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Home My WebLink About2014 Dec 10 - Tobacco Retail Inspection Check Form, ., D��:. 11. 2i�14 9: 05AM No. 2735 F. 3 , , . . � � Yj��d,�� Tobacco Retail Inspection Ch.eck � �st�b[i�hmQl3�t��G1�r)��-I' lnsoecfion Dste: �� Emplovce Name: [ns ectio '� ' i '1 � '�F�,�� Emulovea TIt1e:(Cir�le Ono) Owner Manager Snpervisos Clerk (J� uv Yurpoxe of Vieii:(Circic One) Rootinc[nspcction/Education Compiaint Rcceived Failed Compliance Check Follow-Up Suspcnsion of Permit ,' fnsQection Retailer Requestcd Eduuttipn OthcrPlease 5pecify IY Unable to�omul�;(Circle bne) Out of Busincss Closcd Na Longcr Sct1s Tobacco Ctosed-Scasonal Closed-Construetion Too$u.ry Other-Please Spccif� ts Cu[r�nt 6oard of Hcalth Tobscco reieiler permit posted? Y�' �N� TopiG�Iiiscu&sed with Merci� n�t�. ❑N/A Checkcd Permit Co�rent Mass DOR license posted? Ycs 0 No ❑ ��cw�d Regufations(fobaceo 5ales Laws I �. Only Cigarettes in pack's of 20 0�rt�o�e sold(No'Lo�'sies}? Ycs CE No 0 R.eraile�s Responsibility � � ❑ P;opar fdontification � Arc Sc1f Scrvice Dis !a � �Y� �� i p ys ir►Lcgal Location. �wA � Compli�nce Chccks(minors � may loak olde.t) i ❑Yes ❑No ❑ Pcnalties All humidors are loeked? i � . NJA ❑ T[ainings Largc ycllow signs(MQL)posbed? Yes�No � Requircd Sig�jtge Placcmcnt ❑ Smokc-Free Workplaoc Law If more than one regisir,s,small yeUo��signs(MGL)posted? ❑Xcs l7 No ❑ Rctailer�Cit Matcrials j�i�l/A 11�ateriata Given: No smoking si�►s posted? �--Ycs�No _.�apy of Rcgulations If single cigats sre sold,health waming sign ppsted whorc hand- Large Yellow(MGH)Sign(s) rolled or manufacturcd ci �Ycs ❑No gars outside of original package arc • �N/A � Small Ydlow(MCxH)Si�(s) displaycd7 � � ❑.,Cigar Hcalth Warning Sign(s} Employee agrcements on ftle(if cequired by Ioct�l regulations)7 ' �Yts C)Ne p No 5lmoldng Sign(s) (opaonal) �.NlA ❑ Retailer Kit/I'raining Msterials ❑Yes ❑No � �S�►Plc Employee AgrecmcnYs IP thtrt is s�et►ding machinc,dbc5 it trieef all re�ulatiOnS? �'d FAACCEuIallon violalloR�_nqted Wcrc Thcrc any violeGonS�ound7 Y� - ,�;fQ d�trMQ insvec lon� - �Flavored cigarctixs available for Are�rty'Under 27'tampaign items displsyed in[he 5[ore? ❑Yes(�-t�10 salo Doe.s chis esmblishmcnt hav�a liquot I�censo� p y��6 �Cigarettes avaitable with'low' mild'as dcscripmrs Whaz is the priee of the smalJcst single cigerilio available7 • "--- � �ve�ding machincs ira a non-adult Are there any frcc giveaways associaGed w;th tt+c purchase oFthis on1Y eaCablishmcnt ittm7 •• � �Y��0 ❑Sale vf loose cigarcttes �[vlolatioas found.DI �se circle w6fc6 act��,g�a txken: Educational Wtunicr.g Givcn kcferred w$OH $25 Fine �50 Pine 5100 Fine Other Pine(Ploasc Spccif)'): tes/Commenfs:�t� (, d,��G� �6i!//j/�j �yO�Q� (?,/Z��i"''[. FDA Adys �in¢reeulatioa !��,�� " y,lolations noted_i�u1'ias[nsvectiod, �a�k�,ruGc�S � t�"�1 ��. �� O Smokelessads �� ►i � �'-t w e�..e , �,-� S�tzsz..� � P�' �--� t,`,'�.S '�"��ue_c� .� �eS�d�a.�j .