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Home My WebLink AboutCI 1987-06V The Commonwealth of Massachusetts City\Town of New and Renewal Certificate of Inspection In accordance with 780 CMR, Chapter 1(The Sixth Edition of the Massachusetts State Building Code) and Chapter 304 of the Acts of 2004 (an Act to further enhancefire and life safety), this certificate of inspection is issued to the premise or structure or part thereof as herein identified. Idents Name of Establishment Cert ykate No. Issued to SANDBAGGERS @ BASS RIVER GOLF COURSE 1987 Idents property address including street number, name, city or town and county Certificate Expiration Located at 62 HIGHBANK ROAD FEBRUARY 18,2007 SOUTH YARMOUTH, MA 02664 Basement First Floor Second Floor Third Floor Fourth Floor Other Use Group Classification(s) A-3 73 PERSONS Allowable Occupant Load This certy!wte of inspection is hereby issued by the undersigned to certify that the premise, structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall be framed behind clear glass and\or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to post or tampering with the contents of the certy1cate is strictly prohibited. Name of Municipal RANDALL SHERMAN Name of Local ANDREW ARNAiILT Date of Fire Chief Building Inspector Inspection // 7-4 i! Signature of Municipal Signature of Local Date of Fire Chief Buil g Inspector Issuance V .A* ;OF'YAR of c Date: TOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 260 APPLICATION FOR CERTIFICATE OF INSPECTION PAYABLE UPON RECEIPT (X ) Fee Required $ 50.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 106.5, I hereby apply for a Certificate of Inspection for the below -named premises located at the following address: Street and Number. Name of Premises: s �� la�(FRt Trel: 146 Purpose for which permit is used: SVK 0 C License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit R C1,0 By: Certificate to be issued Address: Owner of Record of Bt Address 4(A Present Holder 6171S-Wi Signature of pers6n-to whom Certificate is issued or his agent Agency11�. r i< Instructions: Make check payable to: Town of Yarmouth Return this application to: (01II Title Dat 1146 Route 28, South Yarmouth, MA 02664 Building Inspector's Office Please note: Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified. Application must be received before the certificate will be issued. The building official shall be notified within ten (10) days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate - Z�� 04 - `/17/7 AEOW. CERTIFICATE OF LIABILITY INSURANCE DATE 03/22/2006 VYYI 03I22I2006 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ADD' ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ROGERS & GRAY -SOUTH DENNIS BRANCH HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P 0 BOX 1601 SOUTH DENNIS, MA 02660 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW ITR (888),661-3938 TYPE OF INSURANCE XW885 700 INSURERS AFFORDING COVERAGE NAIC # INSURED ! JAMES M ROGERS INSURER A:THE TRAVELERS INDEMNITY COMPANY OF AMERICA -- INSURER B: D/BIA SANDBAGGERS INSURER C: 62 HIGHBANK ROAD INSURER D: SOUTH YARMOUTH, MA 02664 INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD' POLICY EFFECTIVE POLICY EXPIRATION ITR INNIP� TYPE OF INSURANCE POLICY NUMBER DATE MM/DDIYY DATE(MMIDDIYYI LIMITS_ A X GENERAL LIABIETr 680-8451 B109-06 04/09/2006 04/09/2007 EACH OCCURRENCE $1 000 OOO X COMMERCIAL GENERAL LIABILITY CLAIMS MAOF � OCCUR .. _- - - - -- DAMAGE TO RENTED g 300,000 MED EXP An one rson 115OOO X HIRED AUTO PERSONAL d ADV INJURY $1,000,000 X NON OWNED AUTO GENERALAGGREGATE $2,000,000 COMPIOP AGG s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: Pao - X POLICY El JECT FILOC AUTOMOBILE UABILR`Y COMBINED SINGLE LIMIT (Ea accident) 9 ANY AUTO ALL OWNED AUTOS BODILY INJURY [Per person) E SCHEDULED AUTOS HIRED AUTOS BODILY INJURY (Per accident) S NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) S GARAGGARAGE LIABILITY E - AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACC S ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE 3 S $ DEDUCTIBLE $ RETENTION S WORKERS COMPENSATION AND W A U• TH R IMI R EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERlEXECUTIVE E.L. EACH ACCIDENT $ E.L. DISEASE EA EMPLOYEE $ - - - - - - OFFICER)MEMBER EXCLUDED?. _ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE • POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER IS NAMED ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES FOR THE FOLLOWING LOCATION: 62 HIGHBANK ROAD, SOUTH YARMOUTH, MA 02664 CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH MAIN STREET SOUTH YARMOUTH, MA 02664 ACORD 25 12001/081 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 7i ORD CORPORATION 198 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsementls). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. TOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 261 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG C�,D y NAME Sand Baggers Pub At B. R. ADDRESS 62 Highbank Rd. S. Y. This log is to be signed by the' appropriate inspectors upon a satisfactory inspection of your building/premises. When all signatures are obtained, this log shall be presented to the License & Permits office and/or the Health Department in order to obtain your license. Licenses will be withheld until all inspectors have signed. Building sione p Date Comments Approved for License Issuance UYe's ❑ No Fire Department Rep. Date Comments Approved for LJcenselssuance d 1 >F ,yes ❑ No 1 Is b Board of Health Rep. Date Comments Approved for License Issuance —75 3 ��es ❑ No Plumbing/Gas Inspector . Date Comments Approved for License Issuance ❑ Yes ❑ No Electrical Inspector Date Comments Approved for License Issuance MYes ❑ No Taxes Paid ❑ Yes ❑ No Rcv.sert 2003 TOWN OF YARMOUTH BUILDING DEPART 1146 Route 28, South Yarmouth, MA 0Zi, 4� ctiny,508-398-2231 ext. 261 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG NAME BASS RIVER SNACK BAR ,SAtyDQa66F-R'3 evu ADDRESS 62 HIGHBANK RD. S. Y. This log is to be signed by the appropriate inspectors upon a satisfactory inspection of your building/premises. When all signatures are obtained, this log shall be presented to the License & Permits office and/or the Health Department in order to obtain your license. Licenses will be withheld until all Inspectors have signed. Building Co mis io er Date Comments Approved for License Issuance /� 7•D G e—Yes— ❑ No Fire Department Rep. Date Comments Approved for Lic se Issuance 4AW14�/6 r Yes 13 No w-. Board of Health Rep. Date Comments Approved for MM s Lic eIssuance SElq" y1/Yes ❑ No -723 Plumbing/Gas Inspector Date Comments Approved for License Issuance ❑ Yes ❑ No Electrical Inspector Date Comments Approved for LI se Issuance rt , ❑ No Taxes Paid ❑ Yes ❑ No Rev.SepL 2003