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HomeMy WebLinkAboutBLDCI-17-006523-02 • • t, . The Commonwealth of Massachusetts ' -:i1 City\Town of I. tit=kb' YARMOUTH ,` :. New and Renewal Certificate of Inspection In accordance with the Massachusetts State Building Code,Section 110.7 Identify Name of Establishment Certificate No. • Issued to Business Name:GRAND CAFE BLDCI-17.00652302 Trade Name:GRAND CAFE Identify property address including street number,name,city or town and county Certificate Expiration Located at 80 ROUTE 28 12/31/2019 WEST YARMOUTH,MA 02673 Use Group Floor - Occupancy Use Group Other Classifications(s) A-3 01st Floor 92 A-2 Nightclub/Restaurant/Bar/Banquet Hall 92 PERSONS Allowable Occupant Load This certificate 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 glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to pose or tampering with the contents of the certificate is strictly prohibited Name of Municipal Name of Municipal Mark Grylls Date of /�/O .jzir Building Commissioner Inspection —431 Signature of Municipal Air/ i Signature of Municipal / J/ / Date of I� Building Commissioner CL� ' Issuance /�/ i ./ _ /i%/ /Z/O �(/ Fee:$100.00 • BLD_Certoflnspection.rpt j D TOWN OF YARMOUTH =F' 7 BUILDING DEPARTMENT �, ,i 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION November 13,2018 PAYABLE UPON CEIP (X) Fee Required $100.00 ( ) No Fee Required', In accordance with the provisions of the Massachusetts State Building Code, Section 110.7,I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: cgt3 ¶( k` (2.-K We5{- grevwou'-(I •--tA- cg. 60( Name of Premises: g . co" Q A C Y (—ZIP CS-0- Purpose for which permit is used: inns Q5 fro{u,./' a VT- R E C IVED License(s)or Permit(s) required for the premises by other governmental agencies: _ • License or Permit Agency NOV 2 9 2018 BUILDING DEPARTMENT 11 (XAOY By mob sen,; ca 50£s-tWia-&�SFs� Cat l }c,r Certificate to be issued to ,CAN'S (tts%nun/a$7t Tel: t1-4_L(1.o -65-6 Z- I ns{eC tM' Address: $0 1.o:r4o 27. Wcc-E -iNvVN02 oort I-t2, 6 3 Owner of Record of Building G@oV�Q Ob2L 5 0hMtcltS Address 25 . s nom, - k'wt,2f :o So.n Sv Co . Present Holder of Certificate 'vnvt. Cee tit, Os-0.,C_ 4 - 4 < < go trine fl 4' - 7 y #tco tests C, yy 07tn ;C/t- ,//29 //so Signature operso to whom Lain SSC L/ n Title Certificate is issued or his agent Of7 7 Date Email Address: 1-u;S?RQgaat( P k' skt•-Qni l •CoC ( . Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth,MA 02664 Return this application to: 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 of Inspection# Reba- // 006523-o z- 12/31/2018-12/31/2019 12/31/2018-12/31/2019 ✓ `JACann* PAGUA-1 OP ID: DS kfam ...----- CERTIFICATE OF LIABILITY INSURANCE I DATE(MWDO/YYYY) 11/27/218 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 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 508-775-6060 CONTACT Bryden&Sullivan Ins Agency HAM Bryden &Sullivan Insurance Ag 88 Falmouth Road PHONE 508.775-6060 Hyannis,MA 02601 - (a°'No,Est): I(A/C,o,N,).508-790-1414 Bryden&Sullivan Insurance E-MAIL INSURERIS)AFFORDING COVERAGE NAIC R ..... INSURED Grand Cafe Restaurant Inc.--------__ _ INSURER A:The Hartford____—_.____ 80 Rte 28 - INSURER 13:SCOTTSDALE INSURANCE COMPANY 41297J West Yarmouth,MA 02673 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF ICATE INSURANCE NUMBER: L LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD REVISION NUMBER: 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 ADDL SUER LTR TYPE OF INSURANCE INSR Nvn POLICY NUMBER POLICY EFF POLICY EXP B X COMMERCIAL GENERAL LIABILITY IMMIOD/YYYY) (MMlDO/YYVYI LIMITS CLAIMS MADE OCCUR l:PS3032681 EACH OCCURRENCE $ 1,000,000 04/26/2018 04/26/2019 PREMISES En occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 GEN'L AGGREGATE LIMIT APPLIES PER: PERSONALa ADV INJURY $ 1,000,00 X POLICY LI PELT 0 LOG GENERAL AGGREGATE 2,000,000 OTHER: _PRODUCTS-COMP/OP AGG 3 2,000,000 AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT _ ANY AUTO Ma vrjdentl $ OWNED — SCHEDULED AUTOpS ONLY _ AUTOSSW BODILY INJURY(Per person) $ AUTOS ONLY _ AUTOS.NPD BODILY INJURY(Per accident) $ PROPEpdenI AGE IPer accident Y $ UMBRELLA LIAR OCCUR $ EXCESS LIAR CLAIMS-MADE AGGREGATE EACH OCCURRENCE _$ DED I I RETENTIONS $ A WORKERS COMPENSATION § AND EMPLOYERS'LIABILITY I PER 1 I OTM- ANYPROPRIETORIPARTNEFt/EJ(ECVINE Y/N O8WECAA2S20 ISTATUTE l IFR PqFFICERMIEMBER EXCLUDED? I N I NIA 05/04/2018 05/04/2019 500,000 {MarMatory In NH) Et EACH ACCIDENT $ If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below El.DISEASE•POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) Liquor Liability.