HomeMy WebLinkAboutCanaan Fuels - 12/31/2021#�-7�07 1509
Town of Mansfield
Town of 'Ma isfield - Board of'Health 6 Park Row
Mansfield, MA 02048
E I OCT E� PERMIT NUMBER: 7
E Application for the Sale of Tobacco Products
"ereby 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: co-riao—rl 6-r0LCP Inc., db0. C0-*jCa-n_ T_l.4LeIS
LOCATION OF SALE OF TOBACCO PRODUCTS: C� Pia 51 [/�. $£i CJ.G�AA _0204$
TELEPHONE AT LOCATION: 509 — 33ct ' _ 33_I-)
OWNER OF BUSINESS: ,�am2-K __1-�QneLq
ADDRESS OF OWNER: 53 CDur-1- S+.,__-Ca(kn+o , _MA _QZ_1Bt2__
TELEPHONE OF OWNER:
EMAIL ADDRESS: rtCU1Qh.FirSkCctPi�a�gro eP_S0.m�ll r^�jM�ul•�m
If a corporation or partnership, give name, title, and home address of officers or partner. �J
Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training
documentation
please ser c {-
" Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License.
FEE: $150.00 flia.r� cts
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CT-3T NUMBER: 15q l q(pq L, tpq
FEDERAL ID/SS NUMBER: Z(o- 3 8 cI S (o C( 3
SIGNATURE„ y f
DATE: ( 0( H 12_ o 2 0
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature of Individual or Corporate Name
* z& 3g9 61Pg3
"Social Security No. (Voluntary) or Federal
Identification Nuutber
By: Corporate Officer (Mandatory, if Applicable)
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\Scotts DocumereMood Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization N
Address: ) `J7 Pro �+.
Phone #: ,50$ - 339 - 3317
Are you an employer? Check the, appropriate box: Business Type (required):
1.V I am a employer with employees (full and/ 5. [� Retail
or pail -time). * 6. El 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] 8. ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers
with no employees. [No workers' comp. insurance req.] 121A Other C1a1 ! COn VCn f GtlCe
*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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: T M A I i1 f V YGtt'! ct Co m JL (d
Insurer's
City/State
Policy # or Self -ins. Lic. # WC MA 6600 Z 07 00 Expiration Date: ZLl U Z
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 hereby certify, carder the pains and ueyaltie -af peejtoy that the information provided above is trite and correct.
Phone#: U11— 907- 9917
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
Workers' Compensation and Employers' Liability Insurance Policy
MA WC Assigned Risk Pool Assigned Carrier: PMA Ins Co (Stock) - NCCI Carrier Code 11916
Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website ormarks.com Phone (612) 902-9240 Toll Free (877) 347-3596 Fax (612) 902-9241
INFORMATION PAGE — A/R
Renewal of No: NEW Policy Number: WCMA000020700
Coverage ID: 0883397
ITEM 1. NAMED INSURED AND MAILING ADDRESS: Risk ID/Comb ID: 0883397
CANNAN GROUP INC Date of Mailing 02/20/2020
157 PRATT STREET
MANSFIELD, MA 02048
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See Schedule of Names and Locations)
ITEM 2. POLICY PERIOD: From: 02/14/2020 To: 02/14/2021
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3 COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here:
MA
91
C.
RE
Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of
liability under Part Two are:
Bodily Injury by Accident: $1,000,000 each accident
Bodily Injury by Disease: $1,000,000 policy limit
Bodily Injury by Disease: $1,000,000 each employee
Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
WC 20 03 06 B
This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules,, Classifications, Rates -and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject
to verification and change by audit. See Classification Schedule
Minimum Premium $266
Required Deposit Premium $4,464
Date: 02/20/2020
Total Estimated
Annual Premium $5,838
�
Countersigned by: /
Producer's Name: ROGER KEITH & SONS INSURANCE AGENCY INC
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY
Commonwealth of Massachusetts Letter ID: LI229073984
p
b - - I•
• • IF' F�
Department of Revenue Notice Date: October 15, 2020
Geoffrey E. Snyder, Commissioner Account ID: CRL-11310564-009
L't C
iFh7w"t-
mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
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CANNAN GROUP INC
CANNAN FUELS
N= 157 PRATT ST
MANSFIELD MA 02048-1555
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
4rct't'Ser MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
J
b �, Retailer License for Sale of Cigars and Smoking Tobacco
,F.� or4� This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
CANNAN GROUP INC Account ID: CRL-11310564-009
CANNAN FUELS License Number: 549464064
157 PRATT ST
MANSFIELD MA 02048-1555
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 15, 2020 Expiration Date: September 30, 2022
Commonwealth or Massachusetts
Department of Revenue
�}' I Ceoffrey E. Snyder, Commissioner
sNTU1`c9F8 mass.gov/dor
pro
Letter ID: L1447075392 .3
Notice Date: October 19, 2020
Account ID: CGL-11310564-006
RETAILER LICENSE FOR SALE OF CIGARETTES
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CANNAN GROUP INC
o— CANNAN FUELS
157 PRATT ST
MANSFIELD MA 02048-ISS5
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
55^c"osF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
Retailer License for Sale of Cigarettes
�roroe F�a� This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
CANNAN GROUP INC Account ID: CGL-11310564-006
CANNAN FUELS License Number: 804734976
157 PRATT ST
MANSFIELD MA 02048-1555
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 19, 2020 Expiration Date: September 30, 2022
Town of Mansfield
Board of Health
PERMIT
To license the:
Sale of Tobacco & Nicotine Delivery Products
In accordance with Regulations promulgated under authority of'Chapter 94,
Section 3o5A and Chapter in, Section 5 of the General haws, a Permit is hereby
granted to:
Sammy Kanan
Whose place of business is:
Canaan Fuels
located at
157 Pratt Street
In the event of change in the permit holder, the Health
Department must be notified of change within io business days.
