TOWN OF BURLINGTON BOARD OF HEALTH 61 CENTER STREET, BURLINGTON, MA 001803 781-270-1955 Fax 781-273-7687 APPLICATION FOR RETAIL TOBACCO SALE PERMIT The undersigned hereby applies for a permit in accordance with the provisions of the Board of Health Regulations relating thereto: REGULATIONS AFFECTING SMOKING IN CERTAIN PLACES. Fee: $100.00 Date: 1. 2. NAME OF ESTABLISHMENT ADDRESS OF ESTABLISHMENT 3. TYPE OF BUSINESS Grocery Store Liquor Store Convenience Store Pharmacy Gas & MiniMart Restaurant_ Gas only Bar/Tavern_ Other (Describe) 4. NAME OF ESTABLISHMENT OWNER 5. ADDRESS OF OWNER 6. HOMEPHONE:; BUSINESS PHONE: 7. NAME OF MANAGER (If Different From Above) MA DEPARTMENT OF REVENUE TOBACCO SALES PERMIT NUMBER Emergency Response Person: Cell # Home # Dates and Hours of Operation: Type(s) of Tobacco to be sold: Cigarettes Dip/Chew Pipe Tobacco Cigars Other: Pursuant to MGL Ch. 62C sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: Date: Signature of Individual or Corporate Name: Print Name
TOWN OF BURLINGTON BOARD OF HEALTH 61 Center Street BURLINGTON, MA 001803 781-270-1955 Fax 781-273-7687 RETAIL TOBACCO SALES PERMIT Checklist This form must be completed by the owner/operator of the establishment applying for a permit for location and sales of tobacco products. 1) I have read and I understand all sections of the Burlington Board of Health Regulations Affecting Smoking in Certain Places 2) I understand that it is against the law to sell cigarettes or any tobacco product to anyone under the age of 18 years, regardless how old the person looks 3) I understand that the Board of Health Regulation and State and Federal law require businesses to establish positive proof of age before selling tobacco to any customer less than 27 years of age. This means that the clerk must ask for and see identification proving the person is at least 18 years of age _ 4) I understand that the owner/operator of a business holding a retail tobacco sales permit will be responsible for all violations of the Burlington Board of Health regulations controlling the sale of tobacco products 5) I understand that the Town of Burlington Board of Health or its agent will conduct unannounced compliance checks of my business to ensure that minors are unable to purchase tobacco from my business. 6) I understand that other government agencies, such as the Food and Drug Administration or the State Attorney General's Office, may conduct additional compliance checks of my place of business 7) I understand that if I am caught selling tobacco to minors, I will be required to appear before the Burlington Board of Health and I will be issued a citation pursuant to Board of Health Regulation. If I am repeatedly cited, I will be called for a hearing before the Burlington Board of Health to show cause as to why my permit should not be suspended By signing this form I acknowledge that I have read and understand all of the above statements. I further understand that failure to abide by these conditions as well as all the requirements of the Burlington Board of Health Regulations Affecting Smoking in Certain Places may jeopardize my permit for Retail Tobacco Sales Permit. Owner/Operator Date
Regulations of the Burlington Board of Health Sale of Tobacco Products to Minors A. Statement of Purpose: Whereas there exists conclusive evidence that tobacco smoke causes cancer, respiratory and cardiac diseases, negative birth outcomes, irritations to the eyes, nose and throat; and whereas more than eighty percent of all smokers begin smoking before the age of eighteen years (Centers for Disease Control and Prevention, "Youth Surveillance - United States 2000," 50 MMWR 1 (Nov. 2000); and whereas nationally in 2000, sixty nine percent of middle school age children who smoke at least once a month were not asked to show proof of age when purchasing cigarettes (Id.); and whereas the U.S. Department of Health and Human Services has concluded that nicotine is as addictive as cocaine or heroin; and whereas despite state laws prohibiting the sale of tobacco products to minors, access by minors to tobacco products is a major problem; now, therefore it is the intention of the Burlington Board of Health to curtail the access of tobacco products by minors. B. Authority: This regulation is promulgated pursuant to the authority granted to the Burlington Board of Health by Massachusetts General Laws Chapter 111, Section 31 that "Boards of Health may make reasonable health regulations." C. Definitions: For the purpose of this regulation, the following words shall have the following meanings: Business Agent: An individual who has been designated by the owner or operator of any establishment to be the manager or otherwise in charge of said establishment. Employee: Any individual who performs services for an employer. Employer: Any individual, partnership, association, corporation, trust or other organized group of individuals, including Burlington or any agency thereof, which uses the services of one (1) or more employees. Minor: Any individual who is under the age of eighteen (18). Permit Holder: Any person engaged in the sale or distribution of tobacco products directly to consumers who applies for and receives a tobacco sales permit or any person who is required to apply for a tobacco sales permit pursuant to these regulations, or his or her business agent. Person: An individual, employer, employee, retail store manager or owner, or the owner or operator of any establishment engaged in the sale or distribution of tobacco products directly to consumers.
