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TOBACCO MASTER - CLOSED TOBACCO
i (Tobacco Master i 606 Main St. 44, HY FORMERLY ECLECTIC CAFE p1P Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. Fr►Nx81AIl1�. S F.P.(Thomas)Lee MM Daniel Luczkow.Alternate 1619. 200 Main Street,Hyannis,MA 02601 Phone: (508)862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code,a permit is hereby granted to: Permit No: 409 Issue Date: 1/1/2021 DBA: TOBACCO MASTER OWNER: QASWA INC. Location of Establishment: 606 MAIN STREET-UNIT#4 HYANNIS, MA 02601 Type of Business Permit: Adult Only Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS,CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY y For Office Use Only& Initials: Town of Barnstable Date Paid Amt Pd$ 4 Inspectional Services ®S'7go Public Health Division check# b _ Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 S,I ptA�A Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION'(Non-Flavored). DATE ! .''fin' NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT:C w 0, ADDRESS OF TOBACCO ESTABLISHMENT:6_b6 M a 01\ 6N Vvy'i -01601. MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: /�I>%/1�L� �(� l Y rlDfll'IW �a t TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: MAD A OWNER'S NAME: �I S)l1! [� - OWNER'S PH# c 1 - �)? OWNER'S ADDRESS: 2 e'Y-14-P Pane :Ci IAAA. CORPORATE NAME: Utf l -,T C CORPORATE ADDRESS: .. G I), ���;Am(1 CORPORATE FID# ANNUAL:_ SEASONAL: DATES OF OPEERATION: C /bC4 TO 'g DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS). TOWN OF BARNSTABLE CODE/1V1A GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: httRs:Hmale�islature ggov/Laws/GeneralLaws/ 44IV/Titlel/Chapter270/Section6 r ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. --PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SMIT THE UB FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 : S SIGNATURE: PRINTED NAME: DATE: Q:1Application FormsITOBACCO APP-NonFavor 12-18-19.docx i ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: 4 1 Sales to Minors— 371-9. Sale and Distribution of Tobacco Products. } a 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: r Si natur Printed,Name q t , g me Dat � I ( � -. ignature Printed Name Da ENRE 'gigVgiure Printed Name Date Signature Printed Name Date Signature Printed Name Date x F Signature Printed Name Date Signature Printed Name Date k x: 4. Q:\Application Forms\TOBACCO APP•NonFavor 12-15-19.docx TOBACCO SALES TO MINORS PROHIBITED BY MASSACHUSETTS GENERAL LAWS Sales to Minors— § 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under the minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. { 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the fr age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older, Verification is required for any person under the age of 27. Persons, firms, corporations, or agencies selling tobacco products to minors or selling tobacco products without a tobacco sales permit shall be punished as follows: A. In the case of a first violation,a fine of one hundred dollars ($100.00). B. In the case of a second violation within 24 months of the date of the current violation, a fine of two hundred dollars ($200.00) and the Tobacco Product Sales Permit shall be suspended for up to seven (7) consecutive business days. C. In.the case of three or more violations within a 24-month period, a fine of three hundred dollars ($300,00) and the Tobacco Product Sales Permit shall be suspended for up to thirty (30) consecutive business days. In the case of four violations or repeated, egregious violations of this regulation, as determined by the Board of Health, within a 24-month period, the Board of Health shall hold a hearing in accordance with