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HomeMy WebLinkAboutMansfield Gas Service (W. Samrout Corp., Inc.) - 12/31/2021�I Town of Mansfield - Board ofh'ealth PERMIT NUMBER: TowhW Mansfield 6 Pj4rk Row Mansfield, MA 02048" r t l Application for the Sale of Tohaeco 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. F1, NAME OF BUSINESS: WCllc� `JctrnCw� Cv/P^C LOCATION OF SALE OF TOBACCO PRODUCTS: 'S4 ( le'l :4 d TELEPHONE AT LOCATION: 5e-� -- 339 - 3 FI OWNER OF BUSINESS: U (A(J _'C�)alhCari r _ ADDRESS OF OWNER: �Co uC'ePke4 5 1- 6X �J m4i/ Od o ? J _ TELEPHONE OF OWNER: EMAIL ADDRESS: iSS� p'}Ctl[Yl(Ai, C_a'1 If a corporation or partnership, give name, title, and home address of officers or partner. ! Ui )A SGmr �i � ec �r � J4tl�e � _ SG ��u- Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation A4thCte * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3T NUMBER: 02 3 S_lIN-_ FEDERALIDISSNUMBER: O,� 6& SIGNATURE: DATE: 11/3/2020 Mail - wissam samrout - Outlook hllps://outlook.live.com/mail/O/inbox/id/AQMkADAwATYwMAItYVVM3NS1 kMGE 1 LTAwAiOwNIAoARgAAAygQL % 2BwikMBJvOle5bbtlPQHABMlwvweA... 1 /1 A check mark signifies your understanding and agreement. I understand and agree that: -al 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. nyone 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. must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. 9— 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. � lavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite consumption only. lJ /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. _!/(-may 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 cigarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue. I✓Tobacco vending machines are prohibited. ✓I�lon-residential Roll -Your -Own machines are prohibited. It_-Bfunt wraps are prohibited. Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. L-f-ffiay 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. 1ir fnust 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). IL-4-must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". 4--Tmust display signs provided by the Board of Health that discloses referral information about cessation. — I sell nicotine delivery devices (e.g. e-cigarettes) 1 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 Tobacc d Nicotine Delivery Products" and agree to abide by it. Signature _ Date IN Print Name 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. Signatu • ndividual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number w(A)L� P30 By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Dsers\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe commonwealth of Massachusetts Lotter ID: LI200370240 W, 10 FIR Doparhnent of Rownao Notice Date: August 13, 2020 Gcomey'E. Snyder, Commissioner Account ID: EDL-11753998-014 Ctvr of mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS III�u01'1°IIII'III°III°IIIIIm�II°'llllile�li°mllLlm�h�tlll WALID SAMROUT CORPORATION INC o e MANSFIELD GAS SERVICE 54 CHAUNCY ST MANSFIELD MA 02048-1902 Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut — '- almg the dotted -line —and -,display -at your business location- At any time, you can_ loginto 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 ss� SFj MASSACHUSETTS DEPARTMENT OF REVENUE — - - o Retailer License for Sale of Electronic Nicotine Delivery Systems 9 Fm -t This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. WALID SAMROUT CORPORATION INC Account ID: EDL-11753998-014 MANSFIELD GAS SERVICE License Number: 1283115008 54 CIiAUNCY ST MANSFIELD MA 02048-1902 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: August 13, 2020 Expiration Date: September 30, 2022 commonwealth of Massachusetts Letter ID: L1428526656 Department of Revenue Notice Date: August 18, 2020 vGeoffrey E. Snyder, Commissioner Case ID: 0-000-795-852 mass.gov/dor CERTIFICATE, OF GOOD STANDING AND/OR TAX COMPLIANCE ,iuihl°Ilr°Ill°h°rII°lh°II6h111°ihlumuPitildrl°°I WALID SAMROUT CORPORATION INC 54 CIIAUNCY ST MANSFIELD MA 02048-1902 Wky did l receave tfzis notice? The Commissioner of Revenue certifies that, as of the date of this certificate, WALID SAMROUT CORPORATION INC is in compliance with its tax obligations under Chapter 62C of the Massachusetts General Laws. This certificate doesn't certify that the taxpayer is compliant in taxes such as unemployment insurance administered by agencies other than the Department of Revenue, or taxes under any other provisions of law. This is not a waiver of lien issued under Chapter 62C, section 52 of the Massachusetts General Laws. F What if l hays 4uestions? If you have questions, call us at (617) 887-6400 or toll -free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m.. visit us online!, Visit mass.gov/dor to learn more about Massachusetts tax laws and DOR policies and procedures, including your Taxpayer Bill of Rights, and MassTaxConnect for easy access to your account: • Review or update your account • Contact us using e-message • Sign up for e-billing to save paper • Make payments or set up autopay t,_ 01�f Edward W. Coyle, Jr., Chief Collections Bureau TOAVELERN WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6HUB-1 K96621 -3-20 ) RENEWAL OF (6HUB-1K96621-3-19) INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA NCCI CO CODE:13439 WALID SAMROUT CORPORATION INC 54 CHAUNCY STREET MANSFIELD MA 02048 Insured IS A CORPORATION 17Ie7i]II614 DOWLING INS AGENCY INC PO BOX 850962 BRAINTREE MA 021a5 Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period Is from 03-28-20 to 03-28-21 12:01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ Bodily Injury by Disease: $ Bodily Injury by Disease: $ 100000 Each Accident 500000 Policy Limit 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy Includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information Is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 04-02-20 AG ST ASSIGN: MA OFFICE: RMD POOL 161 PRODUCER: DOWLING INS AGENCY INC 23SNT 000754 e CLASSIFICATION SCHEDULE: CLASSIFICATIONS CODE NO WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (GHUS-1 K96621 -3-20 ) PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTALANNUAL PER $100 OF ANNUAL REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC -CODE: 5511 NAICS: 441110 -------------------------------------------------------------------------------- STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 3750 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 338 TERRORISM 45 TOTAL ESTIMATED PREMIUM 4133 TAXES AND SURCHARGES 132 DEPOSIT AMOUNT DUE 4265 A/R (WCIP) # Minimum Premium: $ 266 ST ASSIGN: MA DATE OF ISSUE: 04-02-20 AG OFFICE: RMD POOL 161 PRODUCER: DOWLING INS AGENCY INC 23SNT VELERS J WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE -SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (CHUB-i K9662i -3-20 ) INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA INSURED'S NAME: WALID SAMROUT CORPORATION INC RATE BUREAU ID: 000000397 PREMIUM BASIS ESTIMATED RATES TOTAL ANNUAL PER $100 OF CLASSIFICATION CODE REMUNERATION REMUNERATION LOCATION 001 01 FEIN 042805171 ENTITY CD 001 WALID SAMROUT CORPORATION INC 54 CHAUNCY STREET MANSFIELD, MA 02048 SIC CODE: 5511 NAICS: 441110 AUTOMOBILE SERVICE OR REPAIR CENTER & DRIVERS 8380 150612 2.49 m o� o .�. ---------------------------------------'----------_---- MERIT RATING/EXPERIENCE MOD: NONE MODIFIED PREMIUM $ ° TOTAL ESTIMATED ANNUAL STANDARD PREMIUM EXPENSE CONSTANT(0900) 0.0300 TERRORISM (9740) 3.51% MA WC SPECIAL FUND AND TRUST FUND T01"AL ESTIMATED PREMIUM DEPOSITAMOUNT DUE NONE 3750 338 45 132 4265 4265 13439-MA ESTIMATED ANNUAL PREMIUM 3750 DATE OF ISSUE:04-02-20 AG ST ASSIGN: MA OVUM SCHEDULE NO: 1 OF LAST The Commonwealth of Massachusetts Department of Industrial Accidents O%fice of Investigations 600 Washington Street Boston, MA 02111 IN wn,minass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: 06 Phone M q Are you an employer? Check t appropriate box: Business Type (required): 1. Q 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 (met. real estate, auto, etc.) employees working for me in any capacity. 8. []Non-profit 3.❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 100 Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp, insurance req.] *Any applicant that checks box Nl nmst 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 organization should check box 91. I am an employer that is provides n Insurance Company Name: � CU compensation insurance for my employees. Below is the policy information. Insurer's Address: at q } City/State/Zip: Policy # or Self -ins. Lie. #—"l — � �tAems/ �— ).,� 0 Expiration Date: 6 q' �9 —cX 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 MGL 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. I do hereb}, certify, colder the pug it�nn 'esy4wdace that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by cify or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Phone www.mass.gov/dia 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 or 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 ajoint 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 at, 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 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 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 burn 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 Form Rmsed 5-26-05 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. ' Employee Signature Date 2- aZr S re Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) r 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 th, age of twenty-one (21) a valid Id will be required from.all members of the pa rty. 1 have read and understand the Mansfield Board of Health Regulations'which prohibits the -sale of tobacco` and nicotine delivery products to anyone under the age of twenty-one (21) years, I also understand that if l above. Failul=e`to follow this terminate ;,' L Store Operator Signature Date //- I-2u. Date (This form will be maintained in your personnel file as a part of your permanent employee record) 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. 1 have read and understand the Mansfield Board of Health Regulations which prohibits the; sale of tobacco and nicotine delivery products to anyone under the age of twenty-one (21) years. I also understand that if I fail to follow store policy;and local and state laws about the sale of tobacco or nicotine deliveryproducts to any person under the legal age, I could lose myjob orbe tined. I agree to the following rules about the sale of tobacco products: I will not sell any tobacco products,iineiuding cigarettes, cigars, chewmmg tobacco, bidis, orainy other form of tobacco, orany nicotine delivery ;product to any person under the age of 21. If any person regardless of ageeattempts to make a tobacco purchase without an acceptable, will not make the sale. ,I will not accept a note from an adult giving permission to a person under the age of.21 to buy tobacco products. In turn, management agrees to support my judgmentnotto 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 Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) I MA www.mass:povirmvwffll� _ 6��1saa�o6�zi-iuie B: SrellwM<leleas tlun&,06f EwOflSFMEMS.. REflPICibNS- xon�B.', B: `Corteetiue lenses CH EOG MBBB6S.DBIMBBLOW. PE POJ:EMIiBC ,m 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 front all members of the party, I have read and understand the Mansfield Board of Health Regulations which prohibits the -safe of tobacco s In turn, management agrees to support my judgment -not to make the sale in any of the cases described Employee Signature Date Store Operator Signature Date (This form will be maintained in your personnel file as a part of your permanent employee record) Christopher George From: wissam samrout <wissol8@hotmail.com> Sent: Friday, November 20, 2020 11:47 AM To: Christopher George Subject: RE: Tobacco Permit Application Each employee including my self took the retailer education and training course hLtps://www.mass.gov/service- details/retailer-education-and-traininl?-resources -------- Original message -------- From: Christopher George <cgeorge@mansfieldma.com> Date: 11/17/20 1:53 PM (GMT-05:00) To: WISSOl8kHOTMAIL.COM Subject: Tobacco Permit Application Hello, I've received your tobacco permit application but a section was left blank. Please briefly describe your tobacco and nicotine delivery product sales training. If you email it here I can print it with your application. Thank you, -Chris George Administrative Assistant, Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here.