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HomeMy WebLinkAboutBLDCI-16-003546-04 The Common e ith of Massachusetts I _ ft Town of ='� '' YARMOUTH awl New and Renewal Certificate of Inspection In accordance with the Massachusetts State Building Code, Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name: RYAN FAMILY AMUSEMENTS bLUUI-1b-UU.ib4b-U4 Trade Name: RYAN FAMILY AMUSEMENTS Identify property address including street number, name, city or town and county Certificate Expiration Located at 1067 ROUTE 28 04/17/2022 SOUTH YARMOUTH, MA 02664 I I Use Group Floor Occupancy Use Group Other Classificate(s) A-3 01st Floor 300 A-3 Amusement/Church/Gym/Library/Museum 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 withthe contents of the certificate is strictly prohibited. Name of Municipal Philip Simonian III Name of Municipal Mark Grylls Date of (/ /Q � BuildingCommissioner Inspection CJ Signature of Municipal Signature of Municipal Date of Building Commissioner . Issuance // ��. Z Fee: $150.00 BLD_Certoflnspection.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: Ryan Family Amusement Center ADDRESS: 1067 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 Fire Departmentep. Date Comments Approved for 1 1.1,g_2 l License Issuance tX'� es No Board of Health Rep. Date Comments Approved for License Issuance Yes No Plumbing/Gas Inspector Date Comments Approved for License Issuance ////1 Z� Yes No Electrical Inspector Date Comments Approved for License Issuance Yes No Taxes Paid Yes No Rev.Sept.2003 �q s-. TOWN OF YARM. OUTH lot k'it .ice BUILDING DEPARTMENT 1.,, ”n s[%" 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION October 1, 2021 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: UM 'Route 2g Name of Premises: cow0►+k1 AmJ se v►'t-e n.'r Tel: . 03 —39q -51,eici Purpose for which permit is used: j_...iqtnr( c.en S.c. License(s) or Permit(s)required for the premies by other governmental agencies: RECEIVED License or Permit Agency A c e d C L° hi % . , bpv)I n BUILDING DEPARTMENT V.?rr-s .r.no w it 6y. _ Certificate to be issued to •`{•A Co-',A! 11 Atmv-1e* tAT Tel: Address: 100 Rork 28 S.Y(411440).4, Owner of Record of Building F� ,ne„�.1.r'r Co Address II L Wraicr C- l rv. . 0►1 v 3 5'2 Z Present Holder of Certificate I (?bz .,,, klety.e.r Signature of p son to whom Title Certificate is issued or his agent ti�\z4 Date Email Address: r_FA VA. KC, Q co r Cos-t• Nam' -- 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# ,3(0,1-06- C 93 /67.00 12/31/21-12/31/2022 ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE 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 John McLaughlin Agency PHONE FAX 828 Lynn Fells Pkwy (A/c.No.Extt: 781-665-2775 (A/C,No):781-665-0295 Melrose MA 02176 ADDRESS: info@mclaughlinins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Commerce Insurance Company 34754 INSURED RYANF-1 INSURER B:Guard Insurance Group Ryan Family Amusements, Inc. INSURER C:Everest National Insurance Corn 116 Waterhouse Road Bourne MA 02532-3867 INSURER D:National Insurance Fire Ins Co. INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1515541899 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. INSR LTR TYPE OF INSURANCE INSD SUBRDDL POLICY EFF POLICY EXP D WVD POLICY NUMBER /Y(MM/DD/YYYY) (MM/DDYYY) LIMITS C X COMMERCIAL GENERAL LIABILITY SI8ML01505-201 5/1/2021 5/1/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 X LIQUOR LIAB MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: Liquor $1 m/1 m A AUTOMOBILE LIABILITY BDPRLQ 4/10/2021 4/10/2022 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED x SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) D X UMBRELLA LIAB X OCCUR EBU035651640 5/1/2021 5/1/2022 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED X RETENTION$ B WORKERS COMPENSATION RYWC12698 12/31/2020 12/31/2021 PER STATUTE E ERH- AND EMPLOYERS'LIABILITY Y/N R ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED? N/A (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 C Property S18ML01505-201 5/1/2021 5/1/2022 Limit Various (See below) DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance Coverages apply at 1067 Route 28 and include any and all activities in the parking lot. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall 1146 Route 28 AUTHORIZED REPRESENTATIVE So.Yarmouth MA 02664 �©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD i/Berkshire � Worker's Compensation and Employers Liability Policy Hathawa AmfauARD Insurance Company - A Stock Co. j Policy Number RYWC120698 Insurance Renewal of RYWCO17284 Companies NCCI No. [21673] Policy Information Page Extension of Information Page Schedule of Locations (L2) 200 Main Street , Buzzards Bay, MA 02532 (12/31/2020 - 12/31/2021) (L3) 441 Main Street , Hyannis, MA 02601 (12/31/2020 - 12/31/2021) (L4) 1067 Rte 28 , South Yarmouth, MA 02664 (12/31/2020 - 12/31/2021) (L5) 115 New State Hwy , Raynham, MA 02767 (12/31/2020 - 12/31/2021) (L6) 1170 Main Street , Millis, MA 02054 (12/31/2020 - 12/31/2021) (L8) 23 Town Hall Sq. , Falmouth, MA 02540 (12/31/2020 - 12/31/2021) (L9) 19 Circuit Ave , Oak Bluffs, MA 02557 (12/31/2020 - 12/31/2021) (L10) 268 Thames St , Newport, RI 02840 (12/31/2020 - 12/31/2021) (L11) 769 Iyannough Rd , Hyannis, MA 02601-5027 (12/31/2020 - 12/31/2021) (L12) Cape Cod Inflatable Park, 512 Route 28 , Yarmouth, MA 02664 (12/31/2020 - 12/31/2021) (L13) Cape Codder Resort, 1225 Iyannough Road , Hyannis, MA 02601 (12/31/2020 - 12/31/2021) (L14) 136 Water St , Plymouth, MA 02360-8727 (12/31/2020 - 12/31/2021) (L15) 769 Iyannough Rd Cape Cod Mall, Hyannis, MA 02601-5027 (12/31/2020 - 12/31/2021) INTERNAL USE xx Page - 2 - Information Page MGA ; RYV0C120698 Date : 11/26/2020 WC 40a40IA MANOTE Lssuing Office: P.O. Box AM, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com _� Worker's Compensation and Employer's Liability Policy " wBerkShire Hathaway AmGUARD Insurance Company - A Stock Co. AVI 7 Policy Number RYWC120698 Ai; lr G I IARD Insurance Renewal of RYWC017284 /A Companies NCCI No. [21873] Policy Information Page 1[1]Named Insured and Mailing Address Agency Ryan Family Amusements Inc MACKINAW UNDERWRITERS INC. OBA/TA Ten Pin Eatery 10 NEW ENGLAND BUS LI K 116 Waterhouse Rd SUITE 110 Bourne, MA 02532 Andover, MA 01810 Agency Code: MATPAA10 Federal Employer's ID XX-X)0(1210 Insured is Corporation Risk ID Number 917565287 Additional Names of Insured (N2) 769 Iyannough, Inc- (N3) Ten Pin Eatery Locations on Policy - See Extension of Information Page-Schedule of Locations [2] Policy Period From December 31, 2020 to December 31, 2021, 12:01 AM, standard time at the insured's mailing address. (3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts, Rhode Island B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit S500,000 i I C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [(4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, . Classifications, Rates, and Rating Plans. All required information is subject to verification and change by laudit. (Continued on another page) Total Estimated Policy Premium $ 32,413 Total Surcharges/Assessments $ $1,059.00 • Total Estimated Cost $ $33,482.00 Biagi ___' Page - 1 - Information Page MGA : RYWCI20698 WC 000001A Date : 11/26/2020 MANOTE Issuing Office: P.O. Box AH, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com