Permit Expires: 12/31/2020
License Number: T-13
M� N� Pees Paid: $ 150.00
BOARD OF HEALTH
THIS PERMIT SHOULD BE POSTED CONSPICUOUSLY
A check mark signifies your understanding and agreement. I understand and agree that:
L✓ 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.
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.
rK I must consent to unannounced, periodic inspections and compliance checks of the permitted retail
establishment.
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.
IV Flavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite
consumption only.
1-K Self-service tobacco product and/or nicotine delivery product displays from which the customer may select
products are prohibited.
Y'�The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited.
I may not distribute any free samples of tobacco products or nicotine delivery products (e.g. e-cigarettes) and I
may not accept any means, instruments or devices that allow for the redemption of tobacco products for free or
cigarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue.
C� Tobacco vending machines are prohibited.
IV' Non-residential Roll -Your -Own machines are prohibited.
LV Blunt wraps are prohibited.
Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or
thirty days.
L� I may not allow any employee to sell tobacco products or nicotine delivery products (e.g. e-cigarettes) until such
employee reads this regulation, state and federal laws regarding the sale of tobacco and signs a statement, a
copy of which will be placed on file, that he/she has read the regulation and applicable state laws.
Sr' I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices".
G/ 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,
I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited".
SY 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.
I have received, read and understand the Board of Health regulation "Regulation Affecting Smoking and the Sale,
Vending, and Distribution of Tobacco- e-Detivery.Products" and agree to abide by it.
Date l()P y � Z� oZ z o
Print Name V am-e_I-L tf:�a r l x,.
MASSACHUSETTS GENERAL LAWS
CHAPTER 270 SECTION 6
TOBACCO SALES TO MINORS
"Whoever sells a cigarette, chewing tobacco, snuff or any tobacco in any of its forms
to any person under the age of eighteen or, not being his parent or guardian, gives a
cigarette, chewing tobacco, snuff or tobacco in any of its forms to any person under
the age of eighteen shall be punished by a fine of not less than one hundred dollars
for the first offense, not less than two hundred dollars for the second offense and not
less than three hundred dollars for any third or subseq>;}ent offense."
I understand that Massachusetts law prohibits the sale of tobacco products to anyone under the
age of 18; however, in the town/city I am working I am prohibited from selling tobacco products
to anyone under age 21. I understand that if I fail to follow company policy and town/city law
about the sale of tobacco to minors I will lose my job and may be fined.
I agree to the following rules about the sale of tobacco products:
1. I will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis,
or any other form of tobacco, to any person under the age of 21.
2. I will ask for photo identification (I.D.) of any person attempting to buy a tobacco
product. If there is any doubt about the person's age, I will not make the sale.
3. 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 judgement not to make the sale in any of the cases
described above.
Employee's Printed Name
Employee's Signature
Location Working
2-3D- 20
Date
-3� -2nad
Regional Manager's Signature Date
(This agreement will be maintained in your personal file as part of your permanent employee record.)
MASSACHUSETTS GENERAL LAWS
CHAPTER 270 SECTION 6
TOBACCO SALES TO MINORS
"Whoever sells a cigarette, chewing tobacco, snuff or any tobacco in any of its forms
to any person under the age of eighteen or, not being his parent or guardian, gives a
cigarette, chewing tobacco, snuff or tobacco in any of its forms to any person under
the age of eighteen shall be punished by a fine of not less than one hundred dollars
for the first offense, not less than two hundred dollars for the second offense and not
less than three hundred dollars for any third or subsequent offense."
I understand that Massachusetts law prohibits the sale of tobacco products to anyone under the
age of 18; however, in the town/city I am working I am prohibited from selling tobacco products
to anyone under age 21.1 understand that if I fail to follow company policy and town/city law
about the sale of tobacco to minors I will lose my job and may be fined.
I agree to the following rules about the sale of tobacco products:
1. I will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis,
or any other form of tobacco, to any person under the age of 21.
2. I will ask for photo identification (I.D.) of any person attempting to buy a tobacco
product. If there is any doubt about the person's age, I will not make the sale.
3. 1 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 judgement not to make the sale in any of the cases
described above.
Employee's Printed Name
Employee's Signature
1 Ao1Vxst1 IJ
Location Working
a -3
Date
Regional Manager's Signature Date
(This agreement will be maintained in your personal file as part ofyour permanent employee record.)