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HomeMy WebLinkAboutBLDCI-22-006035 The Common a th of Massachusetts j =_ `=eri Ci own of = 'r!'= YARMOUTH 4.... 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 I Certificate No. Issued to BLDCI-22-006035 Business Name:Wendy's Restuarant Trade Name:Wendy's Restuarant Identify property address including street number,name,city or town and county Certificate Expiration Located at 465 STATION AVE 5/25/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 96 A-2 Nightclub/Restaurant/Bar/Banquet Hall Allowable r 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 /s� ,. Signature of Municipal Signature of Municipal ate of Fire Chief Building Commissioner Issuance 7/3/Z i Fee:$100.00 BLD Certoflnspection.rpt �° TOWN OF YARMOUTH ` '� BUILDING DEPARTMENT 4•... .• 1146 Route 28, South Yarmouth, MA 02664 508-398-2 -t, ift . tEIVED APPLICATION FOR CERTIFICATE OF INSPECTION rApc 1 9 2022 April 1, 2022 PAYABLE UPON RECEIPT 6UILD►NG 3 7A ENr sY(X) Fe- . . . .—. .::.:.e ( ) 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. - 7,7, Street and Number: --:- C -X-- /w/V/y�-e' ,, y zo.v�t1 Name of Premises: w V. 5 Tel: S08 z '7—63 zl i�o.4.a/7v> Purpose for which permit is used: �r...u./� �v.�� ,�� License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to b issued to e, W s�� Tel: S"b 8 -.;a --632.2 Address: 4P0 66 7„em3?— ..es ,�,, ,,,d¢v,vs,•t. -7.4c2glic, Owner of Record of Buil ing /7o,-v7i?o-S • y-.' Yrs v27so--v ,44..4 Address /s 9 ,g.: .C. '-, /+--1,c.6•7.•v /7,4 mL3,7 Present Holder of Certificate \\/,ep yr)S Si a of person to wh Title Certificate is issued or his agent y�i/.42 Date Email Address: ---� �= .�!//.y=7 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 ISSUEYOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# fi C/- �"1- 35- P 05/25/2022-05/25/2023 P rs Liability Workers Compensation PolicyandEmp 34355 Carrier Polic #: Polic Period MAIns Re I e 014005030559121 01/01/2021 to 01/01/2022 MA Retaill M Mercchh ants WC Group Inc. PO Box 859222-9222 Braintree,MA 02185-0000 Renewal Policy Carrier Prior Polic #:014005030559120 Information Page FEIN:861176398 A.enc Item 1: Named Insured and Address HUB NE Association Programs Fashion Food LLC 300 Ballardvale Street Wendy's Wilmington,MA 01887 66 Pondside Circle Centerville,MA 02632 Otht Shown Above: See chedule of di tonal Named Insured: See Additional Operations Named Insurreds if Ad Applicable Ad FederallD#: 861176398 Type of Business: Corporation NCCI 1 Bureau#: 34355 Risk ID: 000000000 File#:014005030559121 Unemployment ID#: Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2021 to 12:01AM on 01/01/2022 based on the insured's mailing address time zone. Item 3.Coverage: to the Workers Compensation Law of the states listed: A. Workers Compensation Insurance: Part One of the policy applies MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000.00 each accident Bodily Injury by Disease $500,000.00 policy limit Bodily Injury by Disease $ 100,000.00 each employee C• Other States Insurance: D. This policy includes these endorsements and schedules: WC ( ) (/),WC000414A(01/19),WC000422B(01/15), NOE(01/01), 01/14),WC200301(04/84), WC2200302A(09/08D(08/0) WC200306B(06/13),WC200405(06/01),WC200601A(07/08)),WC200303 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 verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $32,013.00 $0.00 $0.00 $211.00 $32,013.00 Issuing Office: Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: 01-13-2021 2- --).-1 . 4-7 Braintree MA 02185-0000 Form#WC000001 C (Ed.) Porno , ©Coovnaht 2013 National Council on Compensation Insurance.Inc.All Rights Reserved. Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 Carrier Policy#' Policy Period MA Retail Merchants WC Group Inc. 014005030559121 01/01/2021 to 01/0112022 PO Box 859222-9222 Braintree, MA 02185-0000 Renewal Policy Information Page FEIN: 861176398 Carrier Prior Policy It: 01400503055912C Agency Item 1: Named Insured and Address HUB NE Association Programs WFashion Food LLC ndy's 300 Ballardvale Street 66 Pondside Circle Wilmington, MA 01887 Centerville, MA 02632 Schedule of Covered Workplaces Other Workplace Fashion Food LLC Effective Date: 01/01/2021 Wendy's NAICS Code: 722511 32 Old Townhouse Road Division#: 0 South Yarmouth, MA 02664 Workplace#: 0000000007 State Risk ID#: 000072530 Form#WC 00 00 01 C (Ed. ) J Copyright 2013 National Council on Compensation Insurance.Inc.All Rights Reserved. Page 2 of