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HomeMy WebLinkAboutMansfield Service, Inc. - 12/31/2021Town of Mansf eld - Board of Health D f$�r" f PERMIT NUMBER: Town of Mansfield 6 Park Row Mansfield, MA 02048 Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. 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. / Q / NAME OF BUSINESS: I 14 hCXfir JB�Lj� LOCATION OF SALE OF TOBACCO PRODUCTS: /27 rbr u�4 , A / �a TELEPHONE AT LOCATION: 2 9 _ 33 q — q ps Cr AAAF� OWNER OF BUSINESS: ADDRESS OF OWNER: TELEPHONE OF OWNER: �'09 — V 73 — 7 I Z Z EMAIL ADDRESS: P._!L�d q Wi a 1,e, Co vvk If a corporation or partnership, give name, title, and home addofficers or partner. vnL Briefly describe your tobacco and nicotine delivery product sales training. Attach documentation training IN * Provide a coov of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3T NUMBER: q 9so Y 'Z K % R FEDERAL ID/SS NUMBER: 71/_` 12 SIGNATURE: tJ DATE: 12 /Z/ / 20 A check mark signifies your understanding and agreement. I understand and agree that: Q' 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. 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. I must consent to unannounced, periodic inspections and compliance checks of the permitted retail stablishment. Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in tensed 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 �tores and licensed smoking bars. �' Flavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite /Sonsumption only. elf-service tobacco product and/or nicotine delivery product displays from which the customer may select A�iroducts are prohibited. Ahe 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. obacco vending machines are prohibited. Non-residential Roll -Your -Own machines are prohibited. ,unt wraps are prohibited. enalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or �hirty 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 /ropy 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". must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts dI must of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license). Zust display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". ust 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 Nicotine Delivery Products" and agree to abide by it. gr/y-\ `�/y-\ Date 1ZZi 1&7 Print Nam Commonwealth of Massachusetts Letter Ill: L1071163968 ,r Department of Revenue Notice Date: May 7. 2020 q 9i S I Geoffrey E. Snyder, Commissioner Account to: EDL-I 1477902-013 r�4 Nro4Q" mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS Illrlr��l''�'i'ill'III'I��'I'I'II�'I'llllll�'lll�'��tldlnlrlll MANSFIELD SERVICE INC o MANSFIELD SERVICE INC w 189 CHAUNCY ST MANSFIELD MA 02048-1355 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 ��ycrrgr,TTs MASSACIIUSETTS DEPARTMENT OF REVENUE ° Retailer License for Sale of Electronic Nicotine Delivery Systems y4 1' �'svro4�� This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. MANSFIELD SERVICE INC Account ID: EDL-1 1477902-013 189 CHAUNCY ST License Number: 2062419968 MANSFIELD MA 02048-1355 - 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 taws and regulations. Effective Date: May7, 2020 Expiration Date: September 30, 2022 Commonwealth of Massachusetts Department of Revenue ylYr Gcotircy E. Snyder, Commissioner d�� oao-�`j� mass.gov/dor Letter ID: L0559063360 Notice Date: November 30, 2020 1L' Account ID: CGL-11477902-007 RETAILER LICENSE FOR SALE OF CIGARETTES u6'6'hIIIPIrPru01hr1111d1'llrull4lh'Id4111'Ilhll MANSFIELD SERVICE INC o � MANSFIELD SERVICE INC w 189 CHAUNCY ST MANSFIELD MA 02048-1355 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 ------------------- s MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 m Retailer License for Sale of Cigarettes �svror� This license must be posted and visible at all times. The sate of tobacco products to anyone under 21 years of age is prohibited. MANSFIELD SERVICE INC Account ID: CGL-I 1477902-007 189 CHAUNCY ST License Number: 995043328 MANSFIELD MA 02048-1355 - This certifies that the taxpayer named above is licensed tinder 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 `'f�f'urF Commonwealth of Massachusetts O„'rO De artment of Revenue Letter ID: L0034746688 2 { P Notice Date: November 30, 2020 Geoffrey E. Snyder, Commissioner Account to: CRL-11477902-010 'd �t rF<Yr ops' mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO t�dynl�ll�dlll'I�I'I�'11111�uillrl�Pur111116d�11��u1d1 .. MANSFIELD SERVICE INC o MANSFIELD SERVICE INC 9 189 CHAUNCY ST MANSFIELD MA 02048-1355 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut along the dotted line -and displayatyour 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+c sFTT MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco y This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. MANSFIELD SERVICE INC Account ID: CRL- 11477902-0 10 189 CHAUNCY ST License Number: 1978615808 MANSFIELD MA 02048-1355 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 Tobacco Retailer Employee Training Aqreement I understand that Mansfield Service Inc. Located in Mansfield MA prohibits the sale of tobacco products and paraphernalia to persons under 21 years of age. I have reviewed the information regarding the sale of tobacco products and paraphernalia to persons under 21 years of age and understand that if I make an illegal sale of tobacco products or paraphernalia to a minor, I could lose my job, receive a fine and cost my employer a fine or loss of license to sell tobacco products. I agree to the following rules and company policy about the sale of tobacco products: • I will not sell tobacco products or paraphernalia (pipes, cigarette papers, etc.) to any person under the age of 21. • If the person appears to be under age 27, I will ask for identification, look at it and determine their age. If there is any doubt about the person's age, I will NOT make the sale. • I will not knowingly sell tobacco to any adult for use by individuals under the legal age. If I think this is happening, I will NOT make the sale. • I understand that access to all tobacco products is restricted to store employees only. • I have received training concerning state and local laws as well as store policy regarding the sale of tobacco. This Company will NOT sell tobacco products or smoking paraphernalia to anyone under the age of 21. I have received training in tobacco sales from my employer. I understand and agree to the statements on the previous pa Sp,A i-,VtN,C i a a l,_L Employee's nameprinted, te^d, signature and date �1�l:41 Employee's pr�signature, and date rz/zr Employee's name Tinted, signature, and date Employee's name printed, signature, and date Employee's name printed, signature, and date Employee's name printed, signature, and date Employee's name printed, signature, and date Employee's name printed, signature, and date Employee's name printed, signature, and date Employee's name printed, signature, and date ge. " J q e ' 12��'��/� I Store manager's signature and date , � 'D �� z�l o�1� Store managerUs signature and dad Store manager's signature and date Store manager's signature and date Store manager's signature and date Store manager's signature and date Store manager's signature and date Store manager's signature and date Store manager's signature and date (This agreement will be kept on store premises at all times and must be presented for review when requested by persons performing tobacco sales compliance checks.) 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) l 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. 0 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 policy may termination. Employee Signature result in disciplinary action up to and including Date PA, Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) 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 minorsli 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. 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 policy may result in disciplinary action up to and including terming 'on 7 12�16 /Zo 117- Employee Signature Date hkw T Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) 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. 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 thi s in disciplinary action up to and including V2-\C"i-'LO Date Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) 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. 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. 1 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. Employee Signature Date ®�9 Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) 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) l 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. 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 policy may result in disciplinary action up to and including termingt+on. Employee/Signature v�✓1 ��� 7 Storkp 0 eratorSig nature Date 2 12 2� MO (This form will be maintained in your personnel file as a part of your permanent employee record)