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Home My WebLink Aboutbldci-16-003439-04 The Commonwealth of Massachuse• tts ., City\Town of '.=i^gri c wirli= YARMOUTH . __Al__ ., —... 4.,, .11"tummis !E.,. 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-16-003439-04 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 • 12/31/2021 SOUTH YARMOUTH,MA 02664 j Use Group Floor Occupancy Use Group Other - Classifications(s) 18 • A-2 Nightclub/Restaurant/Bar/Banquet Hall OUTSIDE PATIO A-2 Other 01st Floor 315 A-2 Nightclub/Restaurant/Bar/Banquet Hall 115 persons-large bar Allowable 32 persons-smoking bar Occupant Load 1 . 168 perso on otd m �1 TOTAL-333 that the premise,structure or portion thereof as herein specibccted This certificate of inspection is hereby issued by the undersignedcerttfY for general fire and life safety features. This certificate shall be framed behind glass and/or laminar&d 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. Philip • Slmonian III Name of Municipal Mark Gryl Date of //r�`/ Name of Municipal Building Commissioner spection Fire Chief Signature of Municipal Date of Signature of Municipal Building Commissioner 7 Issuance //' Ya•2oZo Fire Chief r Fee:$150.00 BLD_Certofl nspectio n.rpt BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2021 NAME: Loyal Order of the Moose ADDRESS: 769 Route 28 Yarmouth This log is to be signed by the appropriate inspectors upon a satisfactory inspection of your building/premises. When all signatures are obtained, this log shall be presented to the License & Permits office and/or the Health Department in order to obtain your license. Licenses will be withheld until all inspectors have signed. Building Commissioner ep. Date Comments Approved for License Issuance #‘ No Fire Department Rep. Date Comments Approved for 1 _ w Li se Issuance Ye. No f "V Board of Health Rep. Date Comments Approved for License Issuance Yes No Plumbing/Gas Inspector Date Comments Approved for License Issuance Yes No Electrical Inspector Date Comments Approved for License Issuance Yes No Taxes Paid Yes No Rev.Sept.2003 oi•gaR .1A : c: TOWN OF YARMOUTH —.1 BUILDING DEPARTMENT ru tr n . a %-.c. '. ��34cv. 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION October 1,2020 PAYABLE UPON RECEIPT (X)Fee Required. 150.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7,I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: 1 Street and Number: LOGI/}L d n 0 f A /12Uo$c 76 Q ec i-E 2D , SNP) /,hmoo k. Name of Premises: iii yi-( 0014014 0/)lh /1165' Z271) Tel: & — 737 05 Purpose for which permit is used: C Co 8 1 nE9rAL/IZ mu r' License(s)or Permits)required for the premises by other governmental agencies: License or Permit Agency RPMYNdiG -1 -cr nit/ ECE1VED rem gel y/e( M +r o eq-t 1 - - - Zig WC. . NOV 18 2023 Certificate to be issued to Tel: Address: h$ /2OUTC zB BYi- �h � '� r Owner of Record of Building ip Up5 L(W64 2 2.70 .T-1UC` Address 177 /)9UTE Z e 5OU7/I y/f-il o( 't/1 IA Ass A2 4 y Ce rtificate Holder of d X2 flWoit.,ins.47114 t Signs re of person to Title / Certificate is issued or 's agent - //6/��1 Date rr Email Address: /OO$e/270 0 inno5pandc. oly 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 ISSU OUR CERTIFICATE OF INSPECTION. Certificate of Inspection# ceL6C J—��_-- b0 3Y3 y-65/ 12/31/2020—12/31/2021 • NOVA Casualty Company R CENEID NOVA A S1T•OCK INSURANCE COMPANY NOVA CASUALTY cumpatcY 726 Exchahge Street.Suite 1 C20,Buffalo,NY 14210 NOV 25 LO23 • 1-866-633-6945 WORKERS COMPENSATION AND EMPLOYERS'UABIUTY INSURANCEL-p�UC.Y ii:j =`J' INFORMATION PAGE NCCI Company No. 14191 POLICY NO. LFR—WK-10001421-01 RENEWAL OF: LFR—WK-10001421-00 I- ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: YARMOUTH MOOSE LODGE #2270 LOCKTON AFFINITY, LLC. 769 ROUTE 28 P.O. BOX 410679 SOUTH YARMOUTH MA 02664-5101 KANSAS CITY,MO 64141 LODGE2270@MOOSEUNITS.ORG AGENT NO. 10071 LEGAL ENTITY: NON PROFIT ORGANIZATION OTHER WORKPLACES NOT SHOWN ABOVE: SEE NAME LOCATION SCHEDULE ITEM 2. POLICY PERIOD: From: 06-13-2020 To: 06-13-2021 Effective 12:01 A.M.Standard Time at the Insured's mai ing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the licy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy plies 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 applie to the states, if any, listed here: ALL STATES EXCEPT ND, OH, WA, WY AIDsSTATES DESIGNATED IN ITEM 3A b. This Policy includes these Endorsements and Schedules: SEE SCHEDULE OF FORMS AND ENDORSEMNTS ITEM 4. PREMIUM: The premium for this Policy will be determi by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required on the Work rs Compensation Classification Schedule is subject to verification and change by premium adjustment or au it. Minimum Premium: $ 211 (MA) To Estimated Policy Premium: $ 333 Audit Period: ANNUAL De sit Premium: $ 333 Issuing Office:WINDSOR, CT Issued Date: 03-24-20 WC 00 00 01 A 0615 'Includes copyrighted material of National Cou I on Compensation insurance with Ira INSURED PE L N _:..�. Policy No.LFR—WK-10001421-01_vA :or NOVA CASUALTY COMPANY EXTENSION OF INFORMATION PAGE WORKERS COMPENSA ON CLASSIFICATION SCHEDULE State of: MASSACHUSETTS Risk ID: Named Insured YARMOUTH MOOSE LODGE #2270 Effective Date: 06--13-20 Agent Name LOCKTON AFFINITY, LLC. Agent No. 10071 Class Total Rate Classification of Operation Code Estimated per$100 of Estimated No Remuneration Remuneration Premium 0001-01 CLUB NOC 6 CLERICAL 9061 $ 16,000 .90 $ 144.00 TOTAL CLASS PREMIUM $ 144.00 TOTAL SUBJECT PREMIUM $ 144.00 TOTAL MODIFIED PREMIUM $ 144.00 STANDARD TOTAL $ 144.00 LOSS CONSTANT $032 $ 20.00 EXPENSE CONSTANT 0900 $ 159.00 TERRORISM RISK INS ACT 2002 .03 9740 $ 5.00 TOTAL ESTIMATED PREMIUM $ 328.00 MACHWC (SURCHARGE) 1.0351 0087 $ 5.00 FINAL TOTAL $ 333.00 POLICY TOTAL ESTIMATED COST $ 333.00 WC000001A 0615 Policy No. LFR—WK-10001421-01 NOVA CASUALTY COMPANY EXTENSION OF INFORMATION PAGE NAME AND LOCATION SCHEDULE Named Insured YARMOUTH MOOSE LODGE #2270 Effective Date: 06-13-20 Agent Name LOCKTON AFFINITY, LLC. Agent No. 10071 Entity Code: 1 YARMOUTH MOOSE LODGE #2270 FEIN: 042622104 NAICS Code: 813410 769 ROUTE 28 SOUTH YARMOUTH, MA 02664-5101 # EMP: 1 W0000001A0615 INSURED 3 , . . _ N-- -V NOVA CASUALTY COMPANY 726 Exchange Stre Suite 1020,Buffalo,NY 14210 Phone:716.8 6.3722 Fax:716. 56.4351 In Witness Whereof, Nova Casualty Company has executed and attested these presents, and where required by law, has caused this Policy to be countersigned by its duly authorized representative. acci-r„,„4,____ di...c...... c2-7).....a._._, Charles Frederick Cronin John C. Roche Corporate Secretary President WC 99 06 02 06 13 Page 1 of 1 INSURED Policy No. LFR—WK-10001421-01 NOVA CASuALTY COmPAN'Y INSTALLMENT SCHEDULE Named Insured YARMOUTH MOOSE LODGE #2270 Effective Date: 06-13-20 Agent Name LOCKTON AFFINITY, LLC. Agent No. 10071 IT IS HEREBY AGREED AND UNDERSTOOD THAT THIS POLICY IS PAYABLE ON INSTALLMENTS AS FOLLOWS: REVISED DUE PREMIUM SURCHARGE INSTALLMENT 06/13/2020 $ 328.00 $ 5.00 $ TOTAL 333.00 Failure to pay the Installment Premium by the Date Due shown shall constitute non-payment of premium for which we may cancel this policy. WC 99 06 10 A 0615 4 Policy No. LFR—WK-10001421-01 ...tvA NI it 's NOVA CASUALTY COMPANY EXTENSION •F INFORMATION PAGE SCHEDULE OF FORMS AND ENDORSEMENTS Named Insured YARMOUTH MOOSE LODGE #22 0 Effective Date: 06-13-2020 Agent Name LOCKTON AFFINITY, LLC. Agent No. 10071 WORKERS COMPENSATION FORMS AND ENDO' EMENTS WC 99 06 10 A 06-15 INST• IA SCHEDULE WC 00 00 00 C 01-15 INS CE POLICY AIL0014 02-11 CONFeRMITY WITH STATE STATUTES AIL0015 02-11 TRAD OR ECONOMIC SANCTIONS WC 00 01 15 01-20 NOTI ENDT OF PEND LAW CHG TRIPRA 2015 WC 00 04 14 07-90 NOTI• ICATION OF CHANGE IN OWNERSHIP ENDT WC 00 04 22 B 01-15 TERR+RISM RISK PGM REAUTH ACT DISCL ENDT WC 00 04 24 01-17 AUDI NONCOMPLIANCE CHARGE ENDT WC 20 03 01 04-84 MA L MITS OF LIABILITY ENDT WC 20 03 02 A 09-08 MA • SESSMENT CHARGE WC 20 03 03 D 08-10 MA N.TICE TO POLICYHOLDER ENDT WC 20 04 05 06-01 MA PREMIUM DUE DATE ENDT WC 20 06 01 A 07-08 MA C CELLATION ENDT WC000001A0615 rum