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Home My WebLink AboutBLDCI-16-004963-06 The Commonwealth of Massachusetts Iii_�,.,:lei!! 1City\Town of I�= 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: SEAFOOD SAM'S BLDCI-16-004963-06 Trade Name: SEAFOOD SAM'S Identify property address including street number, name, city or town and county Certificate Expiration Located at 1006 ROUTE 28 11/30/2022 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 97 A-2 Nightclub/Restaurant/Bar/Banquet Hall 97 PERSONS 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 Signature of Municipal ignature of Municipal1( . Date of Fire Chief .4. ,i Building Commissioner Issuance 'AO 2 Fee:$100.00 BLDCertotlnspection.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: Seafood Sam's ADDRESS: 1006 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 . /5— 41120100 No Fire Department Rep. Date Comments Approved for f-� 1 o Z License Issuance No Board of Health Rep. Date Comments Approved for License Issuance Yes No Plumbing/Gas Inspector Date Comments Approved for .43VL V/G72 L. Lice a Issuance Yes No Electrical Inspector Date Comments Approved for License Issuance Yes No Taxes Paid Yes No Rev.Sept.2003 4°�' TOWN OF YARMOUTH p BUILDING DEPARTMENT s),*-r l„ �� '� 1146 Route 28, South Yarmouth, MA 02664 508-3S8- 221 1460 �,, t E I V E D z_, m APPLICATION FOR CERTIFICATE OF INSPECTION FEB 182022 February 2, 2022 PAYABLE UPOl` I WtPIFW'DEPARTMENT (X) Fee R _ ( ) 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: /oo (e 20 Name of Premises: SacrtX7d Saints Tel: 6bk-3”y—5.50 CI Purpose for which permit is used: SC SOi &J "ZIT I 60';2„e_, License(s)or Permit(s) required for the premises by other governmental agencies: License or Permit Agency .;:;c i 't w / u".Gt-J,,2,e. Certificate to be issued to Ua,72(,1lt_ MCcSOVI Tel: 77y -Zv I"7/J Address: 357., (Qua-kw lq.LeA4ch4 -Nub ,Ca e..Luia(.co c`, )44- 07c-31 Owner of Record of Building /tia,4i he . i-fa Soh Address Present Holder of Certificate 1Uu.&,-2 Hacoy-) voykiit jia/dm Otat&r- Signature of person to whom Title Certificate is issued or his agent Di-/i(4 c)-3 Date Email Address: (.(SIL/ S/1/fM.(,- 2 )7na...1/,C-4W) 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 r APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection#f3L.N I—J(_ WICK,3 i% •04/01/2022-11/30/2022 are, , r • • 0 ACCORD® CERTIFICATE OF LIABILITY INSURANCE DATE( DD'"`") 1/26/2022 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 RogersGray, Inc.-Kingston Branch PHONE FAX 63 Smith Lane tam.No.Ext):508.746-3311 (A/C,No):877-816-2156 Kingston MA 02364 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Arbella Protection Insurance Company,Inc. 41360 INSURED SEAFSAM-02 INSURERS:Massachusetts Retail Merchants WCSIG,Inc. 0 Seafood Sam's of S.Yarmouth, Inc. dba Seafood Sam's INSURER C: 1006 Rte 28 INSURER D: South Yarmouth MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1455821382 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 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. INSRY EFF POLICY EXP L TYPE OF INSURANCE µSD SUER POLICY NUMBER (MM/DDMIYY) (MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 8500054782 3/20/2021 3/20/2022 EACH OCCURRENCE $1,000.000 GE TO CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY PECOT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) A X UMBRELLA LIAB X OCCUR 4620091340 3/20/2021 3/20/2022 EACH OCCURRENCE $2,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $2,000,000 DED X RETENTION$1 n non $ g WORKERS COMPENSATION 014005032775121 1/1/2022 1/1/2023 X AND EMPLOYERS'LIABILITY STATUTE ER Y N OFF ROPRIE EREXCLUD EXECUTIVE / N/A E.L.EACH ACCIDENT $500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Main Street AU D REPRESENTATIVE South Yarmouth MA 02664 ormizi @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD _ - — tj:;•?: V !v,f=4;-11.,,.). -"' -•.;177't —1-4.••• . „ ; ?•-••.• .-•• • • '!*- ••••IiYr ,` '!"` ;t, ,;:•4; t-.• ::;•-•17 y e.7 1,".•I'41 1.10.4 ,a;i",' '1-.X3 •••' :'• -`•7, •• ' VVV :1,7. • FT 7:74 '7 7. :.1;7! 72 1.4 it5f . 3 V.• • • , •-• ' •• !Vrt4;•°,',i8A.P17.451 ; ***,*, ;,t!.t• ,„ •rf, - rs*•• • • ,• • • !!--sT/°'; : '7, - : '7— •;=, •=‘,J,..f.,•••• • ,,,.:•7•—•.••,• .,••••,• • 11tit 7ti • •-• • I ' . ..„ • • r• .• ft, -S — • • 1, ..1sy , .772 tr V. • ". . , . •t°°:.;.!!".‘”Y1,7•,-- • ;V, • • • • • . ,„ t - - . _______ . • _ .• — *--, • I . V — _ , . • CV% • 14 I 4. I. •, ;41 - — ; • . . •'! • 7:•!'" . _ . . -; . ' — - ; • • • jtellij ... '`' • !7,- , • • . • .. ..i4C•i„• • maitZ4*--