$1,000,000 Each Occurrence $2,000,000 Aggregate CERTIFICATE HOLDER CANCELLATION YARMO03 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN YARMOUTH TOWN HALL ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MAIN ST S.YARMOUTH, MA 02664 A THOR�D REPRESENTATIVE Bryden&Sullivan Insurance I Q /` `-,e .+tetl .J. ..0i-.ACORD 25(2016/03) ©1988-2015 ACORD(CORPORATION;,All rights reserved. The ACORD name and logo are registered marks of ACORD kk�a „ g • The Commonwealth of Massachusetts .l —_—_ Department of IndustrialAccidents ”! += , Office of Investigations `n= • r. 1 Congress Street,Suite 100 "1'= Boston,Mel 02114-2017. • www.massgov/dia Workers' Compensation Insurance Affidavit General Businesses Applicant Information Please Print Legibly Business/Organization Name: f (Av &1 C AFQ , CLec .c rv'c&set t v C Address: 9 O ou k-a D City/State/Zip:(MA--'A(LNAN00.4 tj mkt b2_61.3 Phone#: '} R-'—'41-o - 6 S 62 Ar�e you� an employer?Check the appropriate box: Business Type(required): 1.�`A� I am a employer with employees(full and/ 5. ❑Retail �r part-time).' 6. �estaurant/Bar/Eating Establishment 2.Lid I am a sole proprietor or partnership and have no 7. 0 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. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]" 11.❑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#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 wodms'compensation policy is required and such an organization should check box#I. I am an employer that isprovidinAworkers'1compensaation insurance for my employees Below is the policy information. Insurance Company Name: i� CD-Nl Q.\A CX 5 u 1\l Va. . Insurer's Address: [ Q L ‘1,0 n City/State/Zip: WA A A./.ttii 5 M P-- 02 Go Policy#or Self-ins.Lic. UJ E C..A A 2 S 2-0 Expiration Date: bs'/Od-I,o) n iq 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 e. 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 certify,under the pains and penalties of perjury that the information provided above is true and correct Signature: jLtseOr Date: ///2 / /57 Phone#: 50t) a92- cc Ru Official use only. Do not write in this area,to be completed 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 IContact Person: Phone#: Q wwwmass.gov/die BUILDING • 49�pC TOWN OF YARMOUTH ELEarRI . .. . .„,-4 ii 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 ' Telephone(508)398-2231,Ext.1261 —Fax(508) 398-0836 PLUMBING SIGNS BUILDING DEPARTMENT .- ?S` Inspection and License Report Date ��'"%g Address —,R�-NSC— Business Name G 9 ll7 Ci�ele" Con'• Phone During the Annual Inspection of your premises,performed in accordance with the provisions of Section 110.7 of 780 CMR(Massachusetts State Building Code),the Board of Selectmen,and/or the Board of Health rules,the following violation(s)were observed: Egress • ❑Emergency egress signage Location ❑ Emergenryegress lighting Location �(` c'1C)6/(1 A / I la Maintenance ofexits Location C fL/\ «•• // ❑ Guards/handrails Location v ‘../ Zansag ❑Signs Location L . - ❑ Parkbig Location ❑ Other Location Mechanics( ❑ Combustion Air Location ❑ Storage inBoilerRoom Location ❑Vents Location ❑Automatic door closures on boiler room doors Location ❑ Clothes dryer vents Location aim Location The State Building Code,Section 1001.3-Maintenance,provides that the owner as defined in Section 780 CMR shall be responsible for proper maintenance. In order to abate the above violation(s)volt must o Make corrections immediately and contact this office for a follow-up inspection. o Make corrections prior to opening and contact this office for a follow-up inspection. o Make corrections prior to your next annual inspection. o Make corrections within 5— days and contact this office for a follow-up inspection. LocalOfficial/Inspector A/1-0 Dike,/ - Received By r' `s ')� ver),.j� Tale / Revised 2/8/13