HomeMy WebLinkAbout2001 Feb 22 - Tobacco Compliance Check Form MTCP(D: Q/D�� Tobacco Compliance Check Form 2000
� Section I:
Estabiishment � Survey Participants
Name: � Name oY Purchaser: /�.�/�.
y�uck Island Country Store or IDK
Address: g28 Buck Island Rd. A e: �--
S � Sex: � Male emale
W�. Yannouth, MA 02673
Name Af duit esco �°Collector:
City: /G� ./l./',/ / l`�.L�j
Sample Area(if smaller.than ci or town lease identif : - /I�� �
tY P Y Time of Check: ,� 5 am IYpm p
) /
� � Date of Check: �j�`�Q�
� Type of Establishment: ❑ Chain ��"Independent ❑ Not Known . �—
Style of Establishmen[(CheCk Only �n2): � �
Convenience Store . ❑ Pharmacy/Drug Store ❑ Gas Mini-Mart
❑ Gas Station Onty ❑ Grocery Store ❑ Liquor Store
❑ Department S[ore ❑ Bar ❑ Private Club(VFW, Legion,etc.)
0 Restaurartt Bar Area) ❑ Res[auran[(Other Area) ❑ Other bowlin alle Eolf club etc.
Section 2:
Did the youth enter the premises and attemp[to purchase a tobacco product? Yes No ❑ �
/jYes please continue on to the next question, if No p(ease skip�his sec�ion and go[o section 3.
. �was tobacco marketed? �
Over-the-counter.youth asks[he clerk for the product.
�. ❑ Over-the-counter:youth selects the product from a self-service display. �
❑ From a vending machine with a lockout device.
❑ From a vending machine without a lockout device.
Was fhePurchaser asked for ID? Yes ❑ No �—/ Was ID accurately checked? Yes ❑ No ❑ N/A L9`
Was the Purchaser asked his/her age? Yes❑ No �C3 �
Sex of Clerk: Male ❑ Female� Approximate a�e of clerk �S �'S ���� �,(�, �f �0� �r/�
� i�_„ �
Did the Clerk say any[hing to yqd when Ihe purchase at[empt was made?
/ y
Type of tobacco asked for. Gd Cigarettes ❑ Chew/Dip � Cigars Brand � ' /i ❑ Other Please specifi
Was the sale made? Yes ❑ No ❑ (if Yes how much did the product cost: $�. gS )
Section 3:
If[he youth did not en[er the premises or did not attempt[o purchase[obacco products please check here: O and indica[e whv
❑ closed for the day ❑ couldn't locate business ❑ buyer knows clerk/merchant ❑ admission charge
❑ closed for the season ❑ no longer in business ❑ establishment inappropriate for youth ❑ other(specify)_
❑ closed to the public ❑ doesn'[sell tobacco ❑ unsafe establishmen[ -
❑ denied admission at door ❑ vending machine broken ❑ unsafe area
Please call the MTCP Evaluation Director at (617) 624-5900 if you have any questions.