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HomeMy WebLinkAboutBLDCI-16-005427-06 The Commonwealth of Massachusetts City\Town of � YARMOUTH a 7.:�� 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: SKIPPER RESTAURANT BLDCI-16-005427-06 Trade Name: SKIPPER RESTAURANT Identify property address including street number,name,city or town and county Certificate Expiration Located at 152 SOUTH SHORE DR 11/30/2022 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Classifications(s) Other A-2 01st Floor 80 A-2 Nightclub/Restaurant/Bar/Banquet Hall Up to 80 Persons Allowable 02nd Floor 24 A-2 Nightclub/Restaurant/Bar/Banquet Hall 24 Upstairs Bar Occupant Load Other 60 A-2 Nightclub/Restaurant/Bar/Banquet Hall Outside Deck 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 Grylls Date of Fire Chief 'Building Commissioner Inspection Signature of Municipal Signature of Municipal Date of Fire Chief Building Commissioner %� , Issuance 3 Z ,% Z L f Fee: $150.00 . BUILDING �, P TMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2022 NAME: Skippers Restaurant ADDRESS: 152 South Shore Drive 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 Re . Date Comments Approved for _ License Issuance 4110w No • Fire Department Rep. Date Comments Approved for C Qj( Li a Issuance I~ 3, I- 2 Z Yes No Board of Health Rep. Date Comments Approved for License Issuance Yes No Plumbing/Gas Inspector Date Comments Approved for yr- Licen a Issuance �? es No Electrical Inspector Date Comments Approved for License Issuance Yes No Taxes Paid Yes No Rev.Sept.2003 1 T °r ki� TOWN OF YARMOUTH �A �aItat.„,,,, tif Jva), BUILDING DEPARTMENT MATT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Te ,,,_4' 1 0.5peC+i0,i 1 APPLICATION FOR CERTIFICATE OF INSPECTION { rADYlCititt February 2, 2022 PAYABLE UPON RECEIPT (X) Fee Required $150.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address:Street and Number: /-C-2. S00.1 4 SA OIL ,./- _co /4.iejvoi):;1--- / ((cell) Name of Premises: St cHoa.o� Atli-L.-- Tel:$ Z��7 U(75 -33(, "Sit Z 91 Purpose for which permit is used: MJ7'0-. 4 or Permit(s) re uired for thepremises byothergovernmental agencies: [ License(s) q g I R E D E I V E D 1 License or Permit Agency 1li FEB 2 4 2022 BUILDING DEPARTMENT BY Certificate to be issued to L 4 P AP' Tel: 7 7 3 6 9-Z-7- Address: _Ski f/ 7c i-✓a6 Jb-e— /J 1 Cov mac.- ,2 .S� s �n . S 747144/0,a4 Owner of Record of Building " / "�J 9,�4— `� Address I y L o✓E t/i ►,/ 0, Sc? � 'r/00 � Present Holder of Certificate ,(4--) , �-��" Sig atu of perso whom Title Certificate is issued or his agent 2/Z'j` 2 L �/ Date Email Address: Sic- Ipiceiz co��fT�G ,Cam 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#a(j)C I-- I 60.--COSLi)7-06 04/01/2022-11/30/2022 Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 014005032678122 01/01/2022 to 01/01/2023 I Braintree, MA 02185-0000 Information Page Renewal Policy FEIN: 043438184 Carrier Prior Policy#: 014005032678121 Item 1: Named Insured and Address Agency Beachview, Inc. Deland Gibson Insurance Associates Inc. The Skipper Restaurant 36 Washington St 152 South Shore Drive Wellesley Hills, MA 02481 South Yarmouth, MA 02664 Other Workplaces Not Shown Above: No Other Workplaces for this Policy Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation Federal ID#: 043438184 Risk ID: 000000000 NCCI I Bureau#: 34355 Unemployment ID#: File#: 014005032678122 Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2022 to 12:01AM on 01/01/2023 based on the insured's mailing address time zone. Item 3.Coverage: A. Workers Compensation Insurance: 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 listed 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(01/19),WC000422C(01/21), NOE(01/01),WC200102(01/14),WC200301(04/84), WC200302A(09/08),WC200303D(08/10),WC200306B(06/13),WC200405(06/01), WC200601A(07/08) 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 $261.00 $6,531.00 $6,531.00 $0.00g)J(-1 :6(47 $0.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by:Braintree MA 02185-0000 01-13-2022 Form#WC 00 00 01 C (Ed.) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1 NOTICE NOTICE TO b,:` ; TO EMPLOYEES f,Ntri EMPLOYEES ^ Sye, The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MASSACHUSETTS 02111 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General 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: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222, Braintree, MA 02185-0000 ADDRESS OF INSURANCE COMPANY 014005032678122 01/01/22 - 01/01/23 POLICY NUMBER EFFECTIVE DATES Deland Gibson Insurance Associates Inc. 36 Washington St, Wellesley Hills, MA 02481 (781) 237-1515 NAME OF INSURANCE AGENT ADDRESS PHONE # The Skipper Restaurant 152 South Shore Drive, South Yarmouth, MA 02664-0000 EMPLOYER ADDRESS 01/13/2022 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 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 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