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Home My WebLink AboutTown Food Mart/AMDA Conv. Corp. - 12/31/2021- 1� m - -Y5 I() VT Lll Town of Mansfield Town of Mansfield - Boa a a Park Row 0M Mansfield, MA 02048 f, �y ILI" PERMIT NUMBER: 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. AMDA CONVENIENCE CORP NAME OF BUSINESS: LOCATION OF SALE OF TOBACCO PRODUCTS: TELEPHONE AT LOCATION: Dinesh OWNER OF BUSINESS: 242 CHAUNCY STREET, MANSFIELD, MA 02048 USA 508-982-8177 ADDRESSOFOWNER: 4 old stable dr , Mansfield, MA, 02048 508-982-8177 TELEPHONE OF OWNER: EMAIL ADDRESS: pdinesh68@yahoo.com If a corporation or partnership, give name, title, and home address of officers or partner. Ashok Patel, President, 6 Country Club Way, Norton, NIA ,02766 Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation all tobacco products that are for sale , out of customer reach and behind the counter. Make sure to arty pro uc s a are a igi a or sae in own. ec or every cus omer a oo s un er he age ff—-r.nrnnnrhi chock in fnr hirihdatn anrf to matchAhe-.DlctUre-on Id with the person presenting it. * Provide a copy of current Department of Revenue CT--3T Retail Excise Unit License. FEE:$150.00 CT-3r NUMBER: 1627666432 FEDERAL ID/SS NUMBER: 86-2829571 SIGNATURE: •Rem, DATE: 04/12/2021 A check mark signifies your understanding and agreement. I understand and agree that: It is against the law to sell any tobacco product and/or nicotine delivery product (e.g. e-cigarettes) to anyone less than 21 years of age, regardless of how old the person looks. Anyone selling tobacco products and/or nicotine delivery products must conclusively establish the customers 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. 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. 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. 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. Tobacco vending machines are prohibited. Non-residential Roll -Your -Own machines are prohibited. Blunt wraps are prohibited. Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or thirty days. 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. I must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices". I must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts Department of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license). I must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited". 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 and Nicotine Delivery Products" and agree to abide by it. Signature � Date 04/12/202 m Print Name Dinesh Patel The Commonwealth ofMassaehuselts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: AMDA CONVENIENCE CORP 242 CHAUNCY STREET City/State/Zip: MANSFIELD, MA, 02048 Phone #: 508-982-8177 Are you an employer? Check the appropriate box: Business Type (required): 1.❑ I 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. g. ❑ 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]* I1.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: J.K Olivieri Ills. Agency Insurer's Address: City/State/Zip: 64 East Grove St Middleboro.MA. 02346 Policy # or Self -ins. Lic. # TBD Expiration Date: 06/01 /2021 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investisations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct Signature: J)k&444 Date: 04-12-2021 WGi F�OTIM i`jl 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 TOWNF01 Up IU: CERTIFICATE OF LIABILITY INSURANCE DA0411612021TE Y) OM16/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(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 Corp dba - -- REVISION NUMBER: COVERAGES CERTIFICATE NUMBER; 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,_ _ _ _ INSRDOL TYPE OFINBURANCE UBR POLICY NUMBER POLICY ERF POLICY E%- LIMITS - _ _ 1,000,000 A COMMERCIAL GENERAL LIABILITY EACtLOCCURRENCE DA GE 0RENTED s e _ 50,000 CLAIMS -MADE DccuR O BE DETERMINED 06/0112021 0010112022 5,000 g Business Owners MEP EXP -e Person _ IDCIUded PERSONALSADVV,IJJURY _ S 2,000,000 _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL OGOREGATE $ 2,000,000 X POLICY L—] JEryLT LOC PRODUCTS COMP/OP AGa $ , OTH[ER'----. -... _.-. -. COMBISINGLE LIMIT _-- --- --_-. S AUTOMOBILE LIABILITY E eal)- ANY AUTO BODILY INJURYIPar Person OWNED SCHEDULED AHUgTOS ONLY --- AUTOS BODILY INJURY Pol accideN y� R q PetOaalde 1 AMAGE AUTOS ONLY HIlIOS QNF, --- - UMBRELLALIAB- -OCCUR --- - -- -- - -- EACH OCCU ENCE A-- AGGREGATE -_ EXCESS LAS CLAIMS -MADE DED-- RETENTION$ !� SER._E A WORKERS COMPENSATION AND EMPLOYERS` LIABILITY YIN OBE DETERMINED 06/01/2021 06/0112022 _ E EL EACH A�CIDENT� 1000,000 .,— ANY PROPRIETORIPARTNERIEXECUTIVE ��ppFIC,1%9M�T EXCLUDED? N] (Mandan NIA El I� EAEMPLgY€E „_ 1,000,000 $ -1,00 NO I1 es describe antler D S� 1 ON OP E Sbelaw _._. -_-. -__ EL OS sE. LC L -- - -. _ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD tat, Addltlonal Ramada; Schedule, may be attached If more space Is requited) CERTIFICATEHOLDE -..- _..-.. .......�..-_....... --.... -. _-.. _.. _... __.. _ --... TOWNMAO_. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THB POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 ACORD 25 (2016/03) W 11100-4V 10 fi Wm- yvRrviV'\.. IVn. .. „ynw ,vv.. - The ACORD name and logo are registered marks of ACORD TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. AMDA CONVENIENCE CORP Dinesh Patel Signature of Individual or Corporate Name 86-2829571 **Social Security No. (Voluntary) or Federal Identification Number 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:\Us=\sleite\Desktop\.Sceu's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc M ync�orcA t Commonwealth of Massachusetts Letter ID: LI3549R0160 �^ J`S •• J Department of Revenue Notice Date: April 21, 2021 Suyder, Couunissioner Account ID: CR1,20267059-007 ^` Geoffrey E. �r6NTltF4' mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO IPtllttttphqutlltnp117pquhPdldltplttt11e1111'lllll AMDA CONVENIENCE CORP ® TOWN FOOD MART ® 242 CHAUNCY ST N® MANSHELDMA 02048-1256 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-31). 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 �P54acuus� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco ° a �<1rF,vt r`.�.4� This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. AMDA CONVENIENCE CORP Account ID: CRL-20267059-007 TOWN FOOD MART License Number: 941766656 242 CHAUNCY ST MANSFIELD MA 02048-1256 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: April 21, 2021 Expiration Date: September 30, 2022 -PygPl tltLr�. Commonwealth or mossachusetts Department of Revenue ° { Geoffrey E. Snyder, Commissioner mass.gov/dor 101 Letter ID: L1092317632 I '" Notice Date: April 22, 2021 RI Account ID: CGL-20267059-004 RETAILER LICENSE FOR SALE OF CIGARETTES hpttlltlpltlmtulppl1llPllPlllllllllhllttlllttdllllvl AMDA CONVENIENCE CORP TOWN FOOD MART m 242 CHAUNCY ST MANSFWLD MA 02048-1256 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 �Pgn t.IF�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes '1,*v �a� This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. AMDA CONVENIENCE CORP Account II): CGL-20267059-004 TOWN FOOD MART License Number: 1627666432 242 CHAUNCY ST MANSFIELD MA 02048-1256 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: April 22, 2021 Expiration Date: September 30, 2022 p• p gsMaltt,e Commonwealth of Massachusetts Letter to: 1,0147020608 iT J Department of Revenue Nofioe Datc: April 21, 2021 Ge9gkey E. Snyder, Commissioner Account to: EDL-20267059-013 rBlyr pS mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS llttr�kryntdtlhdlllll"°hN"1911114h'd�hdtlll�rrnl ® AMDA CONVENIENCE CORP g ® TOWN FOOD MART 242 CHAUNCY ST ® MANSFIELD MA 02048-1256 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 gPCHtsE MASSACHUSETTS DEPARTMENT OF REVENUE o A Retailer License for Sale of Electronic Nicotine Delivery Systems PI This license must be posted and visible at all times. The sale of �'Fn roFs tobacco products to anyone under 21 years of age is prohibited. AMDA CONVENIENCE CORP Account tD: EDL-20267059-013 TOWN FOOD MART License Number: 606222336 242 CHAUNCY ST MANSFIELD MA 02048-1256 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: April 21, 2021 Expiration Date: September 30, 2022 Photos must be visually matched to the customer purchasing and licenses scanned into the register. Driver's License is to be scanned into the register system. All other identification from the acceptable list will require manual entry of the date of birth listed on the documentation. 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. follow this Employee Store Operator Signature result in disciplinary action up to and including 4/12/2021 Date 4/12/2021 Date (This form will be maintained in your personnel file as a part of your permanent employee record) Photos must be visually matched to the customer purchasing and licenses scanned into the register. Driver's License is to be scanned into the register system. All other identification from the acceptable list will require manual entry of the date of birth listed on the documentation. 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 twenty-one (21) years. I also understand that if I fail to follow store policy and local and state 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, 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 termination.'` - Employee Signature Store Operator Signature disciplinary action up to and including Lk-- Zr _a Date /-,k,12-2 Date (This form will be maintained in your personnel file as a part of your permanent employee record)