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HomeMy WebLinkAboutBLDCI-21-003076-01 The Commonwealth of Massachusetts n 1 • r. City\Town of • YARMOUTH I 1 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 BLDCI-21-003076 01 Business Name: Papa Gino's Restaurant Trade Name: 1 Identify property address including street number, name,city or town and county Certificate Expiration Located at 12/31/2022 932&940 ROUTE 28 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) 98 person totally o ist Floor 98 A-2 Nightclub/Restaurant/Bar/Banquet Hall A-2 . 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 •. Philip Simonian III Name of MunicipalMark Grylls Date • Fire Chief Building Commissioner 7 Inspection /C) a'afP--A( � • •. �� Date of Signature ' Municipal � Issuance • • • • Q Imo/ ll' 2 • Zt Fire Chief �, =. : , V I.iil// i Fee: $100.00 BLD Certoflnspection.rpt BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2022 NAME: Papa Gino's ADDRESS: 940 RTE 28 This log is to be signed by the appropriate inspectors upon a satisfactory inspection of your building/premises. When all signatures are obtained, this log shall be presented to the License & Permits office and/or the Health Department in order to obtain your license. Licenses will be withheld until all inspectors have signed. Building Commissioner Rep. Date Comments Approved for License Issuance ® No Fire Department Rep. Date Comments Approved for License Issuance Q 4110. No Board of Health Rep. Date Comments Approved for License Issuance Yes No Plumbing/Gas Inspector Date /o/t ilt/ Comments Approved for Lic eIssuance Yes , No Electrical Inspector Date Comments Approved for License Issuance Yes No Taxes Paid Yes No Rev.Sept.2003 J • S • •J t•'• ' �,, .. • IS*N.4 4f °og YqR TOWN OF YARMOUTH .$y BUILDING DEPARTMENT 1 146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION October 1, 2021 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 w-named premises located at the following address: Street and Number: Ib Name of Premises: fAl FA 61 /OP 12 Tel: -1 g-'/' Purpose for which permit is used: f€S1 Jt'4JJ- License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency FO pA fa ;r g1foDc cf4 Z A ' RECEIVED pAMHop gae9 Dc a(. �Mv) OCT 22 2021 Certificate to be issued to EWE ,a 0 ►�� . - -VTel: FK' /b /V/7 BU L i Address: ( e 00 Qle-6Vl4) Gf11'LM , kb/.& I44 can('4 °y — Owner of Record of Building .L�1Q e NV 1'L t A i1Y Address //7 -1'& -3 4I 1 R-�c�1 i S bUr4 Y4 o✓ 4) 1174 0 U49' Present Holder of Certificate PAri t)Ts )( Yrtq67/Q2614040(6 Signature of person to whom Title Certificate is issued or his agent /0` "-a-( Date Email Address: L/-vi @� Pell G-i IUDs. CDC( 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# BC.1YJ— a J-.[ 3Q7 ,-p 12/31/21-12/31/2022 The Commonwealth of Massachusetts 1-......74,7_ /, Department of Industrial Accidents _mit 1 Congress Street,Suite 100 ' Boston, MA 02114-2017 e �,� „. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information P-lease Print Legibly Business/Organization9110 Name: New England Authentic Eats LLC DBA Papa Gino's Address: /4I{lp S>1 -f_ . -. City/State/Zip: V iattl 011114 i /i. Q wV Phone#: 5 ,37e-/1 f( Are you an employer? Check the appropriate box: Business Type(required): 1.[1 I am a employer with 20 employees (full and/ 5. ❑Retail or part-time).* 6. a 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. [No workers' comp. insurance required) 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment • their right of exemption per c. 152, §I(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required)*" f 4.❑ We are a non-proft organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers'comp. insurance req.] 12.D Other _ 'Any applicant that checks box II I must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an orpanizatinn shrndd rherk hnz k I I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name._Crum &—Forster Indemnit C mpany Insurer's Address: t00 High St 1/1350 City/State/Zip:Boston:MA 02110' Policy#or Self-ins.Lic.#_WC 408740677-2 Expiration Date:_02/112022 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the ains and penalties of perjury that the information provided above is true and correct. Signature: T6)0/ U Date: / 34 - None#:781-467-1647 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. Other Contact Person: Phone#:__ www.mass.gov/dia ® DATE(MM/DOIYYYY) A��o CERTIFICATE OF LIABILITY INSURANCE 02/12/2021 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 Certificates NAME: The PLEXUS Groupe LLC HONEN Exq: (847)307-6100 FAX(A/ No): (847)307-6199 21805 W Field Parkway,Ste 300 E-MAIL certificates@plexusgroupe.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Deer Park IL 60010 INSURER : United States Fire Insurance Company 21113 INSURED INSURER B: The North River Insurance Company 21105 New England Authentic Eats LLC,DBA:Papa Gino's/D'Angelo INSURER C: Crum&Forster Indemnity Company 31348 600 Providence Highway INSURER D: XL Insurance America,Inc 24554 INSURER E: Dedham MA 0202E INSURER F: COVERAGES CERTIFICATE NUMBER: 21/22 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW'HAVE13EEt lSSIYED 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY N JMBER (MMIDD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAED CLAIMS-MADE X OCCUR PREMISESO(EaEoccurr nce) 5 1,000,000 MED EXP(Any one person) s Excluded A 543-227191-2 02/11/2021 02/11/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 PRO- X POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 5,000,000 B EXCESS LIAB CLAIMS-MADE 5821158006 02/11/2021 02/11/2022 AGGREGATE $ 5,000,000 DED RETENTION $ $ WORKERS COMPENSATION X OTH- AND EMPLOYERS'LIABILITY /� STATUTE ER Y/N 1000 000 C ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA 408-740677-2 02/11/2021 02/11/2022 E.L.EACH ACCIDENT $ , , OFFICER/MEMBER EXCLUDED? 1000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ , If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S Per Occurrence $1,000,000 Liquor Liability A 543-227191-2 02/11/2021 02/11/2022 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate is issued as evidence of coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I (4� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 00005588 LOC#: AC 3R�� ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED The PLEXUS Groupe LLC New England Authentic Eats LLC,DBA:Papa Gino's/D'Angelo POLICY NUMBER CARRIER NA CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance:Notes Excess Liability Policy Term:2/11/2021 -2/11/2022 Policy Number:US00089484L121A Carrier:XL Insurance America,Inc. Limit:$10M x$5M Named Insured Schedule: New England Authentic Eats LLC(DBA Papa Gino's/D'Angelo's) WC PG Franchising LLC(Papa Gino's Franchising Corp.) WC DA Franchising LLC(D'Angelo Franchising Corp.) D'Angelo Sandwich Shops Advertising Fund,Inc. NEAE card services LLC ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD