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HomeMy WebLinkAboutShaw's #431+-51�60 15 q2'�,- Town of Mansfield - Board of Health PERMIT NUMBER: Town of IN'' sf�fId 6 Par Ro "' Man Meld; MA 004W l 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: Shaw's #431 LOCATION OF SALE OF TOBACCO PRODUCTS: 390 West St. Mansfield, MA 02048 TELEPHONE AT LOCATION: 508-339-3987 OWNER OF BUSINESS: Shaw's Supermarkets, Inc. ADDRESS OF OWNER: _--PO Box 29096, MS-6531 Phoenix, AZ 85038-9096 _ TELEPHONE OF OWNER: 623-869-4326 EMAIL ADDRESS: NASC.Tax@safeway.com If a corporation or partnership, give name, title, and home address of officers or partner. See attached Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation See attached reO eya- ti it * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3T NUMBER: 826632192 FEDERAL ID/SS NUMBER: 04-1123420 SIGNATURE: DATE: e A check mark signifies your understanding and agreement. I understand and agree that: ® It is against the law to sell any tobacco product and/or nicotine delivery product (e.g. e-cigarettes) to anyone less than 21 years of age, regardless of how old the person looks. Anyone selling tobacco products and/or nicotine delivery products must conclusively establish the customer's age as over 21 years old, by means of government -issued photographic ID. R1 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. 91 1 must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. W Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in licensed smoking bars, for onsite consumption only. K 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. R Flavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite consumption only. Id Self-service tobacco product and/or nicotine delivery product displays from which the customer may select products are prohibited. p The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. b� 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. K Tobacco vending machines are prohibited. R] Non-residential Roll -Your -Own machines are prohibited. ® Blunt wraps are prohibited. &1 Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. 21 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 copy of which will be placed on file, that he/she has read the regulation and applicable state laws. Ph 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). ® 1 must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". kl 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. 1 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 Date ( (4,13 5 ve Bama Print Name Manager Tax 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. Steve Barna Manager Tax By: Corporate Officer (Mandatory, if Applicable) 04-1123420 "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:\Users\sleite\Desktop\ScotPs Docmnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations ' 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Shaw's #431 390 West St City/State/Zip: Mansfield, MA 02048 Phone #: 508-339-3987 Are you an employer? Check the appropriate box: Business Type (required): 1. x❑ I am a employer with 141 employees (full and/ 5. X1 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. 8. ❑ Non-profit [No workers' comp. insurance required] 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]** 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.] I *Any applicant that checks box #1 must also fill out the section below showing Weir workers' compensationpolicy 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Ace American Insurance Company c/o AON Risk Services Central, Inc. Insurer's Address: 5600 West 83rd Street, 8200 Tower, Suite 1100 City/State/Zip: Minneapolis, MN 55437 Policy # or Self -ins. Lic. # WLRC67463511 Expiration Date: 8/1/2021 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. Ido hereby certify, user the pains andpen allies ofperjury that the information provided above is true and correct 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 Person: Phone www.mass.gov/dia ` CERTIFICATE OF LIABILITY INSURANCE DATD( 2920PO n 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 policy(les) 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 t0 the certificate holder in lieu of such endorsement(s). PRODUCER Aon Risk Services Central, Inc. Minneapolis MN Office 5600 West 83rd Street 8200 Tower, suite 1100 CONTACT NAME: _ PHONE (Q. (g66) 