HomeMy WebLinkAboutCertificate of Inspection-Dinning Room •
The Commonwealth of Massachusetts
mil— ►t, City\Town of
_17 ''- 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: MAPLEWOOD MAYFLOWER PLACE ALF, LLC BLDCI-16-007131-02
Trade Name: MAPLEWOOD @ MAYFLOWER PLACE-DINING ROOM
Identify property address including street number,name,city or town and county Certificate Expiration
Located at
579 BUCK ISLAND RD 07/11/2020
WEST YARMOUTH,MA 02673
Use Group Floor Occupancy Use Group Other
Classifications(s)
A-3 01st Floor 187 A-2 Nightdub/Restaurant/Bar/Banquet Hall 187 PERSONS
1ST FLOOR&DINING
ROOM
Allowable 02nd Floor 48 A-2 Nightdub/Restaurant/Bar/Banquet Hall 48 PERSONS
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
Building Commissioner Inspection 6,..8 (g
Signature of Municipal Signature of Municipal / Date of /
Building Commissioner Issuance //. Z r,J,
Fee:$150.00
B L D_Certofl nspection.rpt
• 01'Y"4o TOWN OF YARMOUTH
0 -c BUILDING DEPARTMENT
wwtt'Iw
1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
June 11,2019 PAYABLE UPON RECEIPT
(X) Fee Required 150.00
( ) 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:
Name of Premises: flopkwioadal 1-(Affirver Pht�Te1:_,IZ / e—O O b
Purpose for which permit is used: (JJGTtF TCIO%) c" p sPt-C
License(s)or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to MtWOCOP m*'j `� PLACE Sd&750 39J)
Address: 57 Butt< rv.,4wp $D to, itlAitiviairti 141 02673
Owner of Record of Building WEST yAtesiourpi QizOPf1LZY I.LC
Address ?%00 rArEgrit terrowik PRS/!£ S.,.rf 3400 1-fokliVieLLEV, IrvID al0 g9
Present Holder of Certificate 1v1MLi14700P (Y A%,'FLadeQ PLEAS F LF �C
gNial 6MExrrA SE.Qvtci. Dxj., (`oh—
gnature om Title
Certificate is issued or his agent 7/1 4,l9
Date
Email Address: M AyFLow £SO ) fr L cD05 L .C-0
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#PL C '/L- db-7/3 j
7/11/2019-7/11/2020
•
The Commonwealth of Massachusetts
.Department of Industrial Accidents
=_ /4_ l Office of Investigations
-n= • 1 Congress Street,Suite 100
.
•
= Boston,MA 02114-2017.
•
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Annlicant Information Please Print Legibly
Business/Organization Name: Maplewood at Mayflower Place •
Address: 579 Buck Island Road
City/State/Zip: W Yarmouth, MA 02673 Phone#: 508-790-0200
Are you an employer?Check the appropriate box: Business Type(required):
1.® I am a employer with 8y employees(full and/ 5• ❑Retail
or part-time).* 6. 0 Restaurant/Bar/Eating Establishment
2.❑ 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. g, ❑Non-profit
[No workers'comp.insurance required]
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 l 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.] l2.❑Other :
*Any applcmt that checks box#1 must also fill out the seotloa below showing their woken'commandos policy informatics.
"lithe corporate officers have exempted themselves,but the corporation has other employees,a waters'oompanattaa policy is requited and such an
orpoiation should ohs&box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: The Memic Group
Insurer's Address: .180 Glastonbury Blvd#304
City/State/Zip: Glastonbury. CT 06033 .
Policy#or Self-ins.Lic.# 3102804908 Expiration Date: 6/1/2020
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as -• -. under Section 25A of MOL a 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one- i N imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against L'r .lator. Be advised that a copy of this statement may be forwarded to the.Office of
Investigations of the DIA for *��;, : -coverage verification.
I do hereby cerda,under" ' , and peraldta of perjury that the information provided above is true and corral
sign: j Date:
Phone#: 203-ad . 77
Official use only. Do not write in this area,to be completed by city or town ofcial •
City or Town: Permit/License#
Issuing Authority(circle one): '
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board S.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mw.#ovklia