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HomeMy WebLinkAboutWest Mansfield Variety - 12/31/2021Town of Mansfield - Board of Health PERMIT NUMBER: Town of Mansfield 6 Park Row Mansfield, MA,62048 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. NAME OF BUSINESS: _C"'-t2_(A�._c1— LOCATION OF SALE OF TOBACCO PRODUCTS:v TELEPHONE AT LOCATION: --2" /-L3 -1 Z OWNER OF BUSINESS: _ C12s—__�r�_� ADDRESS OF OWNER: -_ CpzztZ -11J. TELEPHONE OF OWNER: ��O)�_ FAX NUMBER: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 �1�_PJP�fu r1 nL �f'S�h�-� l I d2 u a 5—a�i P * Provide a copy_ of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3T NUMBER: -3 S-o 1 A S S G1 I) - FEDERAL ID/SS NUMBER: SIGNATURE: j, :� DATE: j 0, 1 S) V A check mark signifies your understanding and agreement. I understand and agree that: N 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 photo ID for anyone less than 27 years of age. Iq I must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. 3 Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in licensed smoking bars, for onsite consumption only. $I 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. tA 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. PS 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. Ip Tobacco vending machines are prohibited. $ Non-residential Roll -Your -Own machines are prohibited. W Blunt wraps are prohibited. K Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. �4 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. �4 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 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. p 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 a s• Pa _) Date ► O 1 1 7 1 .2 0 Print Name 1-'16T S- L �gA1, CA-6- Rj k-_) 4r5"' "EiT MASSACHUSETTS DEPARTMENT OF REVENUE t%U V N Retailer License for Sale of Electronic Nicotine Delivery Systems m 'UP 9�i,Fvro<� This license must be posted and visible at all times. The sale of tobacco products to anyone°under 21 years of age is prohibited. ADHYA CORPORATION Account ID: EDL-10510964-012 WEST MANSFIELD VARIETY License Number: 1078259712 428 ELM ST MANSFIELD MA 02048-2610 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: May 27, 2020 Expiration Date: September 30, 2022 -------------------------- y54"OsFTT MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 b A Retailer License for Sale of Cigarettes This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. ADHYA CORPORATION WEST MANSFIELD VARIETY 428 ELM ST MANSFIELD MA 02048-2610 Account ID: CGL-10510964-006 Location ID:10510964-0001 License Number: 350115840 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 20, 2020 Expiration Date: September 30, 2022 --------------------------- 5sp sE� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T ,q, Retailer License for Sale of Cigars and Smoking Tobacco 9t,Fvror�� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. ADHYA CORPORATION WEST MANSFIELD VARIETY 428 ELM ST MANSFIELD MA 02048-2610 Account ID: CRL-10510964-009 License Number: 1569335296 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 14, 2020 Expiration Date: September 30, 2022 TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Od 6"1 CI Cozy Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) **Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Usem\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM,doc Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.rnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization N Address: � c,92- (!5r City/State/Zip: N 12Q!5�a p 1d , po020Lt d Phone #: �A - ,2, f 443 92 Are you an employer? Check the appropriate box: Business Type (required): I. V1 I am a employer with employees (full and/ 5. ® 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. [No workers' comp. insurance required] 8• ❑ Non-profit 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.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 L❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑Other Any applicant that checks box 01 must also fill out the section below showing their workers' compensation policy information. *If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an aganization should check box Nl. ant an employer that is providing ww�oi-kers' conipensatiort insurance for my employees. Below is the policy information. nsurance Company Name: T I \ 1'� �`F '� I -T-n n AA:t t e 11 C N nsurer's Address: J�; 1t —tc 5'i �4e i0y2 6 1- 'ity/State/Zip: M i d ci I P to o';Y-D 028L,6 'olicy # or Self -ins. Lic. #(A) E [ 5__-1 0 9 �%�} Expiration Date: kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 rf up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. 'do hereby certify, under the pains and penalties ofpetjury that the information provided above is true and correct. signature: H fl' A- i) Date: 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. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact wtew.mass,gov/dia Phone WESTMAI OP ID: TI ,acosza CERTIFICATE OF LIABILITY INSURANCE On1001oonvvv) 10TE /01/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(!es) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements . PRODUCER 506-947.1818 J.K. Olivieri Ins. Agency 64 East Grove St. Middleboro, MA 02346 Kenneth W. Olivier! CO DEAdr Kenneth W. Olivier! NA : PHONE 508-947-1818 FAX (ac, No, Eel : AIC, No): EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: Liberty Mutual Insurance Co 12484 ��rysUR West aansfield Variety Adh aC rp, 428 skm �treet Mans !el , MA 02048 INSURERS: The Norfolk & Dedham Group 23965 INSURERC: INSURER D: NSURERE: INSURER F: r r,.rcoAr_cc CERT!F!CATE NUMBER: REVISION NUMBER: v THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR To TYPE OF INSURANCE ODL USR POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 CLAIMS -MADE XOCCUR DAMAGE TO RENTED 1,000,000 A Business Owners BZS56927776 09/25/2020 09/25/2021 X MED EXP An one erson 15,000 PERSONAL &ADV INJURY 1,000,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY❑%cof 11 LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG 21000,000 OTHER: OMOBILE LIABILITY COMBINED SINGLE LIMIT accident) BODILY INJURY Per erson - ANY AUTO BODILY INJURY Per accident $-OWNED SCHEDULED AUTOS ONLY _ AUTOS HIRED NONOWN D AUTOS ONLY AUTOS ONLY q PROPERTY AMAGE Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE EXCESS LIAR CLAIMS -MADE DED RETENTION $ B WORKERS COMPENSATION ANOEMPLOVERS'LIASILITY YIN ANY OFFICEOPRIET ER EXCWD�D7 ECUTIVE N (Man tlstoryIn NH) IN WE159098A 09/25/2020 09/25/2021 X PER OTH- STATUE E E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASEEAEMPLOYE _ 1,000,000 E.L. DISEASE -POLICY LIMIT 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below q Business Owners BZS56927776 09/25/2020 09/25I2021 Included ty Liquor Liabili'Ti DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Liquor Liability Coverage Included rc DTlnrArc HOLDER OANCFI I.ATION MANST02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE i _ ACORD 25 (2016/03) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD information ana Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express m implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance 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 (LLP) with no employees other than the members or partners, are not required to cant' 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 be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any 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 (i.e. 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 www.mass.gov/dia rm Revised 5-26-05 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. k/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. V 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 H ^ ft T ri \t-(-- ( Date: Ca \_d.20 Applicant Name (please print clearly) N1"ire I W �rt 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 minorsll TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all laws and procedures of this,p.olicy 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 registerand 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. 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 termination`,, ' (plli�-2-D Employee Signature Date 1�:\,R.Qcri�el I b)1 o 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 related to the sale of tobacco products including: c loose tobacco, pipe tobacco, rolling papers, cigars, The minimum age to purchase tobacco products is It is our responsibility as a retailer and members less tooacco, e and lighters. years of age. 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�egmpute'r based training and successfully pass with 1000/o 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. 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. 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, l will not make the sale. I will not accept a note from an adult giving permission to a person under the age of 21 to buy tobacco products. In turn, management agrees to support my judgment not to make the sale in any of the cases described above. Failure to follow this policy may result in disciplinary action up to and including termination. Employee Signature Date — , (--\— \ b3 \ 2 —2-0 Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record)