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Home My WebLink AboutLooking Glass Cafe 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD PERMIT 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:. CHRISTOS KALOGERAS Whose place of business is: THE LOOKING GLASS CAFE 310 NORTH MAIN STREET PERSON(S) IN CHARGE: CHRISTOS KALOGERAS, OWNER Permit Expires: December 31, 2016 License Number: FS -161 Food Fee: $62.50 Milk & Cream OO BOARD OF HEALTH NichaeCvicCtean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: CHRISTOS KALOGERAS having a place of business at: THE LOOKING GLASS CAFE 310 NORTH MAIN STREET 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 12131/2016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -161 Scott Leite, Heaah Agent 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 FS -161 FOOD ESTABLISHMENT PERMIT APPLICATION -__ pp�ca ion mus esu mi e a eafT- sf3iS-�be-lore fF►e pie opening�ate�- 1) Establishment Name THE LOOKING GLASS CAFE 2) Establishment Address 310 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 310 NORTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 406-1825 5) Applicant Name & Title: CHRISTOS KALOGERAS, SOLE PROPRIETOR 6) Applicant Address 171 WARE STREET, UNIT 8, MANSFIELD, MA 02048 7) Applicant Telephone No.: 24 Hour Emergency No.: (508) 406-1825 8) Owners Name & Title CHRISTOS KALOGERAS 9) Owner Address (If different from applicant) f_ -- Owner's telephone number 10) Establishment Owned By: ❑ An Association j ❑ A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 13) District Or Regional Supervisor (if applicable) 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: CHRISTOS KALOGERAS, OWNER Address: 171 WARE STREET, UNIT 8, MANSFIELD, MA 02048 Telephone No: (508) 406-1825 24 Hour Emergency No: (508) 406-1825 FAX: E-mail: - Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: I FAX: TEm ail - -— — - — Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN j 16) No. of Food Employees: DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SUN 6AM-3PM 18) Name of Person In Charge Certified in Food Protection Management: GRETCHEN M. KALOGERAS If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 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): 0 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) W Milk & Cream $5.00 I Moblie End Date: Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Moblie Comments: up to 10' PHF display $62.50 Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer 121 Length of Permit: g ❑ Annual or up to 25' PHF display $75.00 ❑ Pushcart $12.50 # of Pushcarts: 0 F] Food Service up to 201 + 25'+ PHF display $137.50 L] Residential Kitchen $50.00 ❑Seasonal ! or ❑ Retail Food $50.00 Seasonal Dates: ❑ Food Service - Institution E]Retail Snack Food $12.50 El Temporary Temporary Start Date: ( Meals/Da Y) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: j I Rain Date: 23) Food Operations Definitions: PHF -Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) !(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service _. F❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service - Delivery of Packaged PHFs ❑ rY g Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer --- ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑Vacuum Packaging /Cook Chill -- -- - ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) ❑ Offers Raw Or Undercooked Food Of ❑ Ice Manufactured and Packaged for Retail Sale i❑ Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale Animal Origin E] Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To becompleted by the Board of Health Total Permit Fee: $62.50 — - 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 comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 599.000 and the fede 1-Fobd Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties 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: 455-29-0167 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 June 1st of each year. NAME OF BUSINESS: THE LOOKING GLASS CAFE ADDRESS: 310 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 406-1825 FAX NUMBER: OWNER OF BUSINESS: CHRISTOS KALOGERAS TELEPHONE OF OWNER: FEDERAL ID/SS NUMBER: 455-29-0167 FEE: $5.00 PERMIT NUMBER: FS -161 SIGNATURE: DATE:' J j 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. * Signatyr'>gf-Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 4 ,5 z ** S cial Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. 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 Business/Organization Address: City/State/Zip U Phone #: � � Li -) �{ � b Are yop,.an employer? Check t _ ppropriate box: Business Type (required): 1. I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. [ testaurant/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]* I 1 ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'.comp. insurance req.] 12.❑ Other *Any applicant that checks box Hl 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 {I1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Ad City/State/Zip: Policy # or Self -ins. Lic. #, 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 DTA for insurance coverage verification, I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct t9 ..t Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person Permit/License # 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www.mass.gov/dia Phone A� " CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 6/14/2016 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 WOOdCOm@ Insurance Agency, Inc. 166A Hamilton Street Leominster MA 01453 NAME CT Alan R. Piro, CISR FAX AHCNNo E : (978) 840-8700 A1C No: (978)840-0440 E-MAIL ADDRESS: apiro@woodcome.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Preferred Mutual Ins Company 15024 INSURED Christos Kalogeras DBA Looking Glass Cafe 56 South Street Wrentham MA 02093 INSURERB:Hartford Ins Co of the Midwest 37478 INSURER C: INSURER D: INSURER E: INSURER F: r]nVFRAr;FS CFRTIFICATF NIIMRFR-16-17 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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 I TYPE OF INSURANCE ADDL D SUBR WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE W OCCUR BOP0100721601 12/3/2015 12/3/2016 EACH OCCURRENCE $ 1,000,000 DAMAGEPREMISES S( RENTED 50 000 $ Ea occurrence� MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑PRO LOC JECT OTHER: GENERAL AGGREGATE $ 2 , 000 , 000 PRODUCTS -COMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NO OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT $ Ea acadeni BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/NE.L. OFFICER/MEMBER EXCLUDED? Y❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 08WECEH7413 6/1/2016 6114=17 >7_..:: X PER OTH- STATUTE ER EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Christos Kalogeras is not covered by the Workers Compensation r`PRTIPIr_ATF 41ni nFR CANCELLATION ------- ------------- Roguel230@comcast.net SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE Alan Piro/APIRO U 1953-ZU14 AGOKU GOKF'OKA I ION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 rgnunn 1 k e �a$ ( LL- \�\ / } \\ 0\ .\� Lo% Zu ƒ � \ \ zr� § U g / 2 ƒ \± u- U) _0 § , .E ! k § Lu ƒ C) A � ± / ± ( 4)o o ' 2 q } ® . \ \ < ƒ v ƒ C \ p Z.2 U)q Z c �� w< 0\z 0 : ƒ $ U) LIC) -Z \c\<• LM IMM \ E� \O\ \O^ 8f ® Cjd CN > \ Lu 7 � § \ i ?0 CL / E \ _ / _ Lu R �F \O < O 4 u ƒ ƒ ./ o Ga e �a$ �0� � 7 \�\ / } \\ 0\ .\� Lo% Zu \ \ zr� ALLERGEN Name of Recipient:, Christos Kdogeras Certificate Number: CW107690 Date of Coriipletion: 041__17/2015 Date of Expiration: 04/15/2020 The above-named person is hereby issued this certficate for completing an allergen awareness training program recognized by the Massachusetts Department of Public Health in accordance with 105 CMR 590.009(G)(3)(a). This certificate will be valid for five (5) years from date of completion. .o Issued By: LOiitNu�s'OiitS CompuWorks Systems, Inc. 591 North Avenue, Door 2 Wakefield, MA 01880 P:781-224-1113 F.781-224-0504 www.compuworks.com