HomeMy WebLinkAboutBldci-18-002140-02 The Commonwealth of Massachusetts
=W=t. _ �r City\Town of
n •�,= YARMOUTH
i 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:CAPE DELI FOODS,INC. BLDCI-18-002140-02
Trade Name: PICCADILLY CAFE&DELI
Identify property address including street number,name,city or town and county Certificate Expiration
Located at 1105 ROUTE 28 12/31/2020
SOUTH YARMOUTH,MA 02664
Use Group Floor Occupancy Use Group Other
Classifications(s) A-2 Nightclub/Restaurant/Bar/Banquet Hall 80 Persons-table&
A-2 01st Floor 80 chairs/15 stools.
Total:80 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 Philip Simonian Ill Name of Municipal Mark Gryl Date of ����/r/�
Fire Chief Building Commissioner Inspection
Signature of Municipal Date of
Signature of Municipal 41Pt ss /
Fire Chief /' Build' missioner r Issuance I f//, v f
'4: Fee:5100.00
B LD_Certofl nspection.rpt
` k TOWN OF YARMOUTH
o� m ' y l -y BUILDING DEPARTMENT
MATTA n ESE'
�, o.•••.,•,.a a 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: 11 OS. 1K O JfiC. a\" So 61 a rolo�ih MA o 16,6 c/
Name of Premises: l t„cid, 1 6 Ca-Ce d' •e.,1 ( Tel: S O (-'-/"Q g?7
Purpose for which permit is used: •2 S-tq, v r-a r) I-
License(s) or Permit(s)required for the premises by other governmental agencies:
z
FZ C E
License or Permit _ Agency
41 Q,,jnCw,0�4-64r0 )C.I ?919 Tat t6,,. of Yq( 0t tr,
Cr)tiiroA v i ram!ct'4(e ,.,_.._____.._. _ ,
5E y..r BUILDING Dt t-_�k ' •1 /1
CJ aY s
Certificate to be issued to
Oa ppr P. Deli rook_ �✓!C, Tel:_cC:52s-3�'jq' ('J?'g 7
Address: 11 O��' kf•P, r ,q , co,die, AT Y (3V)p ._6 l
Owner of Record of Building L e,( i Fr,d.s to r,
Address I I C Rre )S o �,,,, 11
6) .6.
6 '�
Present Holder of Certificate e , oo s C
j�Yj
"tr'rA^t(4
G
Merles ��
Signature of person to whom Title
Certificate is issued or his agent )o J 2 iP I O/ 7
Date` /
Email Address: Ca re.d edi i-For.545O a n C , GOB
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 #
12/30/2019-12/30/2020
Worker's Compensation and Employer's Liability Policy
' Berkshire Hathaway NorGUARD Insurance Company - A Stock Co.
�� y Policy Number CAWC046643
r ,'GUARD Insurance Renewal of CAWC986704
0•/�, Companies NCCI No. [25844],
Policy Information Page
[1]Named Insured and Mailing Address Agency
Cape Deli Foods Inc. THE FAIRWAY AGENCY
DBA/TA Piccadilly Cafe&Deli 944 Washington St
1105 Main St. Suite 2
South Yarmouth, MA 02664 South Easton, MA 02375
Agency Code: MAFAWA10
Federal Employer's ID 04-2692567 Insured is Corporation
Risk ID Number 39868
Additional Names of Insured
(N2) Piccadilly Cafe &Deli
[2]' Policy Period
From August 1, 2019 to August 1, 2020, 12:01 AM, standard time at the insured's mailing address.
t3] Coverage
• A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
• Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $500,000
Bodily Injury by Disease - each employee $500,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
•
Total Estimated Policy Premj m $ 4,897
Total Surcharges/Assessments $ $167.00
Total Estimated Cost $ $5,064.00
INTERNAL USE XX Page - 1 - Information Page
MGA : CAWC046643 WC 000001A
Date : 06/27/2019
MANOTE
Issuing.Office: P.O. Box A-H, 39 Public Square,Wilkes-Barre, PA 18703-0020 •www.guard.com