HomeMy WebLinkAboutBldci-17-002233-03 The Commonwealth of Massachusetts
City\Town of
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YARMOUTH
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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: MID-CAPE RAQUET CLUB BLDCI-17-002233-03
Trade Name:MID-CAPE RAQUET CLUB RESTAURANT
Identify property address including street number,name,city or town and county Certificate Expiration
Located at
193 WHITES PATH 12/31/2020
SOUTH YARMOUTH,MA 02664
Use Group Floor Occupancy Use Group Other
Classifications(s)
A-2 01st Floor 34 A-2 Nightdub/Restaurant/Bar/Banquet Hall 18-Bar Stools
16-Movable chairs
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 III Name of Municipal Mark G ----gate of �n e ��/�
Fire Chief Building Commissioner -late
L
Signature of Municipal Signature of Municipal Date of
Fire Chief Building Commissioner Issuance 0. 23
Fee:$100.00
NO/6: iD Be /sSv-D CON D/7/o 1i9L 66 1 )./5 - 26,°,9' , 2E/N.5,56 7/OA) MUST is 9SS
B LD_Certofl nspection.rpt
9Ro TOWN OF YARMOUTH
0L-y BUILDING DEPARTMENT
N 4. 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: I 9 3 /,ij h "/ `S pay,
ftName of Premises: /( I7 si U. � Tel: 5C1 "39 LJ st
Purpose for which permit is used: (k5S Wl (. 63 U
Licenses or Permit(s) required for thepremises byother o rn ental agencies:
( ) q g g
License or Permit Agency
Certificate to be issued to � /44-7 Le !i'( . Tel: ' -3` t1
l
Address: (C,! (n)h'1')fV1c` 0, E S c(.u�-'f'� I y? I c E `f
7
Owner of Record of Building je Q Se Q - -- Ic---v`
Address _
Present Holder of Certificate b..pjl-* f\ .R,G)C=. t
e?..46Adr- ENvaa:GAQ-'
%-Q.,58•00L,IS
Signature of person to whom Title
Certificate is issued or his agent \1\-? -\
Date
Email Address: bOb , \c C,� ..a l\C - C..c) c)
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 # 73LDC1- /7-dd 7Z3'?. O 3
12/30/2019-12/30/2020
F
NOTICE NOTICE
TO TO
EMPLOYEES =13,1:1= EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900—http://www.mass.gov/dia
As required by Massachusetts Genera Law, Chapter 152, Sections 21, 22, 30,this will give you notice
that I(we)have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
Technology Insurance Company, Inc.
NAME OF INSURANCE COMPANY
800 Superior Avenue East, 21st Floor, Cleveland, OH 44114
ADDRESS OF INSURANCE COMPANY
TWC3814287 9/20/2019 to 9/20/2020
POLICY NUMBER EFFECTIVE DATES
Maguire Insurance Agency, Inc. One Bala Plaza,Bala Cynwyd,PA 19004 (855) 516-1776
NAME OF INSURANCE AGENT ADDRESS PHONE#
Mid-Cape Racquet&Health 193 White's Path, S. Yarmouth,MA 02664
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
g provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the
services provided by the treating physician will be paid by the insurer,if the treatment is necessary and
cor-
reasonably connected to the work related injury. In cases requiring hospital attention,employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER