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HomeMy WebLinkAboutMansfield Xtra Mart - 12/31/20211 Town of Mansfield - Board of Health PERMIT NUMBER: 6 Park Row a,, M,ansffield, MA 02b9$, 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: Mansfield Xtra Mart LOCATION OF SALE OF TOBACCO PRODUCTS: 905 South Main Street, Mansfield, MA TELEPHONE AT LOCATION: (508) 261-2812 OWNER OF BUSINESS: Drake Petroleum Company, Inc ADDRESS OF OWNER: 800 South Street, Suite 500, Waltham, MA 02453 TELEPHONE OF OWNER: (781) 398-4419 FAX NUMBER: (781) 398-7261 If a corporation or partnership, give name, title, and home address of officers or partner. Please see attached Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation Please see attached * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3T NUMBER: 383561728 / 1994174464 / 2101815296 FEDERAL ID/SS NUMBER: 04-2236089 Drake Petroleum Company, Inc. SIGNATURE --� DATE: A check mark signifies your understanding and agreement. I understand and agree that: I3 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. W 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. C� Anyone selling tobacco products and/or nicotine delivery products must check and verify official government photo ID for anyone less than 27 years of age. [� I must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. d Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in licensed smoking bars, for onsite consumption only. II/ 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. C3 Flavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite consumption only. Self-service tobacco product and/or nicotine delivery product displays from which the customer may select / products are prohibited. CA The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited. G✓ 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. II/ Tobacco vending machines are prohibited. C3� Non-residential Roll -Your -Own machines are prohibited. C3� Blunt wraps are prohibited. C3l' Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. 121 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. Cif I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". I/ I must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts Department of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license). I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". C( I must display signs provided by the Board of Health that discloses referral information about cessation. 131 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. Drake.Petroleum Company, Inc. Signature- — Date i Print Nami. Bv: `ld,. ; -. Site #10027 — Mansfield. MA Tobacco Training Protocols for Employees New hires and current employees must successfully complete our online tobacco course (age restricted policies and procedures). A new hire may not work behind the check-out counter/POS until he/she has successfully completed the online tobacco course. Current employees must successfully complete the online course on a biannual basis. COMPLYO:. �, Federal and state taw requkes that all employees involved In the sales of tobacco products are certified to comply wan regulations PRIOR to w Rioll behind the POS. You must compawe am pass three eLewning f ses. meet Win your mallagef to team coriprarly-speafic policies, and rose play adivlies to NOT you certification requirements. PREPARE You are mrocetl m these eLeamaV courses: • Resportslbie Tobacaro Sales I (15 nt4lutes) Responsible Tobacco Sales 11 (10 minutes) E•Ctparedes Addedum (5 minutes) WATCH ELEARNING COURSES • Watch both Responsible Tobacco Sales l and Responsible Tobacco Sales bond pass The exams. o Printable certificates wp display. Printing the certificates is not requited • Watch E•Clgarerres Addendum and pass the exam. o A ceNficate wile display conlinw g you are [edified. DISCUSS WITH MANAGER Beeante familiar wah the diverse types of tobacco products and e-cgarettes In the store by having your manager show you where they are located. a Dis ss compam`9Perfic poficfes and situations you Wall Wely encounter and what •; �' you woum do in sand situations. • s`+t`rltu+A ODepartment Commonwealth or Massachusetts of Revenue Geoffrey E. Snyder, Commissioner 'T OFQ mass.gov/dor Letter ID: L0511614528 ti Notice Date: September 30, 2020 Oli? Account ID: CGL-11154405-069 RETAILER LICENSE FOR SALE OF CIGARETTES �11th9�hldlhl�tllll�tt�ttttlu11t4111P���hll�t^dllthil DRAKE PETROLEUM CO INC MILLBURY XTRA MART 15 NE INDUSTRIAL RD BRANFORD CT 06405-2844 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. G7aWITOMI101L70 ��Ssa SErTs MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 m A 2 Retailer License for Sale of Cigarettes 9 This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. DRAKE PETROLEUM CO INC Account ID: CGL-11154405-069 MANSFIELD XTRA MART Location ID: 11154405-0203 905 S MAIN ST License Number: 383561728 MANSFIELD MA 02048-3149 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 `sn�UrF. Commonwealth of Massachusetts Letter ID: L0025075264 ;'� Department of Revenue Notice Date: September 30, 2020 ro { Geoffrey E. Snyder, Commissioner Account to: CRL-11154405-072 't'S7vr o�v' mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO Ild�lr���p���l�ulr�l�ldl�lll�l�hlw��u��l�lhhhl�h��l DRAKE PETROLEUM CO INC MILLBURY XTRA MART 15 NE INDUSTRIAL. RD BRANFORD CT 06405-2844 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE �,PSs"`<rET MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T m Vi'l Retailer License for Sale of Cigars and Smoking Tobacco 9P�btK pe�� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. DRAKE PETROLEUM CO INC Account ID: CRL- 11154405-072 MANSFIELD XTRA MART Location ID: 11154405-0204 905 S MAIN ST License Number: 1994174464 MANSFIELD MA 02048-3149 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 oo .ta`sss�!urC� Commonwealth of Massachusetts Letter ID; L2024989248 0 } s Department of Revenue Notice Date: May 14, 2020 Geoffrey E. Snyder, Commissioner Account to: EDL-I 1154405-076 i,i. ope mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS DRAKE PETROLEUM CO INC MILLBURY XTRA MART 15 NE INDUSTRIAL RD BRANFORD CT 06405-2844 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 5nc"USF� MASSACHUSETTS DEPARTMENT OF REVENUE N Retailer License for Sale of Electronic Nicotine Delivery Systems b 'Fnn cs� This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. DRAKE PETROLEUM CO INC Account ID: EDL-11154405-076 MANSFIELD XTRA MART Location ID: 11154405-0222 905 S MAIN ST License Number: 2101815296 MANSFIELD MA 02048-3149 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 14, 2020 Expiration Date: September 30, 2022 r Employee Agreement for Tobacco Sales The purpose of this agreement is to Inform all employees involved in customer transactions of the requirement io comply with the Food and Drug Administration (FDA) Regulations as well as applicable state and local laws governing the prevention of tobacco sales to minors. I have met with my manager and reviewed the training videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of my job, as well as the imposition of a fine. I also understand that Global Montello Group Corp. requires employees to ID all persons who attempt to purchase tobacco products. I agree to the following rules about the sale of tobacco products: • I will not sell any tobacco product to any person under the age of 21 ("Minimum Age"). • I will request a valid government -issued photo ID that includes a date of birth for anyone who attempts to purchase tobacco products. • 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 Minimum Age. If I think this is happening, I will not make the sale. • I will not accept a note (or any other implied permission) from any person under the Minimum Age to purchase a tobacco product for themselves or anyone else. In any of the above -referenced situations, management agrees to support my judgment and decision not to make the sale. I understand that failure to comply with the terms of this agreement could lead to action by my employer, the FDA and/or state regulators that may jeopardize my employment and may involve the imposition of fines and/or legal action against me or my employer. loyee's Signature ore Manager's Signature Date Date (, /3--`2-u (This agreement will be maintained in your personnel file as part of your permanent employee record.) Rev. January 2020 FDA Tobacco Carding: Employee Compliance Form This document musl be rend and signed by all employees fn-1heir personnel,Jiles 1. Federal law requires a minimum age of 21 years for all retail tobacco purchases. Tobacco products include, among other things, e-cigarettes and other electronic nicotine delivery systems (ENDS). 2. To comply with FDA tobacco requirements, employees must review a government -issued photo Ill that includes a birthdate from each customer who attempts to purchase tobacco products. 3. The FDA will enforce this regulation by contracting with state agencies. The FDA will enforce this regulation by contracting with state agencies. They will form inspection teams made up of an adult commissioned official and a 15-16 year old who, together, will conduct undercover buy inspections at retail locations. The teenager will attempt to purchase a tobacco product while the adult observes the date, time & whether the sale was made. Violations will be sent to the FDA who will issue a warning letter and/or fine. The FDA has the authority to impose fines up to $15,000 to[ - each violation. 4. Community activists, anti -tobacco groups and parents will be watchdogs in enforcing the regulations. o They will be sending volunteers to stage tobacco purchases and test the carding regulations. o They will report directly to the FDA. o They may be handing out leaflets to store personnel. What you must do to abide by the regulations and conduct yourself professionally: a. Card everyone who attempts to purchase tobacco products. b. 11'a customer objects, hand them a tear sheet from the counter, point to our signage or call a manager immediately for assistance. c, If anyone fi-om the media begins asking you any questions, call the manager immediately. Do not answer the questions. Anything you say is considered 'bn the record" and could appear in the newspaper, on the television, on the internet, or over the radio. d. If any anti -tobacco groups, community activists, parent groups etc., enter the store, call a manager immediately. Do not answer any questions. If they are handing out leaflets, accept them and give them directly to management. e. Always be polite, courteous, and professional. We do not expect you to engage in any discussions or arguments. Management will deal with this. I understand that failure to comply with the terms of this form could lead to action by my employer and/or the FDA that may jeopardize my employment and may involve the imposition of fines and/or legal action against me and/or my employer. Employee Print E tployee Signature Date L. Rev. January 2020 Employee Agreement for Tobacco Sales The purpose of this agreement is to infornn all employees involver! in customer transactions of the requirement to comply with the Food and Drug Administration: (FDA) Regulations as well as applicable state and local laws governing the prevention of tobacco sales to minors. 1 have met with my manager and reviewed the training videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of myjob, as well as the imposition of a fine. I also understand that Global Montello Group Corp. requires employees to ID all persons who attempt to purchase tobacco products. I agree to the following rules about the sale of tobacco products: • I will not sell any tobacco product to any person under the age of 21 ("Minimum Age"). ► I will request a valid government -issued photo ID that includes a date of birth for anyone who attempts to purchase tobacco products. • 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 Minimum Age. If I think this is happening, I will not make the sale. • I will not accept a note (or any other implied permission) from any person under the Minimum Age to purchase a tobacco product for themselves or anyone else. In any of the above -referenced situations, management agrees to support my judgment and decision not to make the sale. I understand that failure to comply with the terms of this agreement could lead to action by my employer, the FDA and/or state regulators that may jeopardize my employment and may involve the imposition of fines and/or legal action against me or my employer. P iployee's rgnaht cz- -�a- - Sto Manager's Signature Date (This agreement will be maintained in your personnel file as part of your permanent employee record.) Rev. January 2020 FDA Tobacco Carding: Employee Compliance Form This document must be read and signed by all employees for their personnel files 1. Federal law requires a minimum age of 21 years for all retail tobacco purchases. Tobacco products include, among other things, e-cigarettes and other electronic nicotine delivery systems (ENDS). 2. To comply with FDA tobacco requirements, employees must review a government -issued photo ID that includes a birthdate from each customer who attempts to purchase tobacco products. 3. The FDA will enforce this regulation by contracting with state agencies. The FDA will enforce this regulation by contracting with state agencies. They will form inspection teams made up of an adult commissioned official and a 15-16 year old who, together, will conduct undercover buy inspections at retail locations. The teenager will attempt to purchase a tobacco product while the adult observes the date, time & whether the sale was made. Violations will be sent to the FDA who will issue a warning letter and/or fine. The FDA has the authority to impose fines up to $15,000 for each violation. 4. Community activists, anti -tobacco groups and parents will be watchdogs in enforcing the regulations. o They will be sending volunteers to stage tobacco purchases and test the carding regulations. o They will report directly to the FDA. o They maybe handing out leaflets to store personnel. What you must do to abide by the regulations and conduct yourself professionally: a. Card everyone who attempts to purchase tobacco products. b. If a customer objects, hand them a tear sheet from the counter, point to our signage or call a . manager immediately for assistance. c. If anyone from the media begins asking you any questions, call the manager immediately. Do not answer the questions. Anything you say is considered "on the record" and could appear in the newspaper, on the television, on the internet, or over the radio. d. If any anti -tobacco groups, community activists, parent groups etc., enter the store, call a manager immediately. Do not answer any questions. If they are handing out leaflets, accept them and give them directly to management. e. Always be polite, courteous, and professional. We do not expect you to engage in any discussions or arguments. Management will deal with this. I understand that failure to comply with the terms of this form could lead to action by my employer and/or the FDA that may jeopardize my employment and may involve the imposition of fines and/or legal action against we and/or my employer. pl�nt� ployee SinDate are D teb Rev. January 2020 Employee Agreement for Tobacco Sales The purpose of this agreement is to inform all employees involved in customer transactions of the requirement to comply with the Food and Drug Administration (FDA) Regulations as well as applicable state and local laws governing the prevention of tobacco sales to minors. I have met with my manager and reviewed the training videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of my job, as well as the imposition of a fine. I also understand that Global Montello Group Corp. requires employees to ID all persons who attempt to purchase tobacco products. I agree to the following rules about the sale of tobacco products: • I will not sell any tobacco product to any person under the age of 21(`°Minimum Age"). • I will request a valid government -issued photo ID that includes a date of birth for anyone who attempts to purchase tobacco products. • 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 Minimum Age. If I think this is happening, I will not make the sale. • Twill not accept a note (or any other implied permission) from any person under the Minimum Age to purchase a tobacco product for themselves or anyone else. In any of the above -referenced situations, management agrees to support my judgment and decision not to make the sale. I understand that failure to comply with the terms of this agreement could lead to action by my employer, the FDA and/or state regulators that may jeopardize my employment and may involve the imposition of fines and/or legal action against me or my employer. yEinplo4ye Signature Date ., l Si't ^'— / l --/p - 2-c1 t e Manager's Signature Date (This agreement will be maintained in your personnel file as part of your permanent employee record.) Rev. January 2020 FDA Tobacco Carding: Employee Compliance Form This document mast be read and signed by all employees,ior their personnel files 1. Federal law requires a minimum age of 21 years for all retail tobacco purchases. Tobacco products include, among other things, e-cigarettes and other electronic nicotine delivery systems (ENDS). 2. To comply with FDA tobacco requirements, employees must review a government -issued photo ID that includes a birthdate from each customer who attempts to purchase tobacco products. 3. The FDA will enforce this regulation by contracting with state agencies. The FDA will enforce this regulation by contracting with state agencies. They will form inspection teams made up of an adult commissioned official and a 15-16 year old who, together, will conduct undercover buy inspections at retail locations. The teenager will attempt to purchase a tobacco product while the adult observes the date, time & whether the sale was made. Violations will be sent to the FDA who will issue a warning letter and/or fine. The FDA has the authority to impose fines up to $15,000 for each violation. 