HomeMy WebLinkAboutBldci-18-006301-02 The Commonwealth of Massachusetts
City\Town of
_; _•
4 YARMOUTH
New and Renewal Certificate of Inspection
In accordance with 780 CMR,Chapter 1 (The Eighth Edition of the Massachusetts State Building Code)and Chapter 304 of the Acts of 2004(an Act to further
enhance fire and life safety),this certificate of inspection is issued to the premise or structure or part thereof as herein identified.
Identify Name of Establishment Certificate No.
Issued to
Business Name:GRILL 43 BLDCI-18-006301-02
Trade Name: GRILL 43
Identify property address including street number,name,city or town and county Certificate Expiration
Located at
43 ROUTE 6A 12/31/2020
YARMOUTH PORT, MA 02675
Use Group Floor Occupancy Use Group Other
Classifications(s)
A-2 01st Floor 78 A-2 Nightdub/Restaurant/Bar/Banquet Hall 78 Persons
Allowable 02nd Floor 18 A-2 Nightclub/Restaurant/Bar/Banquet Hall 18 persons
Occupant Load Total seats:96
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 Philip Simonian III Name of Municipal Mark Gry Date of [ � / —' /
Fire Chief Building Commissioner Inspection
Signature of Municipal / Signature of Municipal Date of
Fire Chief •
Building Commissioner , Issuance/_; /(41
Fee:$100.00
BLD_Certofl nspection.rpt
tna
.Yo TOWN OF YARMOUTH
BUILDING DEPARTMENT
� " T:;:,�j 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
October 1, 2019 PAYABLE UPON RECEIPT
(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: 6/3
G r�
Name of Premises: Li; /fA/L1 CSC.-(,. Tel: —736 553
Purpose for which permit is used: Vr-ST o ysci _ *
License(s) or Permit(s) required for the premises by other governmental agencies: {}
License or Permit Agency o(;i •
pf'
PIA /Pr
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;tip <w t
Certificate to be issued to 7 /1/701i y (C C Tel:
Address: 4/c th/t Y4i-vve, iC-\ b41— /4 OogB 7.5
Owner of Record of Building fora &ouKof`
Address 3 Z72- ?ourv1( M 4- 02 ?2
Present Holder of Certificate q3 r'q LL e-.
\r-
re o person to whom Title /
Certificate is issued or his agent /o(a {//�
Date
Email Address: t Yb> i CO 3P-ta t ro W
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# BLL).Z -/7 (30/ -Q�
12/30/2019-12/30/2020
cvRc� DATE(MM/DD/YYYY)
VR CERTIFICATE OF LIABILITY INSURANCE 10/24/2019
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 CONTACT Judy Pashko
NAME:
Complete Benefit Solutions PHOONNo.Exd, (800)684-5470 FAX No): (413)538-5761
(AICOne Carando Drive,Suite 1 ADD jpashkotcompietepayrollsolutions.com
INSURER(S)AFFORDING COVERAGE NNC S
Springfield MA 01104 INSURER A: Hartford Accident and Indemnity Company 22357
INSURED INSURER B:
43 Main Street LLC INSURER C:
43 Main Street Unit 6A INSURER D:
INSURER E:
Yarmouth Port MA 02675 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL1932902701 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 A SD yj POLICY NUMBER (POLIO (POLMMIICY YYYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMA $
ENTtO
CLAIMS-MADE 1-1 OCCURPREMISES(E a occurrence) $
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY iI JECT LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABLITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
— OWNED SCHEDULED BODILY INJURY(Per accident) $
_ AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY _ AUTOS ONLY (Per accident)
S
UMBRELLA UM OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-PAADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION X STATUTE ERH
AND EMPLOYERS'LIABILITY Y I N
A ANY PROPRIETOR/PARTNER/EXECUTIVE El NIA 76WEGAB1TK7 01/26/2019 01/26/2020 E.L.EACH ACCIDENT $ 100,000
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under 5D0,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
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
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS.
1146 Rt 28
AUTHORIZED REPRESENTATIVE
Yarmouth MA 02664
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