subsection 4 of ` this section and may permanently revoke a Tobacco Product Sales Permit. Posting State Law — In conformance with Massachusetts General Laws, Chapter 270, Section 7, a copy of Massachusetts General Laws Chapter 270, Section 6 shall be posted conspicuously by the owner or other person in charge thereof in the shop or other place used to sell cigarettes at retail. The notice to be posted shall be that notice provided by the Massachusetts Department of Public Health. Such notice shall be at least 48 square inches and shall be posted at the cash register which receives the greatest volume of single cigarette package sales in such a manner so this may be readily seen by a person standing at or approaching the cash register. Such notice shall directly face the purchaser and shall not be obstructed from view or placed at a height of less than 4 feet or greater than 9 feet from the floor. For all other cash registers that sell cigarettes, a notice shall be attached which is no smaller than 9 square inches, which is the size of the sign provided by the Department of Public Health. Such notice must be posted in a manner so that it may be readily seen by a person standing at or approaching the cash register. Such notice shall directly face the purchaser and shall not be obstructed from view or placed at a height no less than 4 feet or more than 9 feet from the floor. p l a Q:1Application Forms\TOBACCO APP-NonFavor 12-18-19.docx J y ,y, 1. a y a.- a "¢ 'A �4s, : :3i' 'S" ,I, 1A^', % w1'q* �- ,use Y• F� 'H,.: 4 �,'n,-,.-;3: _ Y %9` ,;a "zY- _4 `'a S. va ,$`. u,, :u' , ':y^ IS �;. R ,. a .. ,„ ,`wr iA p y^. ^F :• jy ,._ — '- .'sa a,z= a^A' -�:5 �:( ' ,< '2. � k4:,e 11 � .2 ,F..,;. w` w 1,.y ;' Z' . a' ,' .,", a: _' , :�, ." , use „,,. �. Zt 4 #„ x ,�,.:: ,, ,.:., :"%v ^^s', ,,. 1. a;..- .^.;^-g ,,..i ry,:,-., m ,.�,, v. ,a ., r' u`Z y ,` ;:� ,^ ': "M z >:k.. ,,M +` .;i s , '^z..: ."_, ':, J. - x, `, :tea s .w g.J - " 'S :<N. , '_ -.' t r ,, a - ,. - 4 * <., ,. y .; <"+ a cl .,, .,t - ���-+<,� ,.Win: ,. ..: - f_ _. �.. A., - ,. - �' :,v. �'.. 11 �: gip. ,� ,.. '::.; *. •>+ ..- ::<: ..;t ,,. .. ,t:-ar -'. '£" .�. .. 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APtnelYQat lxlavw is ysur 1RCIAi1M 1 1lMt¢q ff l Sal a3 f 9}}81CUC�t�S ttt i l t}.Cia A ang{lic doiled line, and disp3mp at,v,tr[business Itwatatra..A:ant;ua6'gibu ma tug'2q3u y4or Massl'AhCcmtnier'I s)cruuutak: m[vs gvvjtaasst ixcc rYneCR i i v3eK tu)tl re•pran9 a Co}tV ul iius lec' vex tl you h rar ank•a}c,ast)m&mhma acrmr Ricvnr coil us. &87416 arr h,44me Iq�9ur;ft schiia�.^titi aat [",3<3t#,3�'?Y2-59344,fvfu:hlayf§I�rwrte 1:ri+Say;:Q�tl a.iia..is 4.�fl larn::.. . 3 [)E:'CAC'H Hk;Lhk:: MASSACHUSETIS llEPAIUI'SI y'i O tRF.VEN't is Vim%C`i'-.i R etalter Liceam..(or SsIr of Og4unettes to r,wa t'hPs,ltr,Inc,aaaBQOv.,poste'dmrlkalvisrtrtrmt all tla®e,9.'t�k l+hftnt+aecaT praiducls t.auvaue under IS v"rs of age is propil[ited.. U�;}�1 11'i 4reoaoni Ill C.UL-I<y3[0174 i-RFk13_ I f kC t:Y7 A1AYFER L�eruxo Rueabar 4q�475#SR6 K 6UG MAP3t 41 .4 IIIY.+tPM5 " T1uc�Qrtat-ie31�Aa3fl3vLB.tpayz,[u�u,rl�rrx,tQ131iairrselk arlai:•a:rt`k�Ipla,r6Ql;tsFilml4acs+�4lsuce[t Geaj�a'plls�.[�i. gQll et t�Sail"a[t9oc aridrtr,Piz+4wsc vh(te,. n rrc era p autljna}ha.g[aneneletl or r-ev'oAr°k fur iGi[uectncarr,tplt'tY3fflstutelna.sand,tQgs33r�hsns_ efr(-live mite A%T64€4_2014 t;tpPrvriw Nte.:Sep[4Mnber 30,«01.0 i i ,. I 3:27 .0 LTIEAND. A Done QAS.WA INC;- FED TAX O CONFIR:.. ! t4\,J Yii'rap-qA.,nx`i M-E".^�i koca. A Cim2.gnl.tl ta4 OM994102.3:. DaW,of tEls,natice: n8-86-2019 . ..r'"fr�inyr+-r 7d,a7sca;:a::zraL,icxn:v�smlttas: 8Ca2635586, ' .BS=4 '. [S?.`A+bo3 '.oP oti.; a.