4. Community activists, anti -tobacco groups and parents will be watchdogs in enforcing the regulations. o They will be sending volunteers to stage tobacco purchases and test the carding regulations, • They will report directly to the FDA. o They may be handing out leaflets to store personnel. What yore must do to abide by the regulations and conduct yourself professiotially: a. Card everyone who attempts to purchase tobacco products. b. If a customer objects, hand them a tear sheet front the counter, point to our signage or call a manager immediately for assistance. c. If anyone from the media begins asking you any questions, call the manager immediately. Do not answer the questions. Anything you say is considered "on the record" and could appear in the newspaper, on the television, on the internet, or over the radio. d. If any anti -tobacco groups, community activists, parent groups etc., enter the store, call a manager immediately. Do not answer any questions. If they are handing out leaflets, acceptthem and give them directly to management. c. Always be polite, courteous, and professional. We do not expect you to engage in any discussions Or arguments. Management will deal with this. I understand that failure to comply with the terms of this form could lead to action by my employer and/or the FDA that may jeopardize my employment and may involve the imposition of fines and/or legal action agL�nilea/o y employ Emp oy`ce [riot Lploycc Signature Date Rev. January 2020 Employee Agreement for Tobacco Sales The purpose of this agreement is to inform all employees involved in customer transactions of the requirement to comply with the Food and Drug Administration (FDA) Regulations as well as applicable state and local laws governing the prevention of tobacco sales to minors. I have met with my manager and reviewed the training videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of my job, as well as the imposition of a fine. I also understand that Global Montello Group Corp, requires employees to ID all persons who attempt to purchase tobacco products. I agree to the following rules about the sale of tobacco products: • I will not sell any tobacco product to any person under the age of 21("Minimum Age"), • I will request a valid government -issued photo ID that includes a date of birth for anyone who attempts to purchase tobacco products. • 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 Minimum Age. If I think this is happening, I will not make the sale. • I will not accept a note (or any other implied permission) from any person under the Minimum Age to purchase a tobacco product for themselves or anyone else. In any of the above -referenced situations, management agrees to support my judgment and decision not to make the sale. I understand that failure to comply with the terms of this agreement could lead to action by my employer, the FDA and/or state regulators that may jeopardize my employment and may involve the imposition of fines and/or legal action against me or my employer. Employee's Signature a- re Tanager's Signature II/oAm Date r-1 & 4V Date (This agreement will be maintained in your personnel file as part of your permanent employee record.) Rev. January 2020 FDA Tobacco Carding: Employee Compliance Form This doctanent must be read and signed by all employees for !heir personnel files 1. Federal law requires a minimum age of 21 years for all retail tobacco purchases. Tobacco products include, among other things, e-cigarettes and other electronic nicotine delivery systems (ENDS). 2. To comply with FDA tobacco requirements, employees must review a government -issued photo ID that includes a birthdate from each customer who attempts to purchase tobacco products. 3. The FDA will enforce this regulation by contracting with state agencies. The FDA will enforce this regulation by contracting with state agencies. They will form inspection teams made up of an adult conunissioned official and a 15-16 year old who, together, will conduct undercover buy inspections at retail locations. 'file teenager will attempt to purchase a tobacco product while the adult observes the date, time & whether the sale was made. Violations will be sent to the FDA who will issue a warning letter and/or tine. The FDA has the authority to impose fines up to $15,000 for each violation. 