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Home My WebLink Aboutblldci-16-003439-01 • The Commonwealth of Massachusetts ' pi U�: ;►. City\Town of t ==,=+ 'm YARMOUTH �w � -- 4 _ 7 i 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:YARMOUTH LODGE 2270 BLDCI-16-003439-01 Trade Name:LOYAL ORDER OF MOOSE Identify property address including street number,name,city or town and county 'Certificate Expiration Located at 769 ROUTE 28 12131/2018 SOUTH YARMOUTH,MA 02664 Use Group Floor Occupancy " Use Group Other Classifications(s) t/B OUTSIDE PATIO A-2 Other 18 A-2 Nightclub/Restaurant/Bar/Banquet Hall 01st Floor 315 A-2 Nightclub/Restaurant/Bar/Banquet Hall 115 persons-large bar Allowable 32 persons-smoking Occupant Load bar 168 persons-function MOM TOTAL-333 This certificate of inspection is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specifi d-has been in p c ed1 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 Slmonian Ill Name of Municipal Mark Grylls Date of // �/7 Fire Chief Building Commissioner ^Inspection Signature of Municipal a°f Signature of Municipal (I1Iisuance kZ .f r�� Fire Chiefalcantr, Building Commissioner� Fee:;150.00 • • BLD Certoflnspection.rpt .0 •Y`1R } . ! moo_ TOWN OF YARMOUTH ` " -y BUILDING DEPARTMENT .-: **...-,,Y' ' 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Chapter 1 APPLICATION FOR CERTIFICATE OF INSPECTION October 1,2017 PAYABLE UPON CEIPPT (X) Fee Required `. " ( )No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 106.5, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 76 7 RD vre SOQrn Y��1iuOv 1//t/, cc,/ Name of Premises: y,4L''W UP! Aoa Coclx 2271) Tel: dog -39 y- `-°71 1 = .1.5-D33 Purpose for which permit is used: t /&OO>Q 1./C d'Nfe A VEli.4 L License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to YiA.41 0 V lit dO(..6-- (. 4a Tel: /5 2$-" Y-S?I Address: `7 i - ' o Owner of Record of Building 5,1 me Address Present Holder of Certificate 54 Iii ir Sign r erson tow om Title Ce ficat is issued or his agent i f 9 _) is Date Email Address: LOd y6- "2-170 e fres !rv'-'r c cPG 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# as-/4-003V E9--01 12/31/2017-12/31/2018 /- • Policy Number UC Specialty L Fz-Mlr2O0004O1-OO Insurance Company COMMON POLICY DECLARATIONS Renewal Of: LFZ—CL-0020546-7 AIX Specialty Insurance Company 728 Exchange Street Suits 1020,Buffalo,NY 14210 Item 1. Named Insured and Mailing Address Agent Name and Address YARMOUTH MOOSE LODGE #2270 LOCKTON AFFINITY,LLC. PO BOX 186 P.O. BOX 410679 SOUTH YARMOUTH MA 02664-0186 KANSAS CITY.MO 64141-0000 AgentNo. 20018 Item 2. Policy Period From: 10—21-2 017 To: 10—21-2 018 at 12i1 AM.,Standard Time at your msling address shown above. Item 3. Business Description: CLUB ESTABLISHMENT Form of Business: NON—PROFIT ORGANIZATION Item 4. In return for the payment of the premium,and subject to all the terms of this policy,we agree with you to provide the insurance as stated In this policy. This policy consists of the following coverage parts for which a premium is indicated. Where no premium Is shown, there Is no coverage. This premium may be subject to adjustment. Coverage Parts) Prerrfum Commercial Property Coverage Part $ 5, 821.00 Commercial General Liability Coverage Part NOT COVERED Crime and Fidelity Coverage Part NOT COVERED Commercial Inland Marine Coverage Part NOT COVERED Commercial Auto(Business or Truckers) Coverage Part NOT COVERED Commercial Garage/Auto Dealers Coverage Part NOT COVERED • Policy Writing Minimum Premium Retained: $ 500 Total Policy Premium $ 5, 821.00 Item 5. Forms and Endorsements Form(s)and Endorsement(s)made a part of this policy at time of Issue: See Schedule of Forms and Endorsements Countersigned: Date: O 17 By: Au esen THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DEClARK1ON(S),TOGETHER WITH THE COMMON POUCY CONDITIONS, COVERAGE PARr(S),COVERAGE FORMS)AND FORMS AND ENDORSEMENTS,IF ANY,COMPLETE THE ABOVE NUMBERED POUCY. CO-DEC(07/01) INSURED NVAw NOVA Casualty Company A STOCK INSURANCE COMPANY NOVA CASUALTY COMPANY 726 Exchange Street.Suite 1020,Buffalo,NY 14210 1.866633-6945 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE POLICY INFORMATION PAGE NCCI Company No. 14191 POUCY NO. LFR—Wit-10001335-00 RENEWAL OF: LFR—WIC—O 012 4 6 9-2 ITEM 1. NAMED INSURED AND MAIUNG ADDRESS: AGENT NAME AND ADDRESS: YARMOUTH MOOSE LODGE #2270 LOCKTON AFFINITY,LLC. PO BOX 186 P.O.BOX 410679 SOUTH YARMOUTH MA 02664-0186 KANSAS CITY,MO 64141-0000 LOOGE2270@MOOSEUNITS.ORG AGENT NO. 10071 LEGAL ENTITY: NON PROFIT ORGANIZATION OTHER WORKPLACES NOT SHOWN ABOVE: SEE NAME AND LOCATION SCHEDULE ITEM 2. POUCY PERIOD: From: 12-15-2017 To: 12-15-2018 Effective 12:01 AM.Standard Time at the Insured's mailing address. ITEM I COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 100,000 each accident • Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: ALL STATES EXCEPT ND, OE, WA, WY AND STATES DESIGNATED IN ITEM 3A D. This Policy Includes these Endorsements and Schedules: SEE SCHEDULE OF FORMS AND ENDORSEMENTS ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by premium adjustment or audit. Minimum Premium: $ 212 (MA) Total Estimated Policy Premium: $ 894 Audit Period: ANNUAL Deposit Premium: $ 8 94 Issuing Office:WINDSOR, CT issued Date: 10-09-17 WC 00 00 01 A 0615 N cfudea copyrigtied rnetedal of National Council on Compensation knurl nu:* with It's permiselorf t ' 4, iv 7y.. ,x r . - ..O F y' BUILDING ._: TOWN OF YA R M O U T H ELFCTRlCAL „,-,4ii 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 PLUMBING \ Il z r Telephone(508) 398-2231,Ext.1261 Fax(508) 398-0836 / �I` 1�C ` SIGNS /i BUILDING DEPARTMENT / W •:.• ti)11'..1(SA _it) Inspection and license Report / �7 Q C� Date ! /OC//7\ Address 7 �/1T� �G�� Bus ness Name /2,C Z�fr Contact Phone /-,_ _ During the Annual Inspection of your premises,performed in accordance with the provisions of Section 110.7 of 780 CMR(Massachusetts State Building Code),the Board of Selectmen,and/or the Board of Health rules,the following violation(s)were observed: aria ❑Emergencycgrnasignage Location ❑ Emergency egress lighting Location PerA7Yl4}I al f 4 itelAf i/ o i A e /4%7 �j ��.1�r � rV ❑Maintenance of exits Location f c`�j,t "7 m "t t`i�'`� ue l r 1 it rG/iC 'n 4vil U Guards/handrails Location C( 't I e-/R" 7-f illset/ ❑Signs Location ITOCO 6101.eiei Gt�.0- ❑ Parking Location CI Other Location Merhanicaf CI Combustion Air Location ❑ Storage in Boiler Room Location • ❑Vents Location Automatic door closures on boiler room doors Location ❑ Clothes dryer vents Location .Qtcx Location • The State Building Code,Section 1001.3-Maintenance,provides that the owner as defined in Section 780 CMR shall be responsible for proper maintenance. In order to_abate the above vlolation(styou must; o Make corrections immediately and contact this office for a follow-up inspection. • o Make corrections prior to opening and contact this office for a follow-up inspection. o Make corrections prior to your next annual inspection. o Make corrections within 0/e: days and contact this office for a follow-up inspection. 1 rx al Oificial/Inspector ( ' f/`7_e/ Received By — Title Revised 2/8/13