+:st iem: 6`F':75:A,.. or-"WA mc TC7i=CC Na5'rEn 9 A.'NLVL Fb-- ass Latance you,cxy-Ga_1`1 ua.bti.. i6 ,5@:liVICi TiA 1-BDv=$29-45,73 SneaDwzs-x r4:. g2:�:63. iY YQlI�'AB1TE..k'1`rACkl'1'H8 SYUB AT TUE END 4r'MS.%*TICE.. i} WL ASSIC11➢YOr'P-4 i1VWYER!UENT1YlCs fILU W1II= . a Thank you eor•applying £or au Ettzv'layer rdentd£iiatlun 14U:fiuet (Elm1, We assigned you t FIN.84 7635586. This 9717 will identity You. your Wsinexas x<mvnts, tans retnrms, and #t gccwi*pLa evan,lc yqu. ave no employees. Please,keep th.e notice in ybur wrinament SdNen fiYzny tali 6naurc nt9, ..and ralaeed carraalrcBdencee 3t la'very i artan• ty3x•}vsp•use'yrrsr E1N-and 6wriiieie na:De.anti address ezaetly as utioa•:e a=ve. A:Ey vmrta-ion• m.ly:cause a:delay in.pyoceseii 4, result in'incoriect information.in year accoant, or even: ran,�o you tea bo assiynco'mro ,:'enn once rMH.' 7f the:i,funr+ticm fs nnt•rarrra-t ar. sham -above please:make .W correction using tho attached tear off s uu and•return it to::s. ➢mied'iiii t:�- ir,£orixb_lccn r eilved fram}ou'or•yu rt reprey ntetive, you ME rile ;( the,following."rorm(s) lip the,rota;sp- hown.. - - 'f1# Form. 941 al✓3A'zn2U '# "e.94r1, Qi✓lf✓2fi23 riim I '4 C14✓i5/�(1,7u [ of rau'have gtLesti.Qns about tm feJrmjsp ar the.due date(sp shown,:yam+- can Gail us.•a tieo pncna numher or.wri:ta: te."u.at the addronn nhmm',at-tho'•top of this.moiien. xf.ynu - need help in determ-niriel your annual accouhtinc)period 4tax year). se'e:Publication 535; u¢:crin.-jtlrg Jv„•rread and'!Wthedm. We assigned you a Lam classification based on iilt-rmat:ion obtained,from you or your ,representative it " mat 4-legal determination*,f--yoour tax:classifiaation,•and is net bindi iq'on�tb. IRS. If.yoia imnr,a,1.e�Ea;l.otvter^,.�isaatl,oir of your Vix,.'La"if itati€1n.•v6u nwi. rixlua•-t a private letter rrnling frtrx the ISS undo the g-Sidalrn9 in. e.fevevua Procpiura ?.UD4-1 20L+4-2 1 d.B. ]. [cr sure rsed3.ng Rnv nkm rrr�ttduro f6r the }°air.mt iiwn )• unto:, Certo+rY tS x'C$n±ts i£scataoo _lrctitnnx.cbh b.0 requeotdd by'£i13ng rbrm'aR32 Ritftjr C1aa9i1'lcatlaic 51ect17z:•, Sae--.rose 0332..and lle'instructions,Eor adiAtiona3 information:: Alm 7141:'QN1QAl81;9N rQlt'B t:tAirOBAT2C91'83;kC'Pl4ktx 1- cutPorat ff you...intend t_o:elgct to.Ell.your return.as,r� small businesu W:t,•an mlect'_?n tofila.a.f7orm f120-s mint trti.::side within^-main timgfr.mge}and the. ccrporat33n.Host iieael'Cei"ta£n-teats:. All.at.t:nl9 infurt�atYait Is Lnelu&-d in the instl- --ions.tor Folin X§s3 F erwion fy a Sm, 1 t7zaamass eths raesors.. f (IRS-➢SF.'Ti1:LY) i°t`A: 01-46-2tl 1,5 [:ASk 3 9994999949 SS-4 I'f;Veu:are re:rauirnd,to depEmait.Ens sa'^.}tltTy s^ri• taKr;n ttormr, 9d 1,•,.9d3. 9kE3,-.944,.445-; r.l, or 1042), exels'% awed fPani 720), or inceme.taxes (ro_L,11,201, you Will reeeive.a Atial:oome Packa;qe shoitLy, whirls,iccludes�;natrructio a,for tea._ing your teposita � plr.^trdnimpIly,threngh.the Clortr6nir, orpra2' A PrSrscxnal. 3dtant:.dcation Number (rlWS for T,.r TPS vi,U also be.sent ro:you umslor separate cover. ylraan amtivlite the PiN ancu you recetrvo sit, av&^ if you have _qm7 teed thm nemiee..of..•c. . =tax pmfes83onal ot, repteeentakive: :for sure in Ormaltlim about E:V'ITS"reter to _-ubli4atien 966,.216ctre nlr C➢:aL-sb to fay All YBur.kWo—1 5:axe_v. If y'cc weir to - mak@ 8�deaca.ie ismediaateiy, you..wii i need to,rulke arrannemsms wi'th:your•riTiaAcial adsc.irutaon•rg c*+mle",a wlrv:tranotoz., - " Tha IRS Ada rralcsittrad tA'balplag their„tax filLng, f +ibIlgatl6us" 1'£ VO4 need help ca'Pleti'ng.yc1Ut ietums ew!feting,}wur:_iax cbilgpti.Y. , Authorized e-file•Providers, such."Regmrting,'Atents (payroll sersice'providera) are ;{ avallable to assist you "Visit the: IRS wau site at..aw4.Ls.