4. Community activists, anti -tobacco groups and parents will be watchdogs in enforcing tine regulations. o They will be sending volunteers to stage tobacco purchases and test the carding regulations. o They will report directly to the FDA. o They may be handing out leaflets to store personnel. Wltat yott must do to abide by the regulations and conduct yourself pro%ssionrdly: a. Card everyone who attempts to purchase tobacco products. It. If a customer objects, hand them a tear sheet from the counter, point to our signage or call a manager immediately for assistance. c. If anyone from the media begins asking you any questions, call the manager immediately. Do not answer the questions. Anything you say is considered 'bn the record" and could appear in the newspaper, oil the television, on the internet, or over the radio. d. If any anti -tobacco groups, community activists, parent groups etc., enter the store, call a manager immediately. Do not answer any questions. If they are handing out leaflets, accept then) and give them directly to management. c. Always be polite, courteous, and professional. We do not expect you to engage in any discussions or arguments. Management will deal with this. I understand that failure to comply with the terms of this form could teat] to action by my employer and/or the FDA that may jeopardize my employment and may involve the imposition of fines and/or legal action against me and/or my employer. _IYl cf bae', i�jq t I/l'Oho Employee Print Employee Signature Date Rev. January 2020 �i. Employee Agreement for Tobacco Sales The purpose of this agreement is to inform all employees involved in customer transactions of the requirement to comply with the Food and Drug Administration (FDA) Regulations as well as applicable state and local laws governing the prevention of tobacco sales to minors. I have met with my manager and reviewed the training videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of my job, as well as the imposition of a fine. I also understand that Global Montello Group Corp. requites employees to ID all persons who attempt to purchase tobacco products. I agree to the following rules about the sale of tobacco products: • I will not sell any tobacco product to any person under the age of 21 ("Minimum Age"). • I will request a valid government -issued photo ID that includes a date of birth for anyone who attempts to purchase tobacco products. • 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 Minimum Age. If I think this is happening, I will not make the sale. • I will not accept a note (or any other implied permission) from any person under the Minimum Age to purchase a tobacco product for themselves or anyone else. In any of the above -referenced situations, management agrees to support my judgment and decision not to make the sale. I understand that failure to comply with the terms of this agreement could lead to action by my employer, the FDA and/or state regulators that may jeopardize my employment and may involve the imposition of fines and/or legal action against me or my employer. f14 Signahtr%e S re anager's Signature Date % 1--13— "2-0 (Thus agreement will be maintained in your personnel file as part of your permanent employee record.) Rev. January 2020 FDA Tobacco Carding: Employee Compliance Form This document rnusl be rend crud signer! by all employees./br their personnel files 1. Federal law requires a minimum age of 21 ,years for all retail tobacco purchases. Tobacco products include, among other things, e-cigarettes and other electronic nicotine delivery systems (ENDS). 2. To comply with FDA tobacco requirements, employees must review a government -issued photo ID that includes a birthdate from each customer who attempts to purchase tobacco products. 3. The FDA will enforce this regulation by contracting with state agencies. The FDA will enforce this regulation by contracting with state agencies. They will form inspection teams made up of an adult commissioned official and a 15-16 year old who, together, will conduct undercover buy inspections at retail locations. The teenager will attempt to purchase a tobacco product while the adult observes the date, time & whether the sale was made. Violations will be sent to the FDA who will issue a warning letter and/or fine. The FDA has the authority to impose fines up to $15,000 for each violation. 4. Community activists, anti -tobacco groups and parents will be watchdogs in enforcing the regulations. o They will be sending volunteers to stage tobacco purchases and test the carding regulations. o They will report directly to the FDA. o They maybe handing out leaflets to store personnel. What yott must do to abide by the regulations and conduct yourself professionally: a. Card everyone who attempts to purchase tobacco products. b. If a customer objects, hand them a tear sheet from the counter, point to our signage or call a manager immediately lot- assistance. c. If anyone from the media begins asking you any questions, call the manager immediately. Do not answer the questions. Anything you say is considered "on the record" and could appear in the newspaper, on the television, on the internet, or over tine radio. d. If any anti -tobacco groups, community activists, parent groups etc., enter the store, call a manager