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HomeMy WebLinkAboutDubs Liquors (A. Debucas, LLC) - 12/31/2021Town gfMansfaeld - Board of Health PERMIT NUMBER: q -3 73 ®is® f m Town of Mansfield 6 Park R w Matisfie A 0204E 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: A u S+k n'� e� u 0@ S LC LOCATION OF SALE OF TOBACCO PRODUCTS: 3o C ho�i n c� 57t. "I on s��e Id ht A o Zo 4 $ TELEPHONE AT LOCATION: SOS) 33 9 - 3 U ! 4 OWNER OF BUSINESS: YhA S 'T � 11 -- ADDRESS OF OWNER: s O dos }on Tp Le &I . Sh reloS �u rvl O f S'4�- TELEPHONE OF OWNER: SO - —t 5S- I 2.3 EMAIL ADDRESS: 0.SI<oW�rtt drin�G�e0.F. com If a corporation or partnership give name, title, and home address of officers or partner. Arlo S�CowyrcL- CFO o v�oy\sor. YI'\r` Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation J -- * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE:$150.00 1,6'b 142'ZoLF0 �'�nreil2 CT-3TNUMBER: ay1,1 (Lq� �ot CeG FEDERAL ID/SS NUMBER: — 4� pcj b 2 V 6 SIGNATURE: DATE: _ �l lLo TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. ) u 5�'k (,\1) A L/ m5 LCC Signature of Individual or Corporate Name By: orpora e Officer (Mandatory, if Applicable) 0-Icy/02g8 *"Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe Business Type (required): 5. F1 Retail 6. Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. Entertainment 10.❑ Manufacturing I I.[] Health Care Dn 12.0Other Lryor Lo n2neeuo,( *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensau policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # I. 1 one an employer that is providing workers' compensation insurance for my employees. Below is flee policy information. Insurance Company Name: f A Re+o-*% ( t t ylere.[L ILA!S WC Groutn _Trir+ Insurer's Address::0T Pu 6$S ei ZZZ, 9 22L City/State/Zip: 6r6L,n-iree thA oZ1$� Policy # or Self -ins. Lie. # l� 005Q 331 32[ 20 Expiration Date: v t /L�Z I 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 Q^fo surance coverage verification. 1 do hereby pains and penalties ofperjury that flee information providerl above is tree and correct Official use only. Do not write in this area, to be completed by city or town official. City or Town: The Connmonwealill 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 Name: A u s ti n !� e u q ( LC Address: 3 �D C k au rl_ ec t Sfi - City/State/Zip: A n S S, e l� mlq o2oq Phone #: SO8.33 q,3 `(S`4 Are you an employer? Check the appropriate box: I.® I am a employer with 19 employees (full and/ or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4.� We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 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 Phone www.mass.gov/dia Insurer ID No (s): 34355 MA Retail Merchants WC Group Inc. PO Box859222-9222 Braintree, MA 02185-0000 Workers Compensation and Employers Liability Insurance Policy Carrier Policy M Policy Period 014005033232120 01/01/2020to 01/01/2021 Information Page FEIN: 273863971 Renewal Policy Carrier Prior Polic M 014005033232119 Item 1: Named Insured and Address Agency MAS Inc First American Insurance Agency, Inc. 50 Boston Turnpike 510 Front Street Shrewsbury, MA 01545 Chicopee, MA 01013 Other Workplaces Not Shown Above: See Schedule of Operations Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation FederalID#: 273863971 Risk ID: 000000000 NCCl/ Bureau M 34355 Unemployment ID M File #: 014005033232120 Item 2. Policy Period The policy period is from 12:01 AM on 01/0112020 to 12:01AM on 01/01/2021 based on the insured's mailing address time zone. Item 3. Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: 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 $ 500,000.00 each accident Bodily Injury by Disease $ 500,000.00 policy limit Bodily Injury by Disease $ 500,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15), WC000308(04/84), WC000414A(01/19), WC000422B(01/15), NOE(01/01), WC200102(01/14), WC200301(04/84), W0200302A(09/08), WC200303D(08/10), WC200306B(06/13), WC200405(06/01), WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code # Premium Basis Rate Per $100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $ 260.00 $ 5,970.00 $ 5,970.00 $ 0.00 $ 0.