283-7122 FAX (600) 363-0105 No. EXO: AIC, No.: E-MAIL ADDRESS: _ INSURER(S) AFFORDING COVERAGE MARC If Minneapolis MN 55437 USA INSURED INSURERA: ACE American Insurance Company 22667 INSURER B: ACE Property & Casualty Insurance Co. 20699 New Albertsons L.P. Including All Affiliated subsidiaries & Associated Companies 250 E. Parkcenter Blvd. Boise ID 83706 USA INSURER C: INBURERD: -- INSUflER E: _ INSURER F: A6I1LT1-3q:F 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE ADUL INSp WVO POLICYNUMBER Mlpp MIDD LIMITS A X COMMERCIALGENERALLIABILITY CLAIMS -MADE �X OCCUR DmOgra Liablilly Included T XSLG SIR applies per policy ter is & conditions EACH OCCURRENCE $3,000,000 D MAG TED PREMISES Eaocromace $3,000,000 X MED EXP(My one persool EXCluded PERSONAL a ADV INJURY $3,000,000 GENLAGGREGATE LIMITAPPLIES PER: X POLICY PRO- LOC OTHER: JECLiquor GENERALAGGREGATE $19,000,000 PRODUCTS -COMPIOPAGG $6.000,000 Uabilf, Included A AUTOMOBILE LIABILITY X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIREDAUTOS NON OWNED ONLY AUTOS ONLY ISA H25308384 08/O1/202009/01/2021 COMBINED SINGLE LIMIT Ea acciden BODILYINJURY(Par Person) $5,000,000 ...._._..._ BODILY INJURY Per aoclden0 PROPERTY DAMAGE Peraccidenl e X UMBRELLALiAB EXCESS LIAR I X I OCCUR CLAIMS -MADE XEUG2794761AOOS SIR applies per policy ter 08/01/2020 is & condi 08 01/2021 ions EACH OCCURRENCE $5.000,000 AGGREGATE $5,000,000 OED I X IRETENTION A WORKERS COMPENSATION Me EMPLOYERSLUBILnY YIN ANY PROPRIETOR I PAWNER I EXECUnVE ❑ OFFICELMEMBERD(CLUDED? (Mandatory In NH) IT yea. descdbe under DESCRIPTION OF OPERATIONS below MIA WLRC67463511 08/O1/202008 01 02021 )( PER STATUTE OTH- ER E.L EACH ACCIDENT $2,000,000 E.L. DISEASE -EA EMPLOYEE $2.000,000 E.L. DISEASE -POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Memorial Remarks Schedule, may be attached H mare space is required) Blanket Additional Insured for General Liability policy and waiver of subrogation for General Liability policy status extend to those parties to whom the insured has contractually agreed t0 provide this status. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCYPROVISIONS. New AlbertSonS L.P. AUTHORIZED REPRESENTATIVE including All Affiliated subsidiaries & Associated companies E. 36lBlvd. %J/GJIdGQ �C{�J6�E Boise Io 83706 USA T ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD _yMMOHU� Commonwealth of Massachusetts Letter ID: L2071494976 d' q •+it, Department of Revenue Notice Date: November 5, 2020 Geoffrey E. Snyder, Commissioner Account ID: CGL-11546651-107 NTo4 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES IPu'Idlhh'��I'Pthtllu'mhl'hi111'I�II'p'Irlllllll" TAX DEPT SHAWS SUPERMARKET INC SHAW'S #1420 PO BOX 29096 MS # 6531 PHOENIX AZ 85038-9096 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 6 �y�cxoSF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 M Retailer License for Sale of Cigarettes 9'FmoQ¢ This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. SHAWS SUPERMARKET INC Account II): CGL-11546651-107 SHAW'S #431 Location ID: 11546651-0221 390 WEST ST STE 1 License Number: 826632192 MANSFIELD MA 02048-1170 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: November 5, 2020 Expiration Date: September 30, 2022 POLICY: AGE SENSITIVE SALES POLICY & ACKNOWLEDGEMENT REVISION DATE: 08/25/2020 AREA: CUSTOMER SERVICE DEPARTMENT AUDIENCE: Store Management, including Manager Night Relief, Person -In -Charge; Customer Service Management, CSRs, Checkers, Service Desk clerks, Pharmacist, Pharmacy Technician and Starbucks clerks POLICY STATEMENT This policy applies to the sale of age sensitive products which Shaw's/Star Market stores are licensed to sell. Age sensitive products include: Alcohol, Imitation Alcohol, Tobacco, Fireworks, CBD products, Lottery and DXM products. This policy requires employees to be knowledgeable and adhere to the State laws and regulations that govern the sales of age sensitive products in each state in which Shaw's/Star Market operates. LAWS & LIABILITY As an employee who works in a licensed store, there are responsibilities and liabilities that apply to you. Responsibilities are actions that you must take about the sale of age sensitive products. An employee can be personally held liable, for injury and damage that occurs to our customers or is caused by them, which resulted from a violation of this policy; in addition, Shaw's/Star