immediately. Do not answer any questions. If they are handing out leaflets, accept them and give them directly to management. e. Always be polite, courteous, and professional. We do not expect you to engage in any discussions or arguments. Management will deal with this. 1 understand that failure to comply with the terms of this form could lead to action by my employer and/or the FDA that may jeopardize my employment and may involve the imposition of fines and/or legal action against me and/or my employer. / )T L It S Siv I<�)67�mc:. t /% < i �a ( G� ti ✓/ ? ' i Employee Print mill yee`Siiggnatme Date Rev. January 2020 r t Employee Agreement for Tobacco Sales The purpose of this agreement is to inform all employees involved in customer transactions of the requirement to comply with the Food and Drug Administration (FDA) Regulations as well as applicable state and local laws governing the prevention of tobacco sales to minors. I have met with my manager and reviewed the training videos regarding the sale of tobacco products to minors and understand that failure to adhere to federal, state and local rules and regulations could result in disciplinary action, including loss of my job, as well as the imposition of a fine. I also understand that Global Monte] In Group Corp. requires employees to ID all persons who attempt to purchase tobacco products. I agree to the following rules about the sale of tobacco products: • I will not sell any tobacco product to any person under the age of 21 ("Minimum Age"). • I will request a valid government -issued photo ID that includes a date of birth for anyone who attempts to purchase tobacco products. • 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 Minimum Age. If I think this is happening, I will not make the sale. • I will not accept a note (or any other implied permission) from any person under the Minimum Age to purchase a tobacco product for themselves or anyone else. In any of the above -referenced situations, management agrees to support my judgment and decision not to make the sale. I understand that failure to comply the terms of this agreement could lead to action by my employer, the FDA and/or st r ula rs that may jeopardize my employment and may involve the impos' io of fines n r legal do against me or my employer. E ployee's Sign ure Date cry �''iD�—_ 11 /13 /� 21�r Manager's Signature Date (This agreement will be maintained in your personnel file as part of your permanent employee record.) Rev. January 2020 FDA Tobacco Carding: Employee Compliance Form This document must be read and signed by all employees for their personnel files 1. Federal law requires a minimum age of 21 years for all retail tobacco purchases. Tobacco products include, among other things, e-cigarettes and other electronic nicotine delivery systems (ENDS). 2. To comply with FDA tobacco requirements, employees must review a government -issued photo ID that includes a birthdate from each customer who attempts to purchase tobacco products. 3. The FDA will enforce this regulation by contracting with state agencies. The FDA will enforce this regulation by contracting with state agencies. They will form inspection teams made up of an adult commissioned official and a 15-I6 year old who, together, will conduct undercover buy inspections at retail locations. The teenager will attempt to purchase a tobacco product while the adult observes the date, time & whether the sale was made. Violations will be sent to the FDA who will issue a wanting letter and/or fine. The FDA has the authority to impose tines up to $15,000 for each violation. 4. Community activists, anti -tobacco groups and parents will be watchdogs in enforcing the regulations. o They will be sending volunteers to stage tobacco purchases and test the carding regulations. o They will report directly to the FDA. o They may be handing out leaflets to store personnel. What you must do to abide by the regulations and eoudrtet yourself professiortally: a. Card everyone who attempts to purchase tobacco products. K If a customer objects, hand them a tear sheet flnm the counter, point to our signage or call a manager immediately for assistance. a If anyone from the media begins asking you any questions, call the manager immediately. Do not answer the questions. Anything you say is considered "on the record" and could appear in the newspaper, on the television, on the internet, or over the radio. d. If any anti -tobacco groups, community activists, parent groups etc., enter the store, call a manager immediately. Do not answer any questions. If they are handing out leaflets, accept them and give them directly to management. e. Always be polite, courteous, and professional. We do not expect you to engage in any discussions or arguments. Management will deal with this. I understand that failure to comply with the terms of this form could lead to action by my employer and/or the FDA that may jeopardize my employ ten and ma in. Ive a imposition of fines and/or legal action against me and/or my employer. �01 IDCAcI,n 1 / 17Cl Employee Print Employee Signature D• e Rev, January 2020 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. Drake Petroleum Company, Inc. Signature of Individual or Corporate Name By: 04-2236089 **Social Security No. (Voluntary) or Federal Identification Number 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:\Usem\sleite\Desktop\Scotts Docaments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc ' \ The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations r` _ Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02III-1750 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le ibiy Business/Organization Name: Global Montello Group Corp. 800 South Street, Suite 500 City/State/Zip: Waltham, MA 02453 Phone #: (781) 894-8800 Are you an employer? Check the appropriate box: Business Type (required): 1. © I am a employer with employees (full and/ 5. Q 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. [No workers' comp. insurance required] B. ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have 10.❑ Manufacturing employees. [No workers' comp. insurance required]** ❑ 4. ❑ Weno are a non-profit organization, staffed by volunteers, I LHealth Care with no employees. [No workers' comp. insurance req.] 12.❑ Other •*If the corporate officers have exempted themselves, but de corporation has other emplovees, a amrt:ers' compensation policy is required and such an organization should check box #l. 1 am an employer that is protviding workers' cornpensation insurancefor my employees. Below is fire policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lic. # W H9 - LA D - 4(ot r u d,- o1 b Expiration Date:( o Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under § 25A of MOL 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 hereby ce�y, under t{re pains and penalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be eouipleted by city or town official. City or Town: Issuing Authority (check one): IIOBoardof Health 2.❑ Building Department 5.❑Selectmen's Office 6.❑Other Contact Permit(License tk 3.❑City/I'own Clerk Phone #: ut vw.mass.gov/dia 411Licensing Board '1� R� CERTIFICATE OF LIABILITY INSURANCE °10/6/'020 ton/zozl 10/6/2020 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(ies) 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 endorsement(s). PRODUCER Lockton Insurance Brokers, LLC CA License #OF 15767 Three Embarcadero Center, Suite 600 San Francisco CA 94111 NAME CT PHONE FAX INC,No), MAIL ADDRESS, INSURERS AFFORDING COVERAGE NAICB (415) 568-4000 INSURER A: Libea Insurance Co Oration 42404 INSURED Global MDntello Group Corp. 1369067 INSURER B: 404 Wyman St, Ste 425 y Waltham MA 02451 INSURER C INSURER D: INSURER E : INSURER F: COVERAGES GLOPA01 CERTIFICATF NI IMRER- lane alvo 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 LTR TYPEOFINSURANCE A DL INSD SUBS INVID POLICY NUMBER POLICY EFF MMIDO POLICY UP fimmlnn LIMITS COMMERCIAL GENERAL LIABILITY NOTAPPLICABLE EACH OCCURRENCE $ )DDCXXXX CLAIMS -MADE ❑ OCCUR UA G T- PREMISES Me accunence $ )D0C x)Cx _ MED UP (Anyone ermn) $ XXgXXXX PERSONAL &ADV INJURY $ j[}( GEN'L AGGREGATE LIMIT APPLIES PER: PRO-JECT GENERAL AGGREGATE $ ]{xxxxXX PRODUCTS - COMPIOP AGO $x"DCxxx POUCYO 0 LOC OTHER $ AUTOMOBILE LIABILITY NOTAPPLICABLE COMBINED SINGLE LIMIT Ee actltlent $ X)D ANY AUTO BODILY INJURY(Perpemon) $ XXXXXXX OWNED SCHEDULED BODILY INJURY (Per accident) $ X.'c}ii( AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE eraddent $ X $ xxxxxxx UMBRELLA DAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXJK(X AGGREGATE $ }(XXJCfiXX EXCESS LIAR CLAIMS -MADE DED RETENTION$ $ X30C)XX A WORKERS COMPENSATION N X STATUTE 'ER" AND EMPLOYERVUASILITY YIN WA7-69D-460066-010 10/1/2020 10/1P2021 E.L. EACH ACCIDENT $ I000000 ANY PROPRIETOWPMTIVERIE%ECU pVE OFFICERIMEMBER EXCLUDED? FN N/A (Mendalory In NH) describe under E.L. DISEASE -EA EMPLOYEE $ 1000000 E.L.DISEASE -POLICY LIMIT $ 1000 00 D G6 DESCRIPTION OF OPERATIONS belm DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Reneft Schedule, mey be elteched It more space is mqulnd) 17045922 Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ea„vrtu AP t4v IDIU41 ©1988.201 I e ACORD name and logo are registered marks of ACORD All rights