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HomeMy WebLinkAboutLooking Glass Cafe 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: FOOD ESTABLISHMENT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. GRETCHEN KALOGERAS Whose place of business is: THE LOOKING GLASS CAFE 310 NORTH MAIN STREET PERSON(S) IN CHARGE: GRETCHEN KALOGERAS, OWNER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-93 BOARD OF HEALTH -%1ichaeC.fA1cCCean, Chairman Milk & Cream C0] Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: GRETCHEN KALOGERAS having a place of business at: THE LOOKING GLASS CAFE 310 NORTH MAIN STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-93 Board of Health Mlchae(McCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION ------ —� pp ica ion must be submftted at leastdays before the plan opening dalbr_. 1) Establishment a e o_I - 2) Establishment Address SID — ---- 3) Establishment Mailing Address (if different), 4) Establishment Telephone No q - cA164 - 4b* G( 5) Applicant Name & Title: . j l� I Y 1 1 6) Applicant Address �� %�- — - 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title - _ 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: ❑ An Association ❑ A Corporation PAn Individual ❑ A Partnership El Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: nqt a -- Address: 1man�sG_ Telephone Telephone No: 24 Hour Emergency No: rr��)_�lo y � ` FAX: E-mail:-- Alt E-Mail: kj 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 15 r{wi:o'li Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL:( 16) No. of Food Employees: DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS rn� j _ o nS�4(1fa/ I 18) Name of Person In Charge ertified in Food Protection Management: 9Ct 11¢n Y�ci�C0�Ll If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: Permanent Location 22) Establishment Type ❑ Caterer $25.00 ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) [R`Mllk & Cream $10.00 Mobile End Date: ood Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Dessertslice Cream reezer 21) Length of Permit: Annual or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Pushcart $25.00 # of Pushcarts: ❑ Residential Kitchen $100.00 ❑Retail Food $100.00 ❑ Seasonal Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $25.00 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Definitions:PHF - Potentially hazardous food(fimeAemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) RTE -ready--too-eatfoods (Ex.sandwiches,salads, muffins which needno furtherprocessing) ❑ Sale of Commercially Pre -Packaged Non-PHFs F PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs ❑Preparation of PHFs For Hot And ElPHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service - ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ---- ❑ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) _ ❑ Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service ❑Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by fhe Board of Health Total Permit Fee: Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comp)gyj7w�jh 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain cdbi�'s of 105 CMR 590.000 and the federal Food-6odtf 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the-p6nalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. _ 25) Social Security Number or Federal ID: V I v •J� v 3�.aj 26) Signature of Individual or Corporate Name: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: �o'3" � "% ADDRESS: 3vD YJWA,1rl a ftp"j , MR 1R 03-04(_? TELEPHONE AT LOCATION: -�-) 7 J')bm - `t eA of I1NAZI1 itil:34Z1 OWNER OF BUSINESS: TELEPHONE OF OWNER: FEDERAL ID/SS NUMBER: W* 3oq1 ?' FEE: $10.00 1»¢3i't111i1![11]it11 440 SIGNATURE: DATE: } �\ 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 Applicant Information Please Print Legibly Business Address: City/State/Zip: Phone #: qJS - `Uo- plk ) Are you an employer? Check the appropriate box: Business Type (required): 1. 2'I am a employer with �D employees (full and/ 5. ❑ Retail or part-time).* 6. [ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11 •❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 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 41. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: 111A N U l b\-W \ � t � t" U �`r�� `" > Policy # or Self -ins. Lic. # 01WEC -/F— —YAS-1) 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 25A 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. I do hereby c fitt y, under the pains and penalties ofperjury that the information provided above is true and correct. Phone #: LIZ_44 0(o--2�L, P-)1 Official use only. Do not write in this area, to be completer/ 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.nmss.gov/dia A� " CERTIFICATE OF LIABILITY INSURANCE DATE,MW°°"""' ,2112/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIS), AUTHORIZED ( REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Alan R. Piro, CISR, CPIA NAME: Woodcome Insurance Agency, Inc. AIC°N n (978)840-8700 aC se : (978)840-0440 E-MAIL a iro woodcome.com ADDRESS: p 166A Hamilton Street INSURER(S) AFFORDING COVERAGE NAICM INSURERA: Hartford Ins Co of the Midwest 37478 Leominster MA 01453 INSURED INSURER B : INSURER C : Christos Kalogeras DBA Looking Glass Cafe INSURER D: INSURER E : 56 South Street INSURER F: Wrentham MA 02093 COVERAGES CERTIFICATE NUMBER: 17-18 Workers Comp REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR rypE OF INSURANCEADDLUUOK INSD WVD PODCYNUMBER POLICY EFF MWDDIYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS -MADE OCCUR PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMPIOPAGG $ $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaacciden( $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Par accident) $ PROPERTY DAMAGE Peraccidenl $ HIRED NON OWNED AUTOS ONLY AUTOS ONLY 8 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERTUABILITY YIN ANY PROPRIETORIPARTNERIEXECITTJVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) NIA OBWECEH7413 06/01/2017 O6/01M$- X SPERTATUTE OTRH- `EL. EACH ACCIDENT -- $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under DESCRIPTION OF OPERATIONS belay E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD101, Additional Remarks Schedule, may be attached it more space is required) The Workers Compensation policy does not cover Chdstos Kalogeras. Coverage includes location at 350 N. Main Street, Mansfield, MA 02041. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02046 ©1988-2015 ACORD CORPORATION. All rights reserved. TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. 17 Signature of In ' idual or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Usem\sleite\Uesktop\ScoWs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 12/14/2017 XFINITY Connect Your Training Confirmation Be,. When Seconds Count 9:19 PM Q To rogue1230@comcast.net Dear Gretchen Kalogeras, Thank you for your registration for the following class: Class: Adult, Child, Infant Choke Saving Class Date: T� 018 from 3:30 PM to 4:30 PM I- Receipt: Click Here Location: When Seconds Count Training Center - Salem MA Directions: 97 Boston Street Salem, MA 01970 Q� z *-.4 z : a2 � � � W4 z § n � k § \ § � ) E � � � § k � k ' C \ : w (D 4 J R k \ 21 \ / { `\ \ / 0 0 0 o. C za ° � Z W a o c u December 1, 2017 To Who it may concern: Due to unfortunate circumstances, my husband, Christos Kalogeras, the listed owner of The Looking Glass Cafe, and I are divorcing. I have included a court order issued that prohibits Mr. Kalogeras from entering the premises of The Looking Glass Cafe located at 310 North Main Street, Mansfield MA, and authorizing myself, Gretchen Kalogeras, to run and operate the business. I have been successfully operating the business since the issuance of the order on March 15, 2017. 1 file these applications on behalf of The Looking Glass Cafe to continue operating this successful business in Mansfield. Regards, Gretchen Kaiogeras COMMONWEALTH OF MASSACHUSETTS THE TRIAL COURT PROBATE AND FAMILY COURT DEPARTMENT Bristol, ss. Docket No: BR16DI513DR Gretchen M. Kalogeras, Plaintiff VS. Christos G. Kalogeras, Defendant TEMPORARY ORDER On Complaint for Divorce filed on October 14, 2016 Pending a hearing on the merits or until further order of the Court, after hearing, IT IS ORDERED that: 1. Wife shall have the exclusive right to run the restaurant business located in Mansfield. 2. Husband shall have the exclusive right to run the restaurant business in Wrentham. 3_ Each party shall refrain from entering the other's restaurant and shall solely be responsible for the day to day business of his/her respective location. 4. Both parties shall keep and prepare a full accounting of his/her respective business and shall present the same on the 15" of each month for the previous month to their respective attorneys who shall forthwith share the same with the other party. 5. The parties have a son Nelson who is nine years old. The Parties did not argue as to parenting time and as such the Court orders the parties to share legal and physical custody with a parenting plan that they may reasonably agree to such that Nelson is afforded the benefit of as much time as possible with each of the parents who shall attempt to cooperate with regard to all matters concerning his well being. 6. There shall be no child support paid by either party at this time. Wife shall have exclusive use of the marital home and shall be responsible for all payments associated therewith. 8. Nelson shall continue to be covered under Mass Health. March 15, 2017 Date: eter Smola, Associate Justice Probate and Family Department