HomeMy WebLinkAboutCanoe River Campground (Starlin Inc.)- 12/31/2021Town of Mansfield
TO A, ` of Martsfield`Z., q r^d a, f Health 6 Park Row
ov Mansfield, MA 02048
PERMIT NUMBER: W& a O
Applic atron fv the Stile 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: ea ne?_a ki rr C4m)'07 �_J1�10�
LOCATION OF SALE OF TOBACCO PRODUCTS: 137 M;/ Il ST
TELEPHONE AT LOCATION: 5-08 — 331 - Gy��
OWNER OF BUSINESS: ikr ll n The
ADDRESS OF OWNER: 37h l d I ST
TELEPHONE OF OWNER: SDS 33!7
EMAIL ADDRESS: tp L'LIfIOL�hI VCf pIh
If a corporation or partnership, give name, title, and home address of officers or partner.
Pies)d V.-I 131' 691,11 5 T, wwr 5fie i, nizi --Adevirr C'ctrrL�ll,
Sp�rw �rr� lt1Sm;ll _S"T YYLrnrfi lct W f✓l sx %4r.✓m rS1t"r—, Tl^easure+`,�S i21Ved
documentation
/30 4-k wi t t h t' of vnc
product sales training. Attach employee training
m relic e-wa.( O* lje-rf 'f
* Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License.
FEE: $150.00
CT-3TNUMBER: aszyyq/60
FEDERAL ID/SS NUMBER: 6412 37 SS % 1 _
SIGNATURE:
DATE:
f
A check mark signifies your understanding and agreement. I understand and agree that:
�A 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.
I/ Anyone selling tobacco products and/or nicotine delivery products must conclusively establish the customer's
age as over 21 years old, by means of government -issued photographic ID.
Anyone selling tobacco products and/or nicotine delivery products must check and verify official government
photo ID for anyone less than 27 years of age.
I must consent to unannounced, periodic inspections and compliance checks of the permitted retail
establishment.
U2/Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in
/licensed smoking bars, for onsite consumption only.
IX Unflavored E-cigarettes with nicotine content over 35 mg/per ml can only be sold in adult -only retail tobacco
stores and licensed smoking bars.
Flavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite
consumption only.
i Self-service tobacco product and/or nicotine delivery product displays from which the customer may select
/products are prohibited.
I The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited.
Ltd I may not distribute any free samples of tobacco products or nicotine delivery products (e.g. e-cigarettes) and I
may not accept any means, instruments or devices that allow for the redemption of tobacco products for free or
td'/cigarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue.
Tobacco vending machines are prohibited.
LId Non-residential Roll -Your -Own machines are prohibited.
Ilk/Blunt wraps are prohibited.
V Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or
thirty days.
V/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.
I����I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices".
4Y 1 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).
Lw//l must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited".
try 11 must display signs provided by the Board of Health that discloses referral information about cessation.
Ise' 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 Distr` ution of Tobacco nd Nicotine Delivery Products" and agree to abide by/it.
Signature \ _ 4 7 Date Ff 9 r✓
Print Name dja vPity rr"),n S'a ly 47 S
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.
`- / cty — t 1 to -1 N C p....... j_yze Gb�f
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
O y 9-3 '7 � 22 /
'Social Security No. (Voluntaq) 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\Scoa's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, HA 02111
Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: S/car 10c DOO"Cctnoe aQ[ver-Cr-nmpg I'
D 6/ hG
Address: i 3 %1 i�� Sl r e.e `T
o Dry Phone #: 5 FZ3 `; c7 6`iZ9
Are you an employer? Check the appropriate box:
Business Type (required):
I. P t am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no
7• ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
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]*
1 l.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
��
12. [Other r ram" ' 7 t U h
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I are an employer that is providing workers' compensation insurance for my employees. Below is ilne policy information.
Insurance Company
Insurer's
City/State/Zip: _
610 :1
4
Policy # or Self -ins. Lic. # 6 2�� lJ rJ `��� q5 j1� %S CI (� Expiration Date: S a- _
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (late).
Failure to secure coverage as required under Section 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification. _
I do hereby certify, under the pains a penalties o!f�erjury that the information provided above is true and correct.
Signature: tnLi C \ i �,• _ -- Date: // L9De)
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.masagov/dia
VDAC
49
URICH WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
OLICY NUMBER: (6ZZUB-0495N75-0-20 )
RENEWAL OF (6ZZUB-0495N75-0-19)
INSURER: AMERICAN ZURICH INSURANCE COMPANY
NCCI CO CODE: 1 7965
1.
