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HomeMy WebLinkAboutWicked Vaped (Devine Enterprise, Inc.) - 12/31/2021Town of j14an#ielcl - Board ofllealth r� f U� � Town of Mansfield 6 Park4&w PERMIT NUMBER: Application for the Sale of Tobacco Products MA 02046 I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Re0q@uon Affecting Smoking and the Sale, Vending and Distribution of Tobacco. By signing this application, I declare thAlk 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. I , NAME OF BUSINESS: LOCATION OF SALE OF TOBACCO PRODUCTS: 2(e(" N W4,1,^ TELEPHONE AT LOCATION: -7 N- ZSq- Yr (1 Ll OWNER OF BUSINESS: LL4i.,. ADDRESS OF OWNER: (`Z'it. F>A'S4 .S�• W TELEPHONE OF OWNER: '7?q- 711- 0,47 f8b-Ce(00- L-(0 EMAIL ADDRESS: la-79;d � k: •cnvw If a corporation or partnership, give name, title, and home address of officers or partner. Briefly describe your tobacco and nicotine documentation sales training. Attach employee training' ,.I/,:,..nS` .J r•�tPtCt?rt 2t + 1'�i;�-y-I}r\y( a An Ew+Plsy�Y,ia '74, tom, FEE: $150.00 / CT-3T NUMBER: +t," t? ��1j FEDERAL IDISS NUMBER: TURE: DATE: Scanned with CamScanner a A check mark signifies your understanding and agreement. I understand and agree that: It is against the law to sell any tobacco product and/or nicotine delivery product (e.g. e-cigarettes) to anyone less than 21 years of age, regardless of how old the person looks. ! Anyone selling tobacco products and/or nicotine delivery products must conclusively establish the customer's / age as over 21 years old, by means of government -issued photographic ID. 7� 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. C/ I must consent to unannounced, periodic inspections and compliance checks of the permitted retail /establishment. Cf Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in / licensed smoking bars, for onsite consumption only. 2" Unflavored E-cigarettes with nicotine content over 35 mg/per mi can only be sold in adult -only retail tobacco /stores and licensed smoking bars. C( 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 products are prohibited. P / The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. g 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. G✓/ Tobacco vending machines are prohibited. N/ Non-residential Roll -Your -Own machines are prohibited. Q// Blunt wraps are prohibited. Cf Penalties for violation of the regulation include; monetary fines and/or suspension of this permit for seven or thirty days. C� '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 must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". (3 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). 9 1 must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". 9//1 must display signs provided by the Board of Health that discloses referral information about cessation. L9' 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 understand the Board of Health regulation "Regulation Affecting smoking and the Sale, Vending, an 'stri on of Tobacco and Ni Delivery Products" and agree to abide by it. Signature Date Print Name•— "�Q—_ Scanned with CamScanner 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 underlaw. Signature of Individual or Corporate Name By: Corporate Officer (Amdntory, if Applicable) *"Social Security No. (Voltvttary) 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\sleitc\Desktop\ScotPs Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc Scanned with CamScanner 1 Tar t.'ninannnat rnhA of ,1 Mat t°aebuiefti s 001tatirrtrnl fit /tielIIItrial Accidents tficr n� lnta'vigatillnI 600 Holi ingion,4treel ftaslon. IIA 02111 It11 n Inats,gor1dia Workers' Compenst;ilnn insurance Affidavit: General llusinesses Applicant 1nRtt'111ntion Plense Print 1 e fhy Ilusin"WOrgraliZation Name; Devine Enterprise Inc. / Wicked Vaped Address• 266 N. Main St. Unit 2 City/State/zip: Mansfield, MA 02048 Phone Are ymt nn employer? Check the appropriate box: I.Q I nut a employer with 2 employees (full now or part-tintc) t 2.❑ Iran a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' camp, insurance required] 3.0 We are a corporation and its officers have exercised their right of exemption per c. t52, 41(4), and we have no employees, rNo workers' comp, insurance required]" 4,0 We arc n non-profit organisation, staffed by volunteers, with no employees. [No workers' como. insurance real 508-660-6600 Business Type (required): S. n Rein[ l 6. ❑ Rcstaurnnt/Bar/Eating Establishment 7. Q Offee and/or Sales (incl. real estate, auto, etc.) S. QNon-profit 9. QEntertaimnent I Of] tvlanufnchtring I I.Q Health Care 12.Q Other "Any applicant that diecks box to 1 must also till out the section hcio%v showing their worker compensation policy humor ration. "'I (the corporate onicocs have cumpied themsch-cs. but the corporation has other employees, a Workers' compensation policy is required and such an organization should check box qL. I am an employer that is providtn; workers' compensatiwt insurance for my employees. Below Is the policy information. Insurance Company Name: Hartford Fire Insurance Company Insurer's Address: One Park Place 300 South State St. 7th Floor city/state/zip: Syracuse, NY 13202 Policy# or Self•ins, Lie. # 76 WEG AA6WRF 09/01/2021 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 MOL 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. J dohereby certify, ander the pains and penaltles ofperjury that tile Inforniatlon provided above is true and correct Signature: Wze, z?ewe 2d Date 11/25/2020 Official use only. Do not write 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. Cityrrown Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Phone rnnv.mass.govidia Scanned with CamScanner l 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 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. Scanned with CamScanner Atoeti,nInrntnatY,s'ri=�1LasM1stIt t4t't r ,rizr�Ailr ,p".=st'zr t5partstitsnxr�rbrae'r.ttel4�+¢�attn 1 n Ike lfi'o ttrip.F ,Mn 1'+n�unrit Fix Ibis mature, On raatidur rr is therm"! he - ck<l: JN�r3A�A to It" trrnicr of oifdo,I nnt.far atII trnnnaet is Eire, e pr sm to Iniptiell, oral tit uaincn" Ali eViuPrr Is dei1ncd as .,an hahvldual prance nip Am vialltm, c oTamtrnl nr utter legal entity, of aoy live nr to re III life {Orriaring i n}ntu•d it)null )null enicr{rr�:, nerd lac3tsd;ng the lep l n^pmsetfnttives oI'a decciased rift pIII) M, of the txl:aiict lit llwnlee of ran itill iciduel, parmv,slop, at�,xiation,vJ other legal ctnih. empletr lea cugluFeev II,toovct, lire oil. iif, If' l a den riling hounc having not more than three ar.-artoxtntc and tih,a resides thetrin, ur the orsupaiu (if the daelihig hnuce of mother who employs persons to do maimenaue. cotmniction or repair work On such dwcUhng house Or On tiie grrnmds or building nppurtmam thereto shall not because ofsuch employment he dceotcxl it) be mn cut, Allycr,,' tvlt ii., chapter 152. k25C(6) also states that `every state or local licensing a„eneg shall ivithliohi the Issuance or rcnewtil of a license or permit to operate a hasineccor to construct buildings in the commonwealth for tiny applicant who has not produced acceptable evidence of compliance if ith the insurance coverage required:' Additionally, bIOL chapter 152, 425C(7) states `-Neither the comnn mwealth nor any of its political subdivisions shall enter into nny contract for the performance Of public work until acceptable evidence orcompliance 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 your 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 (LI.P) 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 he sore to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pennit or license is being requested, not the Department of Industrial Accidents. Should you have ariv 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 (Le. a dog license or permit to bum 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 us 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 1-877-MASSAFE Fax # 617-727-7749 vvww.mass.gov/dia Forte Revised 5-2(r05 Sunned with CamScanner Photos must be visually matched to the customer purrhasing 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 myjob 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 atobacco 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. Failure to follow t ' p licy may result in disciplinary action up to and including tViTTiination., j 11 2c-/Zv Emplo a Signature Date Store Operator Signature Date lz-o (This form will be maintained in your personnel file as a part of your permanent employee record) Scanned with CamScanner