-4n'v for a.list of C-b-Vantey -Chati orier-in a-file for business piWk+cts aadservices. The list Grov'iocs a[iijl'9ser.8; it 'tolcphern nilmber::..and llnks to their Web aiten. This Cease and Desist Order is Issued to: Asim Jamal Tobacco Master 606 Main Street, Hyannis, MA 02601 07-31-2020 CEASE AND DESIST ORDER The Board of Health of the Town of Barnstable Massachusetts in accordance with and under the authority granted by Section 31 of Chapter 111 of the General Laws of the Commonwealth of Massachusetts.Tobacco Master is hereby ordered to immediately cease and desist the violation of the The Board of Health of the Town of Barnstable. Tobacco Master violated the Section 371 of the Town of Barnstable Code: ❑ the undersigned witnessed the sale of flavored tobacco products by Tobacco Master Ne"' the undersigned witnessed the display of flavored tobacco products by Tobacco Master ❑ other, see the below narrative description, with any necessary additional pages attached: Operation in violation of this Cease and Desist Order is a violation of law and may result in [enforcement detailed in final version of order] Signed by: Date: Name: ��✓ Cq�• G/r�i Agent of the Barnstable County Health and Environmental Department Cease and Desist Order Received by: Date: - -- \V�A 1 7/:3 ) L2-o Name: On behalf of Tobacco Master Instructions to DPH/LBOH agent:Two copies of this form should be completed,with one complete and signed copy given to the firm and one complete and signed copy kept by you. Local Boards of Health must provide a copy of the order to the Department of Public Health and keep a copy for your agency's records. C:\Users\bellaird\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.0utlook\NYXFBPRB\Cease and Desist Document-07- 27-2020 TobaccoMaster.docx t.. a ..ate^-• ., - _. .- - -f_' _ _ - ... ..- --:-i - .. �".- _ TOWN OF BARNSTABLE BAR -w 6106 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager A!5,M amnal Address of Offender MV/MB-Reg. # Village/State/Zip M l Business Name r C� GCSE / IQSTG� 'ZU am/10; onjj Zq 20 2G Business Address �o / 'tG�� �11/V E ii'' Signature n orcing Officer Village/State/Zip HU Afti5 Location of Offense Enforcing Dept/Division 1 Offense C/Cc T10 or Facts This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by.the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK- ENFORCING OFFER GOLD - ENFORCING DEPT. Bellaire, Dianna From: McKean, Thomas Sent: Tuesday, July 21, 2020 11:58 AM To: Bellaire, Dianna Subject: RE:Tobacco Master Yes please assign it to Matthew on Friday. He was trained by the County Tobacco Control Program. From: Bellaire, Dianna Sent: Tuesday, July 21, 2020 9:50 AM To: McKean, Thomas Cc: Bellaire, Dianna Subject: Tobacco Master Hi Tom; I have one Adult Only Tobacco store that has not renewed. I've called, left messages and emailed. I spoke with him once,the first week of June and he stated he would renew. He didn't. This is located at 606 Main Street, Hyannis in Unit #4. Please let me know how you want to handle it. I wasn't sure if the temp person working with Karen finished Tobacco Inspection training. Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire@town.barnstable.ma.us The information contained in this electronic transmission("e-mail"),including;any attachment fthe"Information"),may be confidential or otherwise exempt from disclosure.Tt is for the addressee only.This Information may be privileged and confidential work-product or a privileged and confidential communication.The Information may also be deliberative and pre-decisional in nature.As such,it is for internal use only.The Information may not be disclosed�,,tithout the prior written consent of the Director of Public Health and/or the '1'owtr Attorney's Office of the'Ibwn of Barnstable. if you have received this e-mail by mistake,please notify the sender and delete it from your system.Please do not copy or forward it.Thank you for your cooperation. 