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: r� Braintree MA 02185-0000 72-27-2019 Form # WC 00 00 01 C (Ed. ) 0 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 1 of 1 Insurer ID No (s): 34355 MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185-0000 Workers Compensation and Employers Liability Insurance Policy Carrier Policy#: Polic Period 014005033232120 O1/01/2020to 01/01/2021 Information Page FEIN: 273863971 Renewal Policy Carrier Prior Policy#: 014005033232119 Item 1: Named Insured and Address Agency MAS Inc First American Insurance Agency, Inc. 50 Boston Turnpike 510 Front Street Shrewsbury, MA 01545 Chicopee, MA 01013 Schedule of Covered Workplaces Other Workplace MAS Inc FEIN: 471090248 Austin Debucas, LLC Effective Date: 01/01/2020 30 Chauncy Street NAICS Code: 445310 Mansfield, MA 02048 Division #: 3 Workplace #: 0000000001 Mailing: 50 Turnpike Shrewsbury, MA 01545 MASFANNON, LLC 212 North Main Street Natick, MA 01760 Mailing: 50 Boston Turnpike Shrewsbury, MA 01545 FEIN: 474915831 Effective Date: 01/01/2020 NAICS Code: 445310 Division #: 5 Workplace #: 0000000001 State Risk ID #: 000969387 MAS Inc Effective Date: 01/01/2020 20 Boston Turnpike NAICS Code: 541611 Shrewsbury, MA 01545 Division #: 0 Workplace #: 0000000001 Mailing: State Risk ID #: 000969387 50 Boston Turnpike Shrewsbury, MA 01545 MAS Inc. FEIN: 043496483 landoli Austin's II, Inc. Effective Date: 01/01/2020 20 Boston Turnpike NAICS Code: 445310 Shrewsbury, MA 01545 Division #: 2 Workplace #: 0000000001 Mailing: State Risk ID #: 26666 50 Turnpike agamore Road Shrewsbury, MA 01545 Form # WC 00 00 01 C (Ed.) © Copyright 2013 National Council on Compensation Insurance, Inc, All Rights Reserved. Page 1 of 2 Insurer ID No (s): 34356 MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185-0000 Workers Compensation and Employers Liability Insurance Policy Carrier Policy #: Policy Period 014005033232120 01/01l2020to 01/01l2021 Information Page FEIN: 273863971 Renewal Policy Carrier Prior Polic #: 014005033232119 Item 1: Named Insured and Address Agency MAS Inc First American Insurance Agency, Inc. 50 Boston Turnpike 510 Front Street Shrewsbury, MA 01545 Chicopee, MA 01013 Other Workplace MAS Inc 15 Sagamore Rd Worcester. MA 01605 Form # WC 00 00 01 C (Ed. ) Schedule of Covered Workplaces Effective Date: 01/01/2020 NAICS Code: 541611 Division #: 0 Workplace #: 0000000004 0 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 2 of 2 yssolrF� Commonwealth of Massachusetts N Department of Revenue Ge offrey E. Snyder, Commissioner '�M pep mass.gov/dor ono Later ID: L1936352832 1512 Notice Date: September 9, 2020 Account ID: CGL-12086867-005 RETAILER LICENSE FOR SALE OF CIGARETTES III hhl'1'h1'111pill Jill 'dlPuIII III III dd'I'hhl'''lllul AUSTIN DEBUCAS LLC DUBS'S LIQUORS & FINE WINES 50 BOSTON TURNPIKE ROAD SHREWSBURY MA 01545-3914 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 MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes ,FN:o This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. AUSTIN DEBUCAS LLC Account ID: CGL-12086867-005 DUBS'S LIQUORS & FINE WINES License Number: 1331927040 30 CHAUNCY ST MANSFIELD MA 02048-1958 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 eSK "r:rr Conlmonwrdth of Massachusetts Letter ID: LOS 11911488 � M Department of Revenue Notice Data September 4, 2020 7 Geoffrey E. Snyder, Conunissialcr Account ID: CRL-12086867-008 \T OF I11a5S.60VPoor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO Illlll�l�l�tlllllllllltttltl�'III'llll"I���'�I'�II"Ill���l�tll� AUSTIN DEBUCAS LLC DUBS'S LIQUORS & FINE WINES 50 BOSTON TURNPIKE ROAD SHREWSBURY MA 01545-3914 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 MassTaxConnectaccount at rnass.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 r'Ssat+°Ssr MASSACHUSETTS DEPARTMENT OF REVENUE F Form CT-3T m19 t y Retailer License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. AUSTIN DEBUCAS LLC Account ID: CRL-12086867-008 DUBS'S LIQUORS & FINE WINES License Number: 29771776 30 CHAUNCY ST MANSFIELD MA 02048-1958 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 t, 2020 Expiration Date: September 30, 2022 Age Restricted Products Policy and Procedures: Tobacco Austin Debucas LLC, 30 Chauncy Street, Mansfield, MA 02048 Every Employee at this location has the LEGAL and MORAL responsibility to control the sale and distribution of age -restricted items to ensure these items do not get sold to minors! TOBACCO PRODUCT SALES POLICY Objective: That all store Employees follow all laws and procedures of this policy related to the sale of tobacco products including: cigarettes, smokeless tobacco, loose tobacco, pipe tobacco, rolling papers, cigars, e-cigarettes, vape and lighters. The minimum age to purchase tobacco products is twenty one (21) years of age. 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). PROCUDURES: 1. This policy will be reviewed with all new Employees before they can operate a cash register and sell tobacco products. 2. A valid form of identification will be required for all tobacco purchases regardless of age or frequency of customer visits. Acceptable forms of id are as follows: Valid Massachusetts License Valid Massachusetts state issued Id Valid US passport Valid Out of State License if it passes our ID Checker NO EXPIRED IDENTIFICATIONS WILL BE ACCEPTED 3. Photos must be visually matched to the purchaser. 4. If it is suspected that someone is purchasing tobacco for anyone under the age of twenty-one (21) a valid ID will be required from all members of the party. I have read and understand the Mansfield Board of Health Regulations which prohibits the sale of tobacco and nicotine delivery products to anyone under the age of 21. 1 also understand that if I fail to follow store policy and local and state laws about the sale of tabacco 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 and is unable to provide an acceptable form of ID when asked, 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 Dat 64 er ature Date This form will be maintained in your personnel file as a part of your permanent employee record. 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 and is unable to provide an acceptable form of ID when asked, 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. LZ 4u,r ' LL Employefi signature Store Operat6rsig'netufe Da i � p Date This form will be maintained In your personnel file as a part of your permanent employee record. 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 and is unable to provide an acceptable form of ID when asked, 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 nature p signature Store Ope.,t sigrta ure PLI Date Date This form will be maintained in your personnel file as a part of your permanent employee record. 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 and is unable to provide an acceptable form of ID when asked, 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. lion up to and including termination. Date 1L Date This form will be maintained in your personnel file as a part of your permanent employee record. 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 and is unable to provide an acceptable form of ID when asked, 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 s' tug - ---, re Store Opieratoff signature Date )l I I 'l 1 2 Date This form will be maintained in your personnel file as a part of your permanent employee record. 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 and is unable to provide an acceptable form of ID when asked, I will not make the sale. 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 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. YC Erfiployee signature Date / f stora,ov ra r' natu . re Date / This form will be maintained in your personnel file as a part of your permanent employee record. 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 and is unable to provide an acceptable form of ID when asked, I will not make the sale. I will not accept a note from an adult giving permission to a person under the age of 21 to buy tobacco products. In turn, Management agrees to support my judgment not to make the sale In any of the cases described above. Failure to follow this policy may result in disciplinary action up to and including termination. Employee signature Date Store--arperator signature Date I This form will be maintained in your personnel file as a part of your permanent employee record.