the following rules about the sale of tobacco products: 1 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,) 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 myjudgment not to make the sale in any of the cases described above. fi Falluo follow this policy may result in disciplinary action up to and including 1 z/o*; I- /zoo p oyee Signature Date Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CamScanner i :j Photos trust be visually scanned into the ematched to the customer purchasing and licenses Driver's lice identifica )cerise is to be scanned into the register system. All other Of bi n from the acceptable list will require manual entry of the date rth listed on the documentation. ' 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,ail members of the party. I have read and understand the Mansfield Board of Health Regulations which prohibits he 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 myjob 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 polrcy may result in ra Fws ' terminalorr disciplinary action up to and including 171.Zoao p oyee Signature n _ Date Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CamScanner Photos scanned must be visually matched to the customer purchasing and licenses 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. e; 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 fall 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. 1 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. r this policy may result in disciplinary action up to and including Tl a- L2_-e mployee Signature Store Operator Signature Date Date (This form will be maintained in your personnel file as a part of your permanent employee record) ' Scanned with CamScanner n Photos must be visually matched to the customer purchasing and licenses 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 underthe age of twenty-one (21) a valid Id will be required froth: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. Fa this E ployee Signature Store Ope torSignature result in disciplinary action up to and including Date Date (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CamScanner Photos must be visually matched to the customer purchasing and licenses 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 oft e 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: y other form I will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis, an person regardless regardleof of tobacco, or any nicotine delivery product to any person under the age of 21. If any eptable, I will not make the sale. 1 will not accept age attempts to make a tobacco purchase without an acc a note from an adult giving permission to a person under the age of 21 to buy tobacco products* nt not to make the sale in any of the cases described In turn, management agrees to support my judgme above. ?' 3 Failu`reto foll9w this policy may result in disciplinary action up to and including termination' % InYVIR Date Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CamScanner Photos must be visually matched to the customer purchasing and licenses 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. one under the 4. If it is suspected that someone is purchasing tobacco foall r members of the age of twenty-one (21) a valid id will be required frorrr" K� party. ts I have read and understand the Mansfield Board tof he Regulations which itallsothe sale of tobacco understand that if I and nicotine delivery products to anyone under the age of twenty-one ( ) years. 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: other form I will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis, or any of tobacco, or any nicotine delivery product to any person under the age of 21, If any person regardless of ke the sale. I age attempts to make a tobacco purchase without age of 21 to buy bacco products) not accept a note from an adult giving Permission to a person under the nt not to make the sale in any of the cases described In turn, management agrees to support my judgme above. zr i.`"� Failure to follow this paicy may result in disciplinary action up to and including term) at am > , rt�t Date E ployee ignature Store Operator Signature Date D (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CamScanner Photos must be visually matched to the customer purchasing and licenses 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 pc(Icy rtiay result in term matior%; ' Store Operator Signature disciplinary action up to and including 12/e/Za Date (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CannScanner Photos must be visually matched to the customer purchasing and licenses 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 pay' 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, bldis, 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 ahnve. Store Operator Signature disciplinary action up to and including Date Date (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CarnScanner Photos must be visually matched to the customer purchasing and licenses 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 frotiif:alI 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. l 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. Failureto follow this policy may result in termination, loyee Store Operator Signature disciplinary action up to and including 1a - -P -are Date Date (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CamScanner Photos must be visually matched to the customer purchasing and licenses 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 frgni ail members of the party. 1 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: 1 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 myjudgment not to make the sale in any of the cases described above. Store Operator Signature a result in disciplinary action up to and including Date Date (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CamScanner Photos must be visually matched to the customer purchasing and licenses scanned into the register. Driver's License Is to be scanned into the register system. All other s 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 fro "all members of the pa rty. 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 foiloyy this policy m' y result in disciplinary action up to and including terminatlon,y ``'„r 3`�. • I � i VIA) Store Operator Signature 1 � ✓ V Date I - Date (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CamScanner