Market could lose their license to sell the age sensitive product. STATE AGE TO PURCHASE/RETURN AGETO SELL/RETURN MAINE 21 21/ 171F STORE MANAGEMENT ON DUTY IS 21 YEARS OF AGE MASSACHUSETTS 21 18 MASSACHUSETTS 21- MADRIVER'SUCENSEID STORES: 0602, 0619, 0645, 25 - OUT-OF-STATE DRIVER'S LICENSE 18 1420,2565,2583,3581,3696 ID NEW HAMPSHIRE 21 16 RHODE ISLAND 21 NO RESTRICTION VERMONT 21 16 TATE AGE TO PURCHASE I AGE TO SELL/ RETURN MAINE 21 21/ 171F STORE MANAGEMENTON DUTY IS 21 YEARS OF AGE . .._.. NO RESTRICTION MASSACHUSETTS - - ---__ 21 21 NO RESTRICTION EW HAMPSHIRE INF HODE ISLAND 21 NO RESTRICTION ERMONT 21 16 STATE ' AGE TO PURCHASES IAGE TO SELL'./RETURN 21/ 18 IF STORE MANAGEMENT ON DUTY 1521 YEARS OF AGE MAINE 21 NEW HAMPSHIRE 21 21/ 181F STORE MANAGEMENT ON DUTY IS 21 YEARS OF AGE RHODE ISLAND 16 16 VERMONT 18 18 _ AGE TO PURCHASE AGE TO SELL RETURN ' ®STATE SETTS — VERMONTMASSACHU 21 ISOKSTATE AGE TO PURCHASE REDEEM IAGE TO SELL ALL STATES �18 n10 ftE5TRICTION AGE TO PURCHASE REDEEM jIA�GE TO SELL ®STATE ALL STATES 118 _ —_— r0 RESTRICTION shaurs' Star 1 STATE SALES HOURS ALLOWED MAINE------ 6AM—1AM_---_--- MASSACHUSETTS [STORES: 0602, 0645, 1420, 2565, 3581, 3696] MON-SAT8AM-11PM SUN 10AM-11PM MEMORIAL DAY -SALES BEGIN AT 12PM MASSACHUSETTS (STORE 25831 MON-SAT 10AM-11PM SUN 10AM-6PM MEMORIAL DAY -SALES BEGIN AT 12PM MASSACHUSETTS (STORE 0619] MON-SAT 9AM-10PM SUN 10AM-9PM MEMORIAL DAY -SALES BEGIN AT 12PM NEW HAMPSHIRE 6AM-11:45PM VERMONT 6AM —12AM -Rhode Island stores do not sell alcohol. The POS will prompt the date of birth for Non -Alcoholic Beer and Wine purchases. Valid ID is required to be obtained. I&AG.EENSITIVE SALES - STATE LAWS & COMPANY POLICY a To purchase age sensitive products, the customer must be the legal age required by the state in which they are purchasing, and the customer is required to provide valid ID. To purchase age sensitive products, the customer is required to provide a valid, unexpired, photo ID that is a reasonable likeness of them. • In Massachusetts, ID is required from every customerfor all age sensitive products, except Lottery in which ID is required for customers who appear younger than 30. Massachusetts does not recognize out-of-state driver's licenses as a valid form of ID to purchase alcohol. Therefore, per Shaw's policy, if a customer provides an out of state license, they must be at least 2S years old to purchase alcohol. • In Rhode Island, ID is required from every customer for all age sensitive products, except Lottery in which ID is required for customers who appear younger than 30. • In Maine, New Hampshire and Vermont, ID is required for customers who appear younger than 30 years of age for all age sensitive products. • In all States, the ID Checking guide is required to be used to authenticate out-of-state IDs. shatA Star* 2 To sell /return age sensitive products, the employee must be the legal age required by state in which the products are being sold. Employees under the legal age to sell /return are restricted from checking the customer's ID and restricted from scanning, tendering and bagging age sensitive products. The underage employee must set aside the product and call Front End Management. The Front End Management person of legal age is responsible to check the ID, scan the age sensitive product, tender the order and bag the age sensitive product. No exceptions. • A customer is required to be 18 years or older to purchase from the Lottery Vending machine. • Based on the location of the Lottery Vending machine, Front End Management, Cashiers and Service Desk Clerks are required to constantly monitor the Lottery Vending machine for underage customers who may be attempting to make purchases even if the Lottery Vending machine is equipped with Age Verification technology for scanning ID. • If a customer is suspected of being underage, the Lottery Vending machine is required to be disabled using the remote disabler where available. SALE OF ALCOHOL/TOBAcco To A MINOR / THIRD PARTY SALES Any employee who sells or provides alcoholic beverages/tobacco to a customer under the age of 21 can be convicted and punished by a fine or by imprisonment. A third -party sale occurs when an adult buys alcohol/tobacco for an underage youth from an establishment for his or her underage consumption. Making a Third -Party Sale is just as serious as selling