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HomeMy WebLinkAboutBLDCI-16-003280-04 The Commonwealth of Massachusetts } = = City\Town of mmu • o r YARMOUTH `* �, /r{{/rram y T fM�lr *� e:ice J 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: OLD YARMOUTH INN BLDCI-16-003280-04 Trade Name: OLD YARMOUTH INN Identify property address including street number, name,city or town and county Certificate Expiration Located at 223 ROUTE 6A 12/31/2021 YARMOUTH PORT, MA 02675 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 170 A-2 Nightclub/Restaurant/Bar/Banquet Hall 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 with the contents of the certificate is strictly prohibited. Name of Municipal Philip Simonian III Name of Municipal Mark Grylis Date of //�/ 'Fire Chief Building Commissioner Inspection Signature of Municipal Signature of Municipal i Date of Fire Chief , Building Commissioner �;)� Issuance 7/•it `�. /�` V Fee: $150.00 BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2021 NAME: Old Yarmouth Inn Restaurant ADDRESS: 1223 Rte 6A Yarmouthport 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 �' �� yr..,_, // /2-_J ci es No /////4...„ Fire Department Rep. Date Comments Approved for License Issuance No 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 YAR TOWN OF YARMOUTH LTA1 BUILDING DEPARTMENT n4' ',Po-o•.r�o,� 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: Street and Number: ' LD \p •-z `p A Name of Premises: C) \ A Yc r yni7U \h f - n Tel: jg . Z. CI c9 (_, _ Purpose for which permit is used: (' SA a_.✓°1- - ArILA7cAll,-) / iaU r--J\ License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to(Di �y f r-r)cy`1r�r‘l Tel: �-)�- 3�7. �lQ (•p�- CY-4k).-1C4 Address: ZZ3 cSls*c U14, (('r V\-R•�✓'-t - Owner of Record of Building c rri•� Yr3 V - v v .--k' Address Z Z 3' z V A , ✓YY1bol--i 'c v+ r \A. Present Holder of Certificate DI�-1 A ✓rrlbu1 C Ti nr RY Si Arm� - -. \ Dci(n Uhl, SignatureXCK*I--;CM2_._ on to whom Title Certificate is issued or his agent lol. Z I i 2-0Z.33 Date Email Address: \ .c, (p C_- rYThryV-A- • flt-')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# 6�_k.�.,/-/ *'—O6 s_O g_0(.09( 12/31/2020-12/31/2021 r " _ a /', 1696COR-01 TVANRYSWOOD ACc 10/21 RL CERTIFICATE OF LIABILITY INSURANCE D IDD/YYYY) 10/21l2020 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: RogersGray,Inc. PHONE FAX 434 Rte 134 (A/C,No,Ext):(800)553-1801 (A/c,Na):(877)816-2156 E-MAIL South Dennis,MA 02660 ADDRESS:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Company, Inc. 41360 INSURED INSURER B:Massachusetts Retail Merchants WCSIG, Inc_.00000 1696 Corp dba Old Yarmouth Inn INSURER C 223 Main St. INSURER D Yarmouthport,MA 02675 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 LIMITS LTR INSD WVD (MM/DD/YYYYI (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ _ 1,000,000 CLAIMS-MADE X OCCUR 8500053847 12/31/2019 12/31/2020 PREM SES(Ea occu once) -_$ 100,000 MED EXP(Anyone person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 1 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY fire-F LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) _ - -._—$_ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED - - - - AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ _ - HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ -- -- EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEY/N 014005032709120 1/1/2020 1/1/2021 500,000 FFIGER/MEMBER EXCLUDED? N '..N/A _E L EACH ACCIDENT $ Mandatory m NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 A General Liability ' '8500053847 12/31/2019 12/31/2020'Each Occurence 1,000,000 A General Liability 8500053847 12/31/2019 12/31/2020 Aggregrate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Main Street 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 4: 1-,---/iAraej Z4644A/--"---------- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD