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HomeMy WebLinkAboutbldci-16-003252-05 The Commonwealth of Massachusetts 1 g ity\Town of ' 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: THE GRUMP INC. BLDCI-16-003252-05 Trade Name: SWEET TOMATOES Identify property address including street number, name, city or town and county Certificate Expiration Located at 465 STATION AVE 12/31/2022 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 32 A-2 Nightclub/Restaurant/Bar/Banquet Hall 32 persons total 01st Floor 28 A-2 Nightclub/Restaurant/Bar/Banquet Hall 28 persons with Allowable Occupant Load entertainment 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 ' = mate of Fire Chief Syr` Bfid//)4uilding Commissioner Issuance /Z . ZA Fee: $100.00 RI n (stark nflncnnr+inn.n+ BUILDING DEPARTMENT T 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2022 NAME: Sweet Tomatoes ADDRESS: 461 Station Ave 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 Is No Fire Department Rep. Date Comments Approved for Li ssuance () -- I ). ,O_a rYes No Board of Health Rep. Date Comments Approved for License Issuance Yes No Plumbing/Gas Inspector Date Comments Approved for License Issuance / Z/ /ZI clYe No Electrical Inspector Date Comments Approved for License Issuance Yes No Taxes Paid Yes No Rev.Sept.2003 ( 'Y''tR TOWN OF YARMOUTH \O ou, - 0.9) BUILDING DEPARTMENT st «..,,,.< 1.1.46 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION November 22, 2021 PAYABLE UPON RECEIPT (X) Fee Required 100.00 ( )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: (OS ---- - L1 C\ S �L;N-Th \)-e y-,L\v„,.. ._ Name of Premises:Si1/4,:i t.- N Q.s-0-e S Q•7 7 ,., Tel: (A- t. - (C)'C; ,/ Purpose for which permit is used: License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to x : � Tel: �°j1-1 Ur 3L\ Address: L\Lo S S' �lj� $ - ^ V•A'k_H„u Owner of Record of Bu' ingce CjvLc.-77TNN Address (0.-C -.."' `'L3 N— `� )- S - \p6N\^"Lj Present Holder of Certificate S*NW\-Q \N ,�-rm i ' - • - EKE D i Signature of person to whom Title r NOV 2 3 2021 Certificate is issued or his agent i ) - Pa' a ' Date I BUILDING DEPARTMENT By Email Address: -4\Sk_ 3{e-c7 \)V\�C• (C v 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# 12/31/21-12/31/22 ACCORD0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 11/12/2021 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 CONTACT NAME: Jen Davis PHOMark Sylvia Insurance Agency, LLC (A/CNN.EXt) (508)957-2125 FAX ; (508)957-2781 404 Main Street ADDARIESS: mark©marksylviainsurance.com INSURER(S)AFFORDING COVERAGE NAIL# Centerville MA 02632 INSURER A: Farm Family Casualty Insurance INSURED INSURER B: Scottsdale Ins Co The Grump Incorporated Dba Sweet Tomatoes Pizza INSURER C: 170 Hollingsworth Road INSURER D: Osterville,MA 02655-2153 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. NrgR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE MSD URID POLICY NUMBER (MWDD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(My one person) $ 5,000 A N N 2001X1553 11/30/2021 11/30/2022 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ,SCOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LNrirr $ (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) UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ VVORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER A OFFICER/MEMBER EXCLUDED?ANY ECUTIVE YY N/A N 2001 W8131 3/4/2021 3/4/2022 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 1,000,000 N yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 Liquor Liability General Aggregate $2,000,000 B N N CPS2875152 11/30/2021 11/30/2022 Each Occurance $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remark's Schedule,may be attached it more space is required) Pizza restaurant Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived or extended the coverage provided by the policy provisions. 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. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Fax: Email: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD