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The Commonwealth of Massachusetts
► , ` _ e►r. City\Town of
'.V.
. 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:AZZARO YARMOUTH, LLC BLDCI-16-004965-04
Trade Name:THE LOBSTER BOAT
Identify property address including street number,name,city or town and county Certificate Expiration
Located at
679 8,681 ROUTE 28 11/30/2020
WEST YARMOUTH,MA 02673
Use Group Floor Occupancy Use Group Other
Classifications(s)
A-2 01st Floor 334 A-2 Nightclub/Restaurant/Bar/Banquet Hall 314 PERSONS
20 BAR STOOLS
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 Grylls Date of
Fire Chief Building Commissioner Inspection 3
Signature of Municipal ce, Signature of Municipal _ Date of D�
Fire Chief Building Commissioner Issuance / . / .�Zp
L4Fee:;150.00
BLD Certofins ction. t
_ pe rp
.. •) Y. TOWN OF YARMOUTH
U (,', BUILDING DEPARTMENT
,. TTA M .SC v
--: MA� �•. ,%:- 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
January 23, 2020 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: (a Si Qpult, 2 P
Name of Premises: `'(L [p j l.) boat Tel: CsVT 0-18(e
•Purpose for which permit is used: uc)&.. Qe.: omvzot k)►gvwr .�.' ,
License(s) or Permit(s)required fokhErefet iv,eh governmental agencies: i n - ►
License or Permit i
a Agency
`: 1.i '
A3u, _DING DEPARTMENT
Certificate to be issued to 6 d QJmb ,Liu, Tel:(e)$_) -DAD
Address: (0$1 24Dat, 28 11J.ez t-i-{k_i "Ma. 0 210 4-3
Owner of Record of Building
Address (Q 81 Q.r yh . � aAL/Yny_,-41k , '` Y\rA Q 4-le 4-3
Present Holder of Certificate
0.0- O( t�
Si r of person to whom 'tle
Certificate is issued or his agent aO
ate
Email Address: Q27i a Cy(p @ C'p,,a-. -
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#
4/1/2020- 1H5/24
///30/ -O
Workers Compensation and Employers Liability
Insurance Policy
insurerlD 4s):34355
MA Retail Merchants WC Group Inc. Carrier Policy*: Policy Period
PO Box 8 -8222 014005030290120 0110112020 to 01/0112021
are,MA 021ss0o00
Information Page Renewal Policy
FUN:200666393 Carrier Prior Policy It:.014005030290119
Item 1: Named Insured and Address Agewcy
Azzaro Yarmouth,LLC Dowling&O'Neil Insurance Agency
The Lobster Boat Restaurant PO Box 1998
681 Main Sheet Hyannbs,MA 02601
Route 28
West Yarmouth,MA 02673
Other Workplaces Not Shown Above: See Schedule of Operations
Adtkeonal Named red: See Additional Named htsureds if Applicable
Type of Brsrness: Corporation Federal liNk Z30666393
Risk ID: 000000000 itCCI I Bureau#k 34355
Unemployment Rik File lk01 120
Item 2.Policy Period The poky period is from 12 01 AM on 01/01/202 to 12:01AM on 01 N12121 based on the instreds mailing
address time zone.
Item 3.Coverage:
A. Wu.kL Compensation Ire: Part One of the policy applies to the Workers Compensation Law of the states listed:
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state fisted in Item 3 A The limits of our liability under Part
Two are:
Bodily Injury by Accident $500,000.00 each accident
Bodily injury by Disease $500,000.00 policy limit
Bodily Injury by Disease $500,000.00 each employee
C_ Other States Insurance:
D_ This policy includes these endorsements and schedules:
WC000000C(01/15),WC000414A(01119),WC0004228(01115).NOE(01/01),WC200102(01114),W0200301(04/84),
WC200302A(09108),WC2003030(08/10),WC2003068(06/13),WC200405(06101),W IA(01118)
Item 4: Premium
The Premium for the policy will be determined by our Manual of Rules,Classifications,Rates and Rating Plans. All information required below
is subject to venTrcation and change by audit
Classifications Code# Premium Rats Rate Per$100 of Estimated Annual Premium
Total Estimated Remuneration
Annual Remuneration
See Schedule of Operations on Following Page(s)
Minimum Premhan Prorated Premium Emoted Annual Pmn*an Espana,Constant Deposit
$265.00 $2,679.00 $2,679.00 $0.00 $0.00
Issuing Office: 35 Bridntreet Otace Part Ste 206 Date Printed: Countersigned by: gtf -1-1-4k7Braintree02185-0000 01-15 2020 Form#WC 00 00 01 C
(Ed.)
®tom 2013 National COlifid an Compensation insurance,Inc.At Rates Resolved- 1 of 1