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Tobacco Product Manufacturer (TPM) Certification - Massachusetts
| Tobacco Product Manufacturer (TPM) Certification Form. This is a Massachusetts form and can be used in Tobacco Enforcement Attorney General Statewide . |
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COMMONWEALTH OF MASSACHUSETTS TOBACCO PRODUCT MANUFACTURER (TPM) CERTIFICATION (M.G.L. c. 94F) (February 2012) Please type, or print legibly in permanent blue ink. Select one (see instructions): Initial TPM Certification Annual TPM Certification Supplemental TPM Certification PART I: MANUFACTURER INFORMATION (All TPMs) Company Name: Street Address: Mailing Address: Website: Contact Person: Telephone: Fax: Email: Manufacturing Address: Name of Factory Manager(s): Telephone: Fax: Manufacturer's Federal Taxpayer ID Number: TTB Manufacturer or Importer Permit Number: Name and Title of Person Completing this Certification: Expiration: Telephone: Fax: Email: TPM Certification Page 1 of 6 Rev. 03/2012 American LegalNet, Inc. www.FormsWorkFlow.com PART II: PM/NPM Status (All TPMs) The undersigned certifies that, as of this date, the above-named manufacturer is (select one): a Participating Manufacturer ("PM") under the MSA a Non-Participating Manufacturer ("NPM") in full compliance with M.G.L. c. 94E and M.G.L. c. 94F, and implementing regulations, and has made all required deposits into a qualified escrow fund approved by the Attorney General for sales in Massachusetts since June 29, 2000. PART III: BRAND FAMILY and BRAND STYLE INDENTIFICATION A. ALL MANUFACTURERS (see Instructions) In conjunction with this Certification you must submit by email or on CD-ROM an Excel spreadsheet listing cigarette Brand Styles and RYO Brand Families you manufacture, including discontinued brands and brand styles that you believe are still in the stream of commerce. Include for each cigarette Brand Style the 12 or 13 digit UPCs appearing on the carton. You must notify the Attorney General and Department of Revenue at least 30 days in advance of any changes in the UPCs. Products with unreported UPCs will not be able to be sold in Massachusetts. By listing these Brand Styles and Brand Families, a Participating Manufacturer affirms that they are deemed to be its Cigarettes for purposes of calculating its payments under the MSA for the relevant year, in the volume and shares determined pursuant to the MSA. By listing these Brand Styles and Brand Families, a Non-Participating Manufacturer affirms that they are deemed to be its Cigarettes for purposes of M.G.L. c. 94E. B. NON-PARTICIPATING MANUFACTURERS (see Instructions) 1. State the quantity of Units Sold for each Brand Family for which you are the TPM. Brand Family and Additional Information (see Instructions) Cigarette Cigarette Cigarette Cigarette Cigarette Cigarette Cigarette Cigarette Use additional sheets if necessary. 0.09 oz. of RYO constitutes one unit. TOTAL UNITS SOLD (2011): Escrow Deposit for Sales in 2011 x $0.0282581 = Units Sold in MA (2011) RYO RYO RYO RYO RYO RYO RYO RYO Total from additional sheets: TPM Certification Page 2 of 6 Rev. 03/2012 American LegalNet, Inc. www.FormsWorkFlow.com 2. NPM Supplemental Documentation NPMs must attach the following as exhibits to this Certification: a. Attach documentation such as sales invoices to substantiate the reported RYO units sold in Massachusetts during 2011. This documentation must identify the name and address of the entity (wholesaler/distributor/ retailer/consumer) to which the RYO was sold, and identify the brand name and quantity of units sold. Please note that this documentation is required for all RYO sold in Massachusetts, regardless of whether it is a direct sale or through a distributor (whether or not located in Massachusetts). b. State the address(es) where each Brand Family was manufactured, if different from the addresses provided Check here if not applicable in Part I. c. State the name and address of any other manufacturer (including prior manufacturer) of each Brand Family, and the applicable time period(s). Check here if not applicable d. State the name and address of the trademark holder for each Brand Family, if it is not the Company. Check here if not applicable e. State the name and address of the person, if it was not the Company, who made the most recent filings of the following: health warning rotation plan (15 U.S.C. §1333(c); 19 U.S.C. §1681a(a)(3)); ingredient list for each Brand Family (15 U.S.C. §1335a(a); 19 U.S.C. §1681a(1)); and nicotine yield report (M.G.L. c. 94, §307B(b)). Check here if not applicable PART IV: ALL TPMs SUPPLEMENTAL DOCUMENTATION A. Provide a sample of the packaging for each Brand Style, unless you have previously provided packaging samples which have not changed. An electronic representation (e.g., CD or DVD) is preferred. Check here if you have previously provided packaging samples and the packaging has not changed in any manner. Date: Please note that a Supplemental TPM Certification is required for any packaging changes subsequent to the date of this Certification. B. For each Brand Style of cigarettes listed in Part III.A., provide a copy of the current Federal Trade Commission approval letter for the health warning rotation plan. Not applicable to RYO. C. For each Brand Style of cigarettes listed in Part III.A., provide a copy of the current Center for Disease Control and Prevention ingredient-listing compliance letter(s) pursuant to 15 U.S.C. §1335a(a); 19 U.S.C. §1681a(1). Not applicable to RYO. D. For each Brand Style of cigarettes and/or RYO listed in Part III.A., provide a copy of the current Center for Tobacco Products ingredient-listing compliance letter(s) pursuant to 21 U.S.C.A. § 387d. E. For each Brand Style of cigarettes listed in Part III.A., provide a copy of the Massachusetts State Fire Marshal's approval letter, including the listing of each Brand Style certified as Fire Standard Compliant. Not applicable to RYO. F. For each Brand Family listed in Part III.A., indicate the owner of the trademark. If different from the certifying Company, indicate whether the owner is an Affiliate of the Company. If the owner is not an Affiliate, provide contact information for the trademark owner, and a copy of all manufacturing agreements or other documents granting the certifying Company the right to manufacture the cigarettes or RYO. G. Provide a copy of the Company's TTB Tobacco Manufacturer and/or Tobacco Importer Permit(s). TPM Certification Page 3 of 6 Rev. 03/2012 American LegalNet, Inc. www.FormsWorkFlow.com H. Provide a notarized statement that the Brand Styles listed in Part III.A are not subject to the ban, effective September 22, 2009, by the Food Drug and Cosmetic Act (as amended by the Family Smoking Prevention and Toba
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