1 r wcrt Commonwealth of Massachusetts Lcttcr ID:L1865987968 � �. �• l7'rtt' Department of Revenue Notice Date:August 14,2019 Christopher C.Harding,Commissioner Account ID:CGL-1 9301 7 1 1-003 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES 111I1i1r Jill illillll��illn�l�i1-lllil�l�lilr��il111l1111111111 A.JAMAL N= QASWA,INC. c TOBACCO MASTER 367 SERVICE RD SANDWICH MA 02563-4302 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 A.� Ir J�: Retailer License for Sale of Cigarettes This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. QASWA, INC. Account ID: CGL-19301711-003 TOBACCO MASTER License Number: 952068096 606 MAIN ST#4 HYANNIS MA 02601-5432 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: August 14, 2019 Expiration Date: September 30, 2020 Town -of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARN"AS , : Paul J.Canniff,D.M.D. M ., H MA 02601 F.P. Thomas Lee Alternate 200 Main Street, Hyannis, Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 409 Issue Date: 1/1/2020 DBA: TOBACCO MASTER OWNER: QASWA INC. Location of Establishment: 606 MAIN STREET-UNIT#4 HYANNIS, MA 02601 Type of Business Permit: Adult Only Annual Seasonal FEES TOBACCO SALES: $85.00 YEAR. 2020 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY Initials: } Date Paid Amt Pd$ CI Jr 0c) Barnstable �oFrHEr, � Iq-t'Lgj It?4 (� onal Services D"I * iABN3fABLE Check# L. ru i vG-L MASK• alth Division AAA• Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 ADULT ONLY RETAIL TOBACCO SALES PERMIT APPLICATION DATE -NEW BUSINESS: NEW OWNERSHIP RENEWAL_J,�� NAME OF ADULT-ONLY RETAIL TOBACCO SALES ESTABLISHMENT: IT b01a0 iMAS.Ae(- ADDRESS OF TOBACCO ESTABLISHMENT: 6o6 M o \ Q�Avp—CL i��>1ng!i;JV14 (gyp 1 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAILADDRESS: As jee ih 9 HmIJ ►, BUSINESS PHONE: ktAl TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: ( ► � -' 'OWNER'S NAME: A,S,* 3cwn as _ OWNER'S ADDRESS: �6 Seym,te- Qmj lt7atw ni l pd 5*3 CORPORATE NAME: C CORPORATE ADDRESS:�b Q10(iN S4*t6 A,L LIIh,AA A)SO CORPORATE FID# ANNUAL:��� SEASONAL: DATES OF OPERATION: TO ! /.3"I DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) `iJbw DO YOU CURRENTLY POSSESS A STATE LICENSE TO SELL CIGARETTES?Yes\ZNo DO YOU CURRENTLY POSSESS A STATE LICENSE TO SELL CIGARS/SMOKING TOBACCO?Yes No TOWN OF BARNSTABLE CODF./MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: httpq-//wwwecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: httns//malegisl attire goy/Laws/GeneralLaws/PartIV/TitleL/C'hanter270/Section6 PLEASE ATTACH A PROPOSED FLOOR PLAN OF THE EST.and a LIST OF PRODUCTS PROPOSED TO BE SOLD A HEARING IS REQUIRED BEFORE THE BOARD OF HEALTH. THE BOARD MEETS ONCE PER MONTH. APPLICANT IS REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT ISSUANCE PLEASE CALL 508-862-4644 Q:\Application Forms\Tobacco App 2020 Adult Only Retail Tobacco Sales draft l.docx I E ' � SIGNATURE: PRINTED NAME: A DATE: / &o AaAee, ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—$371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product,as defined herein,to a person under the minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: (s-, Signatur Printed Name D to Z�6IL J61) Signa ure Printed Name Dat Q:\Application Forms\Tobacco App 2020 Adult Only Retail Tobacco Sales draft 1.docx I Amy- Signature Printed Name Date kafra, :� (d 219- Signature Printed Name Dale Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\Tobacco App 2020 Adult Only Retail Tobacco Sales draft S.docx s s Commonwealth of Massachusetts Letter ID:L1865987968 Department of Revenue Notice Date:August 14,2019 { ' Christopher C.Harding,Commissioner Account ID:CGL-19301711-003 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES A.JAMAL N= QASWA,INC. TOBACCO MASTER 367 SERVICE RD SANDWICH MA 02563-4302 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'` MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 T Retailer License for Sale of Cigarettes This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. QASWA, INC. Account ID: CGL-19301711-003 TOBACCO MASTER License Number: 952068096 606 MAIN ST#4 HYANNIS MA 02601-5432 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: August 14, 2019 Expiration Date: September 30, 2020 o Commonwealth of Massachusetts Letter ID:L0008963648 -- s Department of Revenue Notice Date:August 12,2020 4 / w Geoffrey E.Snyder,Commissioner Account ID:EDL-19301711-010 Cr mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS "I�Ill��lll��ll�llllnl'I���II��I����III��I����I�II�IIII'�IIIII o= A.JAMAL o= QASWA,INC. o— A=_ TOBACCO MASTER 367 SERVICE RD SANDWICH MA 02563-4302 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 �S&Nc"1'4 MASSACHUSETTS DEPARTMENT OF REVENUE I' Retailer License for Sale of Electronic Nicotine Delivery Systems This license must be posted and visible at all times. The sale of �'1v'r or tobacco products to anyone under 21 years of age is prohibited. QASWA, INC. Account ID: EDL-19301711-010 TOBACCO MASTER License Number: 1155680256 606 MAIN ST#4 Age-Restricted Store HYANNIS MA 02601-5432 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:August 12, 2020 Expiration Date: September 30, 2022 Commonwealth of Massachusetts Letter ID:L2 1 1 1 559552 Department of Revenue Notice Date:August 13,2019 � ' Christopher C.Harding,Commissioner Account ID:SLS-19301711-008 mass.gov/dor SALES AND USE TAX REGISTRATION CERTIFICATE A.JAMAL QASWA,INC. TOBACCO MASTER 367 SERVICE RD SANDWICH MA 02563-4302 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-1 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 •----------------------------------------------------------------------------------------------------------------------------------------------- MASSACHUSETTS DEPARTMENT OF REVENUE Form ST-1 �° Sales and Use Tax Registration Certificate uu� i This registration must be posted and visible at all 't,vr 0� times. QASWA, INC. Account ID: SLS-19301711-008 TOBACCO MASTER Certificate Number: 637562880 606 MAIN ST#4 HYANNIS MA 02601-5432 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:August 13, 2019 rt ,. Town of Barnstable BOARD OF HEALTH f Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli, M.D. r���txaT � John T. Norman `AS-S' F.P. Thomas Lee Alternate b39• 200 Main Street, Hyannis, MA 02601 €0"max Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 409 Issue Date: 08/28/2019 DBA: TOBACCO MASTER OWNER: QASWA INC-ASIM JAMAL Location of Establishment: 606 MAIN STREET-UNIT#4 HYANNIS, MA 02601 Type of Business Permit: TOBACCO -ADULT ONLY Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR: 2019 RETAIL FOOD: I COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE- FOOD: MOBILE-ICE CREAM: a� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: � g7 - ���o"M - Town of Barnstable Board of Health '• BARNSTABLE, 9 MASS. 200 Main Street,Hyannis MA 02601 i639• RFD Mph a Office: 508-862-4644 John Norman PAX: 508-790-6304 Donald A.Guadagnoli,M.D. Paul J.Cannilf,D.M.D September 11, 2019 Tobacco Master c/o Asim Jamal 367 Service Road Sandwich, MA 02563 RE: Tobacco Master, 606 Main Street, Unit 4, Hyannis Massachusetts Dear Mr. Jamal, You are granted permission to open and operate an adult-only retail tobacco store at 606 Main Street, Unit #4, Hyannis Massachusetts, with the following condition: • The adult-only retail tobacco store shall not