INSURED: PRODUCER:
STARLIN, INC. DBA CANOE RIVER C & S INSURANCE AGENCY
CAMPGROUNDS 190 CHAUNCY STREET
137 MILL ST MANSFIELD MA 02048
MANSFIELD MA 02048
Insured is A CORPORATION
Other work places and identification numbers are shown In the schedule(s) attached.
2. The policy period is from 05-13-20 to 05-13-21 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: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 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: 04-07-20 SS
OFFICE: RMD ZURICH 809
PRODUCER: C & S INSURANCE AGENCY
75W2J
ST ASSIGN: MA
013508
y�cerrs T MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
T
Retailer License for Sale of Cigarettes
Froro4s This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
STARLIN INC Account ID: CGL-11353826-007
CANOE RIVER CAMPGROUND GENERAL STORE License Number: 1252444160
137 MILL ST
MANSFIELD MA 02048-3268
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
Select Page
Due to the new state law regarding tobacco products, the online training is in the process of revision and
currently unavailable. We apologize for any inconvenience this may cause.
Contact
For any questions regarding a tobacco issue in your community please contact:
Sarah McColgan, Tobacco Control Director
(413)636-6418
smccolgan@mhoa.com
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CANOE 1;11tER CAMMROUND
137 Mill Street, Mansfield, MA 02048
Tobacco Sales Policy
OBJECTIVE: That all store employees follow all laws and procedures of
this policy related to the sale of tobacco products. A tobacco product is any
product containing or made from tobacco or nicotine. It can be smoked,
chewed, absorbed, dissolved, inhaled, snorted, sniffed, or ingested.
These laws are designed to make regulated tobacco products less accessible
and less attractive to youth. It is our responsibility as a retailer and members
of the community to prevent the sale of tobacco to anyone under the age of
twenty-one (21).
PROCEDURES:
•3 This policy will be reviewed with all new employees before they can
operate a cash register and sell tobacco products.
❖ All store employees will watch the MHOA online training video.
They will watch it on an annual basis prior to previous year
expiration.
❖ All store employees will read the applicable Board of Health
regulations and state and federal laws.
❖ A valid form of identification will be required as proof of age for all
tobacco purchases. No expired identification will be accepted.
❖ All store employees will check the photo ID of everyone under age 27
who attempts to purchase tobacco products. Photos must be visually
matched to the customer purchasing, and the birth date checked
against the digital calendar supplied by This is Our Watch. IDs should
be checked for any kind of tampering.
Acceptable forms of ID are:
Valid Massachusetts and Out of State License
Valid Massachusetts State ID or Liquor Card
Valid US Passport
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, state, and federal 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 form of
ID, 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.
- YA'" pt% Q !� t� ==-------- --�� -s- a - -------------
Employee Signature Date
--- -+'em ------ --� � = = 0
Store Operator Signature Date
This form will be maintained in your personnel file as a part of
your permanent employee record.
CANOE RIM CAMPGROUND
137 Mill Street, Mansfield, MA 02048
Tobacco Sales Policy
OBJECTIVE: That all store employees follow all laws and procedures of
this policy related to the sale of tobacco products. A tobacco product is any
product containing or made from tobacco or nicotine. It can be smoked,
chewed, absorbed, dissolved, inhaled, snorted, sniffed, or ingested.
These laws are designed to make regulated tobacco products less accessible
and less attractive to youth. It is our responsibility as a retailer and members
of the community to prevent the sale of tobacco to anyone under the age of
twenty-one- (21).
PROCEDURES:
❖ This policy will be reviewed with all new employees before they can
operate a cash register and sell tobacco products.
❖ All store employees will watch the MHOA online training video.
They will watch it on an annual basis prior to previous year
expiration.
:• All store employees will read the applicable Board of Health
regulations and state and federal laws.
•S A valid form of identification will be required as proof of age for all
tobacco purchases. No expired identification will be accepted.
❖ All store employees will check the photo ID of everyone under age 27
who attempts to purchase tobacco products. Photos must be visually
matched to the customer purchasing, and the birth date checked
against the digital calendar supplied by This is Our Watch. IDs should
be checked for any kind of tampering.
Acceptable forms of ID are:
Valid Massachusetts and Out of State License
Valid Massachusetts State ID or Liquor Card
Valid US Passport
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, state, and federal 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 form of
ID, 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
ate: ----
Store Operator Signature
Date
-1L-- -- = ----------
Date
This form will be maintained in your personnel file as a part of
your permanent employee record.