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Home My WebLink AboutBld-20-002135 31D - 076 -62W33` Town of Yarmouth Building Department 1146 Route 28, South Yarmouth, MA 02664 tel. 508-398-2231 ext.1261 Use and Occupancy Permit Application In accordance with the provisions of the Massachusetts State Building Code, section 105.1 Application for a certificate of use and occupancy permit Name of Business p�s Fiume , , 4 /o57.- Property Address lr�5 / 4- 2 Unit# Type of Business *Square Footage to be occupied goo *attach floor plan Fee: $60 The applicant is required to obtain approval sign-offs from the following departments as checked off below: Cotil .1( 0.)( Health Department— 508-398-2231 ext. 1241 ikWX Fire Department— Fire Prevention, 96 Old Main Street, 508-398-2212 Other --e(/eve°;‘ Building owners Signature Applicant Signature Please note: this permit is for use and occupancy only. Any work requiring a building permit will require a licensed contractor to submit an additional application with all the required information based on the scope of the project. **Office use only** Zoning District 12... Proposed Use Change of Use: Yes No1( Allowed Use: Yes N o APD Waiver: Yes No N/A Q'l8 Building Officials Signature Date OCT 1 h 0,15 CO* I�`17 _ "� The Commonwealth of Massachusetts _ / Department of Industrial Accidents i S. 7, 1. 1 Congress Street,Suite 100 _�1= A Boston,MA 02114-2017 "^ .,=,4. • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information ,/ Please Print Legibly Name (Business/Organization/Individual): S .AL �,/ ,' y S/ ---G.Ar,ylcaG,c.e/l Address: 0gr k City/State/Zip: , z4ltsIf4 d ,tf Phone#: S -5-75/ 5 SO Are you an employer?Check the appropriate box: i• employer with _employees(full and/or part-time).* Type of project(required): 2.0 I am a sole proprietor or partnership and have no employees working for me in 7. 0 ReW Jelin construction any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9 0 Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees 11.(�Electrical repairs or additions 12. Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 13.❑ 6.0 We are a corporation and its officers have exercised their right of exemptionper MGL C. 14. 152,§1(4),and we have no employees. P ❑Other emP oY [No workers'comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'com pensation insurance for my e information. mployees. Below is the policy and job site Insurance Company Name: aiitl i7AZ `,,Jm J// • ____ Policy#or Self-ins.Lic.#: 0/'400 So 3't/C 3 7// Expiration Date: //—a030 Job Site Address: 's ,� ger' City/Sta Attach a copy of the workers' compensation policy declaration page(showing the policy number , Failure to secure coverage as requiredexpiration date). under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the ins and penalties of erjury that the information provided above is true and correct Si ature: t Date: I G /-/ , Phone#: e7 S7 3 So 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.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: TNTFAMI-01 ASANZO '-`�C� CERTIFICATE OF LIABILITY INSURANCE D 10/1 201999 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 License#1780862 ACT nee.certificates@hubinternationai.com HUB International New England PHONE 508 945-0446 i FAX No):(508)945-9136 265 Orleans Road (A/C,�N�o,Ead):( ) North Chatham,MA 02650 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Arbella Protection Insurance Company 41360 INSURED INSURER B: TNT Family Enterprises,Inc.DBA Ropes End INSURER C: Family Restaurant 908 Route 28 INSURER D: South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL Sjj VD POUCY NUMBER (POUCY(WYY Y) (M ID�YI UMTS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 7520075520 8/1/2019 8/1/2020 DAMAGE TO RENTED 100,000 PREMISES(Fa occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY 1: LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE UABILITY (Ea c idEen) SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ _ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ _ WNE AUTOS ONLY — AUTO ONLYY (PR er accdentDAMAGE _ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ PER $ AND E APLOYERS UABI�LITY STATUTE ERH Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Liquor Liability 7520075520 8/1/2019 8/1/2020 Liquor Liability 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE n of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 146 Tow 1 ow a ACCORDANCE WITH THE POUCY PROVISIONS. South Yarmouth,MA 02664 A/U�T/HO�RIZED REPRESENTATIVE JV ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD RECEWED de Y4k TOWN OF YARMOUTH l� OCT a ljA sr ° HEALTH DEPARTMENT "., ;Z HEALTH DEPT. PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: 9 * /l-tics L r Proposed Improvement: NS, <elt-4-v,..\ O d C�in4'''� 7 Applicant: / Ali <?-e'sle5Tel. No.. Address: !G / ' -zr-- Date Filed: /.`fC C 7 **Ifyou would like e-mail notification of sign off please provide e-mail address: G 44//C Owner Name: `7'-^ �t(-14 Owner Address: 9 — gee-- c) Owner Tel. No.: S RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed) — Note:Floor plans not required for decks,sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: lag,., //e_2. .1 Cd' DATE: %e) / /9 PLEASE NOTE COMMENTS/CONDITIONS: y,,, p . _--_ MGL AND FIRE MQt,r TOWN OF YARMOU'H REVIEWED FOR CODE COMPLIANCE. } ERRORS OR OMMISSIONS DO NOT RELIEVE ' THE APPLICANT FROM THE RESPONSIBILITY OF "AS BUILT" C MPLI, NCE. � DATE:.`�,30 L (IA Nvc /_-- INSPECTOR YARMOUTH FIRE PREVENTION New Business Transmittal Project Name: Ropes End Family Resturant Address: 908 Rt. 28 Contact Name: Tom Nickinllo Phone: 508-574-2350 Y N NA Subject Regulation ES O X Building Numbers MGL Chapter 148;sec 59 X Fire Lanes 527 CMR 1;22.3 X Extinguishers 527 CMR 1; 13.6,Chapter 148;sec 28 X Maintence of any equipment,system relating to 527CMR1 1.1.4 Fire Protection. X *Hazardous Materials Storage 527 CMR 1;60.1 X Emergency Plan Required 527CMR1 10.9.1 X Commercial cooking,Hood systems 527CMR1 50.2.1.1 X Commercial Cooking Hood Systems Cleaning 527CMR1 50.5.4 X *Commercial Cooking Extinguishment System 527CMR1 50.4.3 X *Candles,open flames,and portable cooking 527CMR1 17.3.2,20.1.1.1 X Blocking electrical panel 527CMR1 10.19.5.1 X Blocking exits 527CMR1 14.4.1 Extension cords shall not be used as a 527CMR1 11.1.7.6, 11.1.7.1 X substitute to permanent wiring X Limit storage heights to 24 inches below 527CMR1 ceiling without sprinklers 18 inches with X Maintain Aisle width of 36 Inch's(3 Feet) 780CMR 1101.1 X Storage inside/outside Buildings 527 CMR 1; 10.19.4,4.4.3.1.1,19.1.2,34.1.1 X The right to inspect MGL Chapter 148 Sec.4 X *Upholstery 527 CMR 1;20.6.2.5 X *Trash Containers 527 CMR 1; 19.1.1, 1.12 X Any Hazard to the Public Chapter 148;sec 28 X *Curtains,Draperies,Blinds 527 CMR 1; 12.6.2 Description of planned project/other requirements: The YFD support the application, subject to applicable submissions, permits and inspections. A Permit from YFD is required any time a fire protection system is shut down. * YFD permit required-depending on occupancy and submittal Plan Reviewed By: Captain Kevin Huck Date: 09-302019 Copy for Applicant Copy to Building Department Copy to Fire Prevention Entered in Firehouse (i Final Inspection