open for business until after the establishment is inspected by an official of the Barnstable County Tobacco Control Program, or by an agent of the Board of Health, and the establishment satisfactorily passes the inspection. Once the establishment satisfactorily passes an inspection, you will be able to remit the required fee and obtain an adult-only retail tobacco store permit from the Board of Health. The permit can be obtained at the Public Health Division Office, located at 200 Main Street Hyannis. If you should have any questions, please feel free to telephone Thomas McKean, Director of Public Health, at 508 862-4640. Sincerely ours, hn Norman Chairman TOWN OF BARNSTABLE BOARD OF HEALTH Q:\WPFILES\AdultOnlyTobacco TobaccoMaster 606 Main Street 2019.docx Town of Barnstable Public Health Division anuvsreetE. v Mass. 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 September 10,2019 NOTICE TO ALL OWNERS OF ADULT-ONLY RETAIL TOBACCO STORES Entrance of Persons All owners of adult-only retail tobacco stores are reminded to ensure full compliance with Section 371-1 of the Town of Barnstable Code,which became effective as of July 28, 2019. Specifically,this Section of the Code requires the permit holder to prohibit any and all persons who are under the age of 21 from entering the store at any time. An adult only retail tobacco store is defined as follows: An establishment which is not required to possess a retail food permit whose primary purpose is to sell or offer for sale to consumers, but not for resale, tobacco products and paraphernalia in which the sale of other products is merely incidental, and in which the entry ofpersons under the age of 21 is prohibited at all times, and maintains a validpermit for the retail sale of tobacco products as required to be issued by the Barnstable Board of Health. To comply with this Section of the Code,you will need to: 1. Station an employee at the front entrance door to check dates of birth(i.e. driver's licenses)of any and all persons before entrance into the store or keep the front entrance door locked until such time an employee is available to the check dates of birth before each customer has the ability to enter the front entrance door into the store and it is suggested you; 2. Post a sign at the front entrance door which reads as follows: `Adult-Only Retail Tobacco Store Persons under the age of 21 years of age prohibited(see suggested sign provided on back of this page) If you should have any questions,please contact Thomas McKean,Director of Public Health, at(508) 862-4644. U LV=J(D) M LY7 RIEULIML V(D) ML%CCO OUORIE Persons under the age of 21 .are not permitted to enter this establishment TOWN OF BARNSTABLE . � BOARD OF HEALTH MW - �pTHET Town of Barnstable For Office Use Only: Initials: ti Inspectional Services Date Paid A,mt Pd$ BARNBPAEM Check# MASS. Public Health Divisiol 1639. �0 200 Main Street, Hyannis MA 026( Office: 508-790-4644 �` ),4_ S FAX: 508-790-6304 CUC n ) t�=o MAIL TO: TOWN OF BARN _ r ( PUBLIC HEALTH DW15 200 Main Street HYANNIS,MA 026011� I �J FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED I APPLICATION FOR A TOBACCO S, 04wr4 'mc COI(OA� 1 © Baca) ESTABLISHMENT NAME (D/B/A) L1 A O l ADDRESS OF BLSINESS Sf�Re S-�n4w[Lk . Vrj 62663 MAILING ADDRESS (IF DIFFER T FROM ABOVE) —J'ArMA`L ASUM ( A 10 6 W-- 954 3ag- EMAIL PHONE # FEDERAL ID# Do you currently ossess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form . (provided herein). Signature r Date Q:1Application Forms\TOBACCO APP2019 dob.docx f ; NOTES FOR NEW — ADULT ONLY RETAIL TOBACCO SHOPS Currently, no restrictions on the number of these shops in the town. Locations granted on case by case upon review of layout, entrances, etc. by Health. *Meet