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HomeMy WebLinkAboutbldci-18-002140-04 • The Commonwealth of Massachusetts M City\Town of ,z � t� —1• , YARMOUTH ltia - 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:CAPE DELI FOODS, INC. BLDCI-18-002140-04 Trade Name: PICCADILLY CAFE&DELI Identify property address including street number, name,city or town and county Certificate Expiration Located at 1105 ROUTE 28 12/31/2022 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01 st Floor 80 A-2 Nightclub/Restaurant/Bar/Banquet Hall 80 Persons-table& chairs/15 stools. Allowable Total:80 persons 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 III Name of Municipal Mark Grylls Date of Fire Chief Building Commissioner Inspection ' `"' —�� Signature of Municipal ` Signature of Municipal Fire Chief c./ _ �' i Date of �J,� f -- Building Commissioner Issuance /2 4.i ?(' Fee: $100.00 RI rl f:artnflncncrtinn rnt BUILDING DEPARTMENT TMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2022 NAME: Piccadilly Deli ADDRESS: 1105 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 /tj " r License Issuance l`�—/" No Fire Department Rep. Date Comments Approved for License Issuance 91)-24 f /a l es No Board of Health Rep. Date Comments Approved for License Issuance Yes No Plumbing/Gas Inspector Date Comments Approved for Ltc eIssuance �l�/ �Z Yes j No Electrical Inspector Date Comments Approved for License Issuance Yes No Taxes Paid Yes No Rev.Sept.2003 �' A_ c TOWN OF YARMOUTH o; .iy„ BUILDING DEPARTMENT MATTAGf, 3(f�Y ...a,...i -' 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION November 8, 2021 R E C E I V E..0 PAYABLE UPON RECEIPT NOV $ 2�2� (X) Fee Required 100.00 ( )No Fee Required In accordance with the provisions oft eEtt4 k tsAgarle iui ding Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below :1c i Fj raises located at the following address: Street and Number: Rcc4 d' ame of Premises: %i /5 I L t , 5' 6 (la.ri0:) 1, Tel: ;- -31 Y 6 9 Purpose for which permit is used: (1Zq_.e_.,kG 1),(Cr\N License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency kil,,e1 1)ni--u 0) 11.t 117eci i i r r V'dull` i / 1 11 Certificate to be issued to c , PP,� , cpvd c 1 C' Tel: co - ''! 'q 67 2 Address: / 1 (L �1 ,.oz2 �o kin o�+i h t O Z ' Owner of Record of Building, c: -I C Address -,r' Present Holder of Certificate n GI . - '�_ P2 Signs re Of person to whom Title 6 Certificate is issued or his agent (1 lC6 :1 0? 1 Datd r Email Address: J,1 , c 0,-0 5 0, qp I , inz r(\- 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# j3'J)/— /&(9/u( 12/31/21-12/31/22 �-"r"1 PICCA-1 OP ID:JA ,acoRGP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) kle....... 11/08/2021 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 508-775-6060 _NAMEACT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-775-6060 FAX 508-790-1414 88 Falmouth Road (EA/cDDR,Noss: Ext): I(A/C,No): Hyannis,MA 02601 AESS: Bryden&Sullivan Insurance INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection 11NapeFbSUR Deli Foods Inc. INSURER B:Guard Insurance Group G dba Piccadilly Deli INSURER C: 1105 Main Street South Yarmouth,MA 02664 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP I LIMITS LTR JNSD WVD IMM/DD/YYYY1 (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILrTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 8500062959 10/01/2021 10/01/2022 DAMAGETORENTED 300,000 PREMISES(Ea occurrence) $ A 8500062959 10/01/2021 10/01/2022 MED EXP(Any one person) $ 10,000 X Liquor Liability PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY Fla LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Perperson) $ OWNED SCHEDULED AUTOS ONLY AUUTNOSSyy E BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS ONNLD (Perr aPcEcidentDAMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESSLIAB CLAIMS-MADE 462008718603 10/01/2021 10/01/2022 AGGREGATE $ 1,000,000 DED X RETENTION$ 10000 $ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE CAWC281469 08/01/2021 08/01/2022 500,000 QFFICE ER EXCLUDED? N 1 A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE,$ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION TOWN-15 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. ROUTE 28 S.YARMOUTH, MA 02664 AUTHORIZED REPRESENTATIVE Bryden&Sullivan Insurance ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD