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HomeMy WebLinkAboutSunoco #40082H / 7 Eleven - 12/31/2021Town of Mansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: i f? IV 7(6 Application for the Sale of Tobacco Produce } I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation -- Affecting Smoking and the Sale, Vending and Distribution of Tobacco. By signing this application, I declare that I have read the regulation and am responsible for tobacco product sales regarding federal, state and local laws. This permit expires on December 31st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: — YJ l - - - --- LOCATION OF SALE OF TOBACCO PRODUCTS: --- k 1, Fr TELEPHONE AT LOCATION: 2 _S�Zl'so OWNER OF BUSINESS:`1L a 7 ADDRESS OF OWNER 2 I TELEPHONE OF OWNER: '2-- "C _- Ni 1 f FAX NUMBER: --- 1-41 3-1 If a corporation or partnership, give name, title, and home gaddress of officers or partner. Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3T NUMBER: ' r /^ V g FEDERAL ID/SS NUMBER: SIGNATURE:1£��d t€a= t DATE: 7 _My r Commonwealth of Massachusetts F' I Department orRevenue } Geoffrey E. Snyder, Commissioner e'Nr ov+ tnoss.gov/dor Lencr ID: L1350970944 ri Notice Dale: September 15, 2020 Account ID: CGL-10196336-110 RETAILER LICENSE FOR SALE OF CIGARETTES 11111141Ppui11111h1411111rltdtlrrl11111111111111111110111 7ELEVENINC 7-ELEVEN 3906W PO BOX 711 DALLASTX 75221-0711 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 MassTaxColmect 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 m ps*tuEF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes '�,E.,�, oFs�' This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age Is prohibited. 7 ELEVEN INC Account ID: CGL-10196336-110 SUNOCO#40082H Location ID: 10196336-0704 70 COPELAND DR License Number: 960014336 MANSFIELD MA 02048-1221 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 Commonwealth of Massachusetts Letter ID: L1793523392 im �Department of Revenue Notice Date: September 17, 2020 l Geoffrey E. Snyder, Commissioner Account ID: CRL-10196336-113 rkr,7 fi� mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO urlll�dllppll�'ll�ll'�'II�IIIIIP��II�II��rl�rllrlllllpuu) 7ELEVENINC 7-ELEVEN 37445H PO BOX 711 DALLAS TX 75221-0711 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 �yybCHtrsF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T �w' Retailer License for Sale of Cigars and Smoking Tobacco m r� y �1,6nrroes�s This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. 7 ELEVEN INC Account ID: CRL-10196336-113 SUNOCO #40082H Location ID: 10196336-0705 70 COPELAND DR License Number: 37459968 MANSFIELD MA 02048-1221 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 STATE OF MA LIST OF OFFICERS Joseph M DePinto Pres/CEO Rankin Gasaway SVP/GC/SEC David Seltzer VP/TR A check mark signifies your understanding and agreement. I understand and agree that: CIZt 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. 4'�,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. L1-/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. �4,, 1 must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. L4_' Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in licensed smoking bars, for onsite consumption only. kl 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. 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. E1 The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. N_ 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. I-K" Tobacco vending machines are prohibited. Non-residential Roll -Your -Own machines are prohibited. \7/'Blunt wraps are prohibited. �VPenalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or. thirty days. r l 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 /dopy of which will be placed on file, that he/she has read the regulation and applicable state laws. M I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". \I/ 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 f must display signs provided by the Board of Health that discloses referral information about cessation. Yl 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 Print Name Date ELEYEn DATE January 10,2020 TO/ Wayne McGee LOCATION FROM/ Rankin Gasaway LOCATION 0182 SUBJECT power of Attorney Dear Wayne: In order to expedite the signing of certain licenses for 7-Eleven stores, I have appointed you attorney -in -fact of 7-Eleven, Inc. This appointment will remain in effect until such time as it is revoked. This appointment gives you certain authority to bind the Company. Please understand, however, that this appointment applies only to the execution of documents reating to certain licenses that the Company holds or is applying for. Notwithstanding the above -described limitations of your author ty, it is possib'e that yo., might , onceivably be able to bind the Company legally in connection with other matters. You shoud not do this, regardless of how important you think the situation might be. If you feel at some point that it Is desirable for you tc sig,t other':nstruments on behaf of the Company, you must receive specific authorization to do so, either from me or any Board appointed Vice President of the company. If you have any questions about the extent of your authority, please give me a call. Otherwise, please sign this letter in the space set forth below in order to acknowledge that you understand contp!ete y t'ie limits of the authority that has been grantee to you. Please return the signed letter to Casey Pennell at location 0182. Very truly yours, Rankin Gasaway 1 Senior Vice President, General Counsel and Secretary I have read this letter and understand the limits of my authority to act as attorney in Fact of 7-Eleven, Inc By, Jr � ay( Mr cGee Date: a (} .has 'c 6 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 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 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 ta4tomp6t'er based training and successfully pass with 100% pi for to starting on a register. This certification to be updated on an an'nuai'basis prior to previous year expiration. 3.'A valid form of ide tification will be required for all tobacco purchases regardless of a:eor frequency of customer visits. Id are as follows: Valid Massachusetts License Valid Massachusetts state ld Valid US passport Valid Out of State License No expired identification will be accepted. 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 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: 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 my judgment not to make the sale in any of the cases described above. Failure to follow tws po11*y may result in disciplinary action up to and including l t ' ,?�" P-O-Z_ o Employee Signature Date Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) ��� O?g'_ A check mark signifies your understanding and agreement, I understand and agree that: Cz' it is against the law to sell any tobacco product and/or nicotine delivery product (e.g. e-cigarettes) to anyone Jess than 21 years of age, regardless of how old the person looks. e Anyone selling tobacco products and/or nicotine delivery products must conclusively establish the customers gage as over 21 years old, by means of government -issued photographic ID. �" Anyone selling tobacco products and/or nicotine delivery products must check and verify official government photo ID for anyone less than 27 years of age. i must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold In Iice�sed 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. avored e-cigarettes with any strength of nicotine content can only be sold In licensed smoking bars, for onsite con umption only, elf -service tobacco product and/or nicotine delivery product displays from which the customer may select pro cts are prohibited. he sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. uli­m�ay not distribute any free samples of tobacco products or nicotine delivery products (e.g. e-cigarettes) and 1 may not accept any means, instruments or devices that allow for the redemption of tobacco products for free or ciga ttes at a price below the minimum retail price determined by the Massachusetts Department of Revenue. ob = vending machines are prohibited. o/n-residential Roll -Your -Own machines are prohibited. )btu t wraps are prohibited. Ialties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirtv days, 14>1 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 co/py of which will be placed on file, that he/she has read the regulation and applicable state laws. Itel must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". r _-YFnust provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts D srrtment of Revenue (DOR) and my OOR business permit (Attach a copy of each permit/license). ,. I myst display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". kL- I mm 3t display signs provided by the Board of Health that discloses referral information about cessation. 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 Distri rf n of Tobac and Nicotine Delivery Products" and agree to abidpe /by it. e^ Signature t r J, Date l ! J a�0 Print Name J *' \\),s 'L'04 %I - 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 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 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 io take`computer based training and successfully pass with=lOQ% prior to staiting on -' egister. This certification to be updated on an annual }basis prior to previous year expiration. 3, :A valid form of,idertificaton 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. \\�..s 4,06 '- 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 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, it cigarettes, nape and lighters. The minimum age to purchase tobacco products is twenty one.(21) years of age, it is our responsibility as a retailer and me`im" hers"of the community to prevent the sale of tobacco to anyone under the age of twenty on, 021). PROCEDURES: 1. This policy will be.reviewed with all new Employees before they can operate a cash reglster and sell tobacco products. 2. All store Employees to take eomputer based training and successfully pass with 100% rrior to start on a -register. This certification to be updated nnual basis prior to previous year expiration. form of Identification will be required for all tobacco purchases ess of site 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. A check mark signifies your understanding and agreement, I understand and agree that! a- 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. 9K 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. 8'-Anyone selling tobacco products and/or nicotine delivery products must check and verify official government photo ID for anyone less than 27 years of age. i' 1 must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. 94' Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in licensed smoking bars, for onsite consumption only. 6�- Unfiavored E-cigarettes with nicotine content over 35 mg/per ml can only be sold In adult -only retail tobacco stores and licensed smoking bars. P, 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. e' The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. tK 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. V Tobacco vending machines are prohibited. e Non-residential Roll -Your -Own machines are prohibited. L'K Blunt wraps are prohibited. Iu� Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days, 1` "l 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. !OK i must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices I must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts Department of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license). i' I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". M�I must display signs provided by the Board of Health that discloses referral information about cessation, 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 Nicoottiine Delivery Products" and agree to abide by it. Signature / c 2y- (�� ' Date Print Name 'a-0 s e p y \as ` 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 II 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' 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 an a register. This certification to be updated on an annual basis prior to previous year expiration. 3 °A valld form of identification will be required for all tobacco purchases "'teaardless of ageor frequency of customer visits. ble 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. TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included, it is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws, The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. compostable materials must meet ASTM (American Society of the international Association for Testing and Materials) Standards for compostability. V I have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Applicant Signature ���� ,1--`-""y Date: l l 2%Z� ea Applicant Name (please print clearly) 3bgaN 7- vRl Oar i G 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. follow this policy may result in disciplinary action up to and including )6 Employee Signature Date Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) Ltloo 78 A check mark signifies your understanding and agreement. I understand and agree that: Cd 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. p Anyone selling tobacco products and/or nicotine delivery products must conclusively establish the customers Jage as over 21 years old, by means of government -issued photographic ID. E� Anyone selling tobacco products and/or nicotine delivery products must check and verify official government photo ID for anyone less than 27 years of age. i I must consent to unannounced, periodic Inspections and compliance checks of the permitted retail / establishment. a Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in licensed 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. 6/ Flavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite consumption only. I/ Self-service tobacco product and/or nicotine delivery product displays from which the customer may select products are prohibited. y jhe sale of single or loose cigarettes or cigarettes In packages of fewer than 20 cigarettes is prohibited. i 1 may not distribute any free samples of tobacco products or nicotine delivery products (e.g. e-cigarettes) and I may not accept any means, instruments or devices that allow for the redemption of tobacco products for free or cigarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue, (V Tobacco vending machines are prohibited, IV Non-residential Roll -Your -Own machines are prohibited. Blunt wraps are prohibited. ✓, Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. i. 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. I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices -_I/ i must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts pepartment of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license). E /jl must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". L,C/ must display signs provided by the Board of Health that discloses referral information about cessation. ! If I sell nicotine delivery devices (e.g. e•clgarettes) 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 s Date illy 45- s-O" Print Name ��i�if ) X%}1✓ 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, bldis, or any other form of tobacco, or any nicotine delivery product to any person under the age of 2L 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 [ Store Operator Signature // 2-. r-00 Z- v Date (This form will be maintained in your personnel file as a part of your permanent employee record) A check mark signifies your understanding and agreement. I understand and agree that: lq-)It is against the law to sell any tobacco product and/or nicotine delivery product (e,g. e-cigarettes) to anyone ass 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 ge as over 21 years old, by means of government -issued photographic ID. © ,Anyone selling tobacco products and/or nicotine delivery products must check and verify official government / photo ID for anyone less than 27 years of age. D I must consent to unannounced, periodic inspections and compliance checks of the permitted retail V,Flavored establishment. tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in /licensed smoking bars, for onsite consumption only. 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. Flavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite consumption only. �J ',Self-service tobacco product and/or nicotine delivery product displays from which the customer may select products are prohibited. The sale of single or loose cigarettes or cigarettes In packages of fewer than 20 cigarettes is prohibited. CI 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. obacco vending machines are prohibited. Non-residential Roll -Your -Own machines are prohibited. #. Blunt wraps are prohibited. Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. I? 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. I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". I must provide the Board of Health with proof of 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". i must display signs provided by the Board of Health that discloses referral information about cessation, 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 th oard of Health regulation "Regulation Affecting Smoking and the Sale, Vending, and Dis ibuti Tobacc d icotine Delivery Products" and agree to bide R. n Signature Date Print Name 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 frorn.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 terminaton,���-��/ Employee Signature Store Operator Signature Date Date (This form will be maintained in your personnel file as a part of your permanent employee record)