Self Service Display: Any display from which customers may select a tobacco product without assistance from an employee or store personnel, excluding vending machines. Tobacco Product: Cigarettes, cigars, chewing tobacco, pipe tobacco, bidis, snuff or tobacco in any of its forms. Vending Machine: Any automated or mechanical self service device, which upon insertion of money, tokens or any other form of payment, dispenses cigarettes or any other tobacco product. D. Tobacco Sales to Minors Prohibited: 1. No person shall sell tobacco products or permit tobacco products to be sold to a minor; or not being the minor's parent or legal guardian, give tobacco products to a minor. 2. In conformance with and in addition to Massachusetts General Law, Chapter 270, Section 7, a copy of Massachusetts General Laws, Chapter 270, Section 6, shall be posted conspicuously by the owner or other person in charge thereof in the shop or other place used to sell tobacco products at retail. The notice shall be provided by the Massachusetts Department of Public Health and made available from the Burlington Board of Health. The notice shall be at least 48 square inches and shall be posted conspicuously by the permit holder in the retail establishment or other place in such a manner so that it may be readily seen by a person standing at or approaching the cash register. The notice shall directly face the purchaser and shall not be obstructed from view or placed at a height of less than four (4) feet or greater than nine (9) feet from the floor. 3. Identification: Each person selling or distributing tobacco products shall verify the age of the purchaser by means of government-issued photographic identification containing the bearer's date of birth that the purchaser is 18 years old or older. Verification is required for any person under the age of 27. 4. All retail sales of tobacco must be face-to-face between the seller and the buyer except for the purchase of tobacco from vending machines. E. Tobacco Sales Permit: 1. No person shall sell or otherwise distribute tobacco at retail within Burlington without first obtaining a tobacco sales permit issued annually by the Burlington Board of Health. Only owners of establishments with a permanent, non-mobile location in Burlington are eligible to apply for a permit and sell tobacco products at the specified location in Burlington. 2. As part of the tobacco sales permit application process, the applicant will be provided with the Burlington Board of Health regulation. Each applicant is required to sign a statement declaring that the applicant has read said regulation and that the applicant is responsible for instructing any and all employees who will be responsible for tobacco sales regarding both state laws regarding the sale of tobacco and this regulation. 3. Each applicant is required to provide proof of a current tobacco sales license issued by the Massachusetts Department of Revenue before a tobacco sales permit can be issued.
4. The fee for a tobacco sales permit shall be determined by the Burlington Board of Health annually. All such permits shall be renewed annually by December 31 of every year. 5. A separate permit is required for each location selling tobacco. 6. Each tobacco sales permit shall be displayed at the retail establishment in a conspicuous place. 7. No tobacco sales'permit holder shall allow any employee to sell cigarettes or other tobacco products until such employee reads this regulation and state laws regarding the sale of tobacco and signs a statement, a copy of which will be placed on file in the office of the employer, that he/she has read the regulation and applicable state laws. 8. A tobacco sales permit is non-transferable. A new owner of an establishment that sells tobacco must apply for a new tobacco sales permit. No new permit will be issued unless and until all outstanding penalties incurred by the previous permit holder are satisfied in full. 9. Issuance of a tobacco sales permit shall be conditioned on an applicant's consent to unannounced, periodic inspections of his/her retail establishment to ensure compliance with this regulation. 10. A tobacco sales permit will not be renewed if the permit holder has failed to pay all fines issued and the time period to appeal the fines has expired. F. Free Distribution: No person shall distribute, or cause to be distributed, any free samples of tobacco products. G. Out-of-Package Sales: No person may sell or cause to be sold or distribute or cause to be distributed, any cigarette package that contains fewer than twenty (20) cigarettes, including single cigarettes. H. Self Service Displays: All self service displays of tobacco products are prohibited. All humidors including, but not limited to, walk-in humidors must be locked. The only exception is self service displays that are located in facilities where the retailer ensures that no person younger than eighteen (18) years of age is present, or permitted to enter, at any time. I. Tobacco Vending Machines: All tobacco vending machines are prohibited. Except that tobacco vending machines are permitted if equipped with a lock out device, in an establishment with a valid pouring liquor license, and located in facilities where the retailer ensures that no person younger than eighteen (18) years of age is present, or permitted to enter, at any time. A lock-out device locks out sales from the vending machine unless a release mechanism is triggered by an employee. The release mechanism must not allow continuous operation of the vending machine and must be out of the reach of all consumers and in a location accessible only to employees. J. Violations:
1. It shall be the responsibility of the permit holder and/or his or her business agent to ensure compliance with all sections of this regulation pertaining to his or her distribution of tobacco. The violator shall receive: a. The Violator of Section D.I. may receive: i. In the case of a first violation, a fine of one hundred dollars ($100.00). ii. In the case of a second violation within 12 months of the date of the current violation, a fine of two hundred dollars ($200.00) and the tobacco sales permit may be suspended for seven (7) consecutive business days. iii. In the case of three or more violations within a 12 month period, a fine of three hundred dollars ($300.00) and the tobacco sales permit may be suspended for thirty (30) consecutive business days. b. The violator of Sections D.2, D.3, D.4, E., F., G., H., and I shall receive: 1. In the case of a first violation, a fine of one hundred dollars ($100.00) or a warning. ii. In the case of a second violation within 12 months of the date of the current violation, a fine of two hundred dollars ($200.00) and the tobacco sales permit may be suspended for up to seven (7) consecutive business days. iii. In the case of three or more violations within a 12 month period, a fine of three hundred dollars ($300.00) and the tobacco sales permit may be suspended for thirty (30) consecutive business days. 2. Refusal to cooperate with inspections pursuant to this regulation shall result in the suspension of the tobacco sales permit for thirty (30) consecutive business days. 3. In addition to the monetary fines set above, any permit holder who engages in the sale or distribution of tobacco products directly to a consumer while his or her permit is suspended shall be subject to the suspension of all board of health issued permits for thirty (30) consecutive business days. 4. The Burlington Board of Health shall provide notice of the intent to suspend a tobacco sales permit, which notice shall contain the reasons therefore and establish a time and date for a hearing which date shall be no earlier than seven (7) days after the date of said notice. The permit holder or its business agent shall have an opportunity to be heard at such hearing and shall be notified of the Board of Health's decision and the reasons therefore in writing. After a hearing, the Burlington Board of Health may suspend the tobacco sales permit if the Board finds that a sale to a minor occurred. For purposes of such suspensions, the Board shall make the determination notwithstanding any separate criminal or non-criminal proceedings brought in court hereunder or under the Massachusetts General Laws for the same offense. All tobacco products shall be removed from the retail establishment upon suspension of the tobacco sales permit. Failure to remove all tobacco products shall constitute a separate violation of this regulation.
K. Non-Criminal Disposition: Whoever violates any provision of this regulation may be penalized by the non-criminal method of disposition as provided in General Laws, Chapter 40, Section 21 D or by filing a criminal complaint at the appropriate venue. Each day any violation exists shall be deemed to be a separate offense. L. Enforcement: Enforcement of this regulation shall be by the Board of Health of Burlington or its designated agent(s). Any citizen who desires to register a complaint pursuant to the regulation may do so by contacting the Board of Health of Burlington or its designated agent(s) and the Board shall investigate. The Board of Health may enforce this Regulation or enjoin violations thereof through any lawful process, and the election of one remedy by the Board of Health shall not preclude enforcement through any other lawful means. M: Severability: If any provision of these regulations is declared invalid or unenforceable, the other provisions shall not be affected thereby but shall continue in full force and effect. N. Effective Date: This regulation shall take effect on December 31, 2008.
Applicant Information Business/Organization Name: Address: 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 City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1.1 1 I am a employer with employees (full and/ or part-time).* 2. EH I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. 1 1 We are a corporation and its officers have exercised their right of exemption per c. 1 52, 1 (4), and we have no employees. [No workers' comp. insurance required]** 4. 1 I We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. D Retail Please Print Legibly 6. Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. O Non-profit 9. 1 1 Entertainment lo.n Manufacturing ll.d HealthCare 12.D 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. / am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self-ins. Lie. #_. Expiration Date:_ 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 25 A 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. / do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area9 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
Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, 25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, 25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Form Revised 5-26-05 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 www.mass.gov/dia