with Zoning / Building to verify location is ok'd with them, as well. Must be a separate, new establishment with its own Fed.I D. Must have State License to Sell Tobacco/Cigarettes in its own separate establishment's name. Must have customer entrance/exit door(s) directly outdoors. (For example, a kiosk at the mall would not be acceptable.) (Drive-through windows are not applicable at this time.) Must view and know new tobacco regulations. Must provide a general list of products they will be selling including the words "will only be selling tobacco and tobacco-related products". (as regulation specifies they are restricted to tobacco and tobacco-related products) Q:\TOBACCO\ADULT-ONLY RETAIL TOBACCO-Policy for New Jul 3 2019.docx r ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—§ 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein, to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Ver.fication is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation-.,and Chapter 270 Section 6 of the Massachusetts General Laws: Asw . YW� Sign Printed Name D to ��oh�r -�Q�t. � �► �� Signa Printed Name Dale Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP2019 dob.docx Town of Barnstable For Office Use Only: Initials: ti i Inspectional Services Date Paid Amt IM RNST Check# Cash * BAAHI,E, ` Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health . Fee: $85.00 � > c1 MAIL TO: TOWN OF BARNSTABLE l� PUBLIC HEALTH DIVISION jet 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT 0 Vf/* colejA 10bacw ESTABLISHMENT NAME (D/B/A) ADDRESS OF BUSINESS f "�,t S�cjxjwj-L AA L MAILING ADDRESS (IF DIFFERENT FROM ABOVE) -JAMAl- A&W 4 r- III G Hai WS - n�m 4q3- gS4- 3ag EMAIL PHONE# FEDERAL ID# Do you currently ossess a state license to sell tobacco products? Yes—A No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form :(provided herein). Signature Date S Q:\Application Forms\TOBACCO APP2019 dob.docx f pro ' rr„? Commonwealth of Massachusetts Letter ID:L1037817728 ,_{ = �i• Department of Revenue Notice Date:August 13,2019 Christopher C.Harding,Commissioner Account ID:CRL-19301711-007 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO A.JAMAL o= QASWA,INC. W_ TOBACCO MASTER Mew 367 SERVICE RD SANDWICH MA 02563-4302 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 •---------------------------------------------------------------------------------------------------------------------------------------------- S;'XC"I'tC MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T 1j, '(r 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. QASWA, INC. Account ID: CRL-19301711-007 TOBACCO MASTER License Number: 1174433792 606 MAIN ST# 4 HYANNIS MA 02601-5432 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: August 13, 2019 Expiration Date: September 30, 2020 ,SAS fist. Commonwealth of Massachusetts Letter ID:L2111559552 N Q Department of Revenue Notice Date:August 13,2019 Christopher C.Harding,Commissioner Account ID:SLS-19301711-008 00 mass.gov/dor SALES AND USE TAX REGISTRATION CERTIFICATE �I�nIIiI��iIIII�IIII�I�IIII�In����l�II�I��Il�ili�lll��Ir��I��i A.JAMAL o= QASWA,INC. w TOBACCO MASTER 367 SERVICE RD SANDWICH MA 02563-4302 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 •---------------------------------------------------------------------------------------------------------------------------------------------- MASSACHUSETTS DEPARTMENT OF REVENUE Form ST-1 T ' r Sales and Use Tax Registration Certificate This registration must be posted and visible at all rr:,v,.t,tit times. QASWA, INC. Account ID: SLS-19301711-008 TOBACCO MASTER Certificate Number: 637562880 606 MAIN ST#4 HYANNIS MA 02601-5432 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: August 13, 2019 1