directly to an underage customer. Employees must be aware of the people around the purchaser, if the purchaser appears to have friends lurking nearby, the employee must call Management for assistance. sraaaaas' stark 3 The sale of products like, cough, cold, allergy, sinus and diet pills that contain Pseudoephedrine, Ephedrine, and Phenylpropanolamine are federally regulated by the Combat Methamphetamine Epidemic Act. The act makes it illegal to sell these products over the counter. Therefore, at Shaw's these products can only be purchased from the Pharmacy and in limited quantities. The sale of products like, cough, cold, allergy, sinus and diet pills that contain Dextromethorphan, can be sold over the counter. Per policy, there is a purchase limit of three products containing Dextromethorphan, per day. Customers are required to be 18 years of age and provide a valid ID to purchase. The following message will be displayed on the POS if more than three products containing Dextromethorphan are scanned: B911 Restricted Quantity Family Care HBC. ahawss' start'u 4 The following two steps are required to be followed for every transaction that involves the sale of an age sensitive product(s). Before beginning a transaction or at the point it is identified that the age sensitive product is being purchased, the employee is required to check if any of the following conditions exists: • Customer appears to be intoxicated. • Customer appears to be purchasing for a minor (3RD Party Sale) • Customer appears underage and is attempting to purchase from the Lottery Vending Machine • Customer cannot provide a valid, unexpired, photo ID • Customer provides an ID that appears to show signs of tampering Important! If a customer meets any of the conditions above, the transaction must stop, and Store Management must be called. The employee is required to follow the ID procedures below based on your store's state laws. 1. Obtain the customers valid ID. Never ask the customer for their date of birth. Valid IDs include: • State Driver's License I State Non -Driver's License card • US Passport / US Passport card • Military ID (with DOB) • Massachusetts Registry of Motor Vehicle Liquor ID card NOTE If the customer provides an out-of-state license, a Front End Management person of legal age is required to use the I.D. CHECKING GUIDE to validate the ID. 2. Verify that the photo on the ID is a reasonable likeness of the customer standing in front of you. 3. Verify that the ID is unexpired. 4. Examine the ID for signs of tampering. S. If, the ID provided is not a reasonable likeness, is expired or shows signs of tampering, stop the transaction and call management. Importantl It is against Company policy to enter a fake DOB or to obtain the DOB verbally. 6. As required, enter on the POS, the customer's DOB as shown on their ID to verify age (MMDDYY) shawe , starry s The CSM, ACSM and Store Management is required to deny the purchase of age sensitive products based on compliance with state laws and/or company policy. Management must deny the purchase of age sensitive product, under the following conditions: • Customer appears intoxicated • Customer appears to be purchasing for a minor (3ftD Party Sale). • In New Hampshire, customer attempting to purchase and cannot provide an ID. The CSM, ACSM or Store Management is not authorized to approve the purchase • Customer cannot provide an ID and appears to be younger than the required age to purchase • Customer provides an ID that is expired, is not a reasonable likeness or shows signs of tampering. MANAGEMENT - AUTHORIZED •WITHOUT In Massachusetts, Maine, Rhode Island and Vermont, if the customer cannot provide valid ID for the purchase of age sensitive product, only the CSM, ACSM and Store Management may approve the purchase if the customer appears to be over the legal age for the product being purchased, in the state being purchased. In New Hampshire, it is against state law to authorize an age sensitive purchase without ID. 6 �EMPLOYEE ACKNOWLEDGEMENT I have read the Age Sensitive Sales Policy and understand my responsibilities either as a cashier and/or as an employee. I understand that failure to follow this policy could result in corrective action up to and including termination of my employment. EMPLOYEE NAME: [PRINTED] EMPLOYEE SIGNATURE: DATE: POSITION: STORE NAME/ NUMBER: 7 sl$ w star c tt _