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HomeMy WebLinkAboutMansfield Station Convenience, Inc. - 12/31/2021kalIkP �iofMansfield Town of Mansfield - Board of 2 y 2U2� sfield. MA 02048 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. NAME OF BUSINESS: 11ansFAI bT4Zk©f1C0A0�)tf i .eA(T-'Tv)C- ` LOCATION OF SALE OF TOBACCO PRODUCTS: ,Q14 `RumgkA hlemAe_ r'11.I.1,\2, ,o-pt' TELEPHONE AT LOCATION OWNER OF BUSINESS: ADDRESS OF OWNER: TELEPHONE OF OWNER: 611 9 4-3o' k EMAILADDRESS: '\Oyu 02VU e AA am If a corporation or partnership, give name, title, and home address of officers or partner. Am�n 6rea,6 owne-2 Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation A * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 , �j CT-3TNUMBER: A4tU{,'p L""� FEDERAL ID/SS NUMBER: aT_ 53060s, i SIGNATURE: DATE: 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. f7 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. PJ I must consent to unannounced, periodic inspections and compliance checks of the permitted retail establishment. jd` Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in licensed smoking bars, for onsite consumption only. F? 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. �d 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. 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. �d 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. �Z 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 ' tP ution of Tobacco and Nicotine Delivery Products" and agree to abide by it. Signature 1 \U r, Date 9-ark-,So Print Name qll(\�G 1"1• �_CtCAY 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. Han�,?Fdj brim exvien' *Tne Signature of Individual or Corporate Name ag— OC J�l 4 C ill' "Social Security No. (Voluntary) or Federal Identification Nuneber 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\sleae\Desktop\Scotts Documents\Food 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 Name: %ne- AA e 1rloin _Tyke Address: City/State/Zip:yjgy� , 1A MA o9i2a Phone #: G�j Are you an employer? Check the appropriate box: LF i am a employer with employees (full and/ or part-time).* 2Z I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 31 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.] Business Type (required): 5. ZRetail 6. Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (me[. real estate, auto, etc.) 8. Non-profit 9. Entertainment IO.R Manufacturing I LR Health Care 12.Q Other *Any applicant that checks box #] 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 #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name Insurer's City/State/Zip: Policy # or Self -ins. Lie. # Expiration 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 Investieations of the DIA for insurance coverage verification. I do hereby feyj fy,,fiiL4er the pains and penalties of perjury that the information provided above is trite and correct Phone #: (S1q, `1 A - 3216 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 �sssr??UrF '� �� Commonwealth of Massachusetts 9 Department of Revenue c� � t�}'�}ttj Geoffrey E. Snyder, Commissioner �w'N 'r4gpp3- mass.gov/dor po Letter ID: L0261088448 Notice Date: September 21, 2021 Account ID: SLS-20422280-008 SALES AND USE TAX REGISTRATION CERTIFICATE 'IIII"I'IIII'llllllllll'I'II'I'I'lll"I"IIII"IIII"IIII'�dlll MANSFIELD STATION CONVENIENCE, IN N MANSFIELD CONVENIENCE 214 RUMFORD AVE MANSFIELD MA 02048-2175 Attached below is your Sales and Use Tax Registration Certificate (Form ST-1). Cut along the dotted line and display at your place of business. You must report any change of name or address to us so that a revised ST-I can be issued. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this certificate. DETACH HERE Pss a� ErT MASSACHUSETTS DEPARTMENT OF REVENUE Form ST-1 b 3 y Sales and Use Tax Registration Certificate This registration must be posted and visible at all times. MANSFIELD STATION CONVENIENCE, INC. Account ID: SLS-20422280-008 MANSFIELD Certificate Number: 671135744 214 RUMFORD AVE MANSFIELD MA 02048-2175 This certifies that the taxpayer named above is registered under Chapters 62C, 64H and 64I of the Massachusetts General Laws to sell tangible personal property at retail or for resale at the address shown above. This registration is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2021 ySstUwF Commonwealth of Massachusetts Letter ID: L2005918912 j Department of Revenue Notice Date: September 21, 2021 Geoffrey E. Snyder, Commissioner Account ID: CRL-20422280-007 iFM owB' mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO 'III I 1 111' 11, 61111"' 111"111111111111111111111111111 r,11111111 MANSFIELD STATION CONVENIENCE, IN MANSFIELD CONVENIENCE 214 RUMFORD AVE MANSFIELD MA 02048-2175 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 "OSe MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T o�y'p]\ Retailer License for Sale of Cigars and Smoking Tobacco ��b�.Vr c.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. MANSFIELD STATION CONVENIENCE, INC. Account ID: CRL-20422280-007 MANSFIELD CONVENIENCE License Number: 1208006656 214 RUMFORD AVE MANSFIELD MA 02048-2175 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: September 21, 2021 Expiration Date: September 30, 2022 ysnt.i�tftcb.�. Commonwealth of Massachusetts Letter ID: L1422222528 �tr Department of Revenue Notice Date: September 22, 2021 Geoffrey E. Snyder, Commissioner Account to: CGL-20422290-003 ,eM.oe'f� mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES UM1ff mnQu=UMU1n1MWW = MANSFIELD STATION CONVENIENCE, IN MANSFIELD CONVENIENCE 214 RUMFORD AVE MANSFIELD MA 02048-2175 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 s sPc"t's r� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 n 2 Retailer License for Sale of Cigarettes y �bwt.ert This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. MANSFIELD STATION CONVENIENCE, INC. Account ID: CGL-20422280-003 MANSFIELD CONVENIENCE License Number: 1372895232 214 RUMFORD AVE MANSFIELD MA 02048-2175 'up Ord 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 revolted for failure to comply with state laws and regulations. Effective Date: September 22, 2021 Expiration Date: September 30, 2022 o s��UrF Commonwealth of Massachusetts LetterlD: LI79373241G 0-3iw�: rjy�y Department of Revenue Notice Date: September 27, 2021 Geoffi'ey E. Snyder, Commissioner Account to: EDL-20422280-010 i �45 rerys pee mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS tIIltPpwlttlilllhdllg1114tphhplthudnilghqptnu MANSFIELD STATION CONVENIENCE, IN MANSFIELD 214 RUMFORD AVE MANSFIELD MA 02048-2175 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 MASSACHUSETTS DEPARTMENT OF REVENUE Retailer License for Sale of Electronic Nicotine Delivery Systems This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. MANSFIELD STATION CONVENIENCE, INC. Account ID: EDL-20422280-010 MANSFIELD License Number: 1171568640 214 RUMFORD AVE MANSFIELD MA 02048-2175 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: September 27, 2021 Expiration Date: September 30, 2022 Mansfield Station Convenience,Inc In my training program, I will make sure to follow the policies and the guidelines and cover all the elements recommended in the tobacco training. 1: laws and penalties. 2: Adopt and enforce a written policy covering federal laws. 3: Age Verifications techniques. 4: Refusing sales S : testing employees to ensure that they have the required knowledge.