HomeMy WebLinkAboutBLDCI-16-004502-05 The Comm Ir ealth of Massachusetts
hT. City\Town of
' YARMOUTH
N
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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 PANCAKE MAN BLDCI-16-004502-05
Trade Name:THE PANCAKE MAN
Identify property address including street number, name,city or town and county Certificate Expiration
Located at
952 ROUTE 28 11/30/2021
SOUTH YARMOUTH, MA 02664
Use Group Floor Occupancy Use Group Other
Classifications(s)
A-2 01st Floor 185 A-2 Nightclub/Restaurant/Bar/Banquet Hall 185 Persons Total
Liquor License 4/1/16-
1/15/17
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 G., s Date of 3 ��
Fire Chief Building Commissioner Inspection
....:2
Signature of Municipal '/ Signature of Municipal Date of
Fire Chief ,� , Building Commissioner ,�'// Issuance c/;,7(
/ / �'� 0.00
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 - 2021
NAME: The Pancake Man ADDRESS: 952 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 Re . Date Comments Approved for
License Issuance
3No
Fire Department Rep. Date Comments Approved for
Li Issuance
Yes No
13) at
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
1
•0Y YARD TOWN OF YARMOUTH
401 y BUILDING DEPARTMENT
oI
tA\ " w/4'
cs-a:41 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
Febuary 5, 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:7
Street and Number: IA q\,.u,... w if
Name of Premises:_ 'gell Pic4kt A4.4.) Tel: b 3 j - Z
Purpose for which permit is used: 51A V 1 R/l t.c
License(s)or Permit(s)required for the premises by other governmental agencies:
Ts I V
s>r
License or Permit `�
Agency s-u:
�Jb� (WI af 14-6, MAR 1— 2021
t1' A-16,6kb l � LVG'fUAJ
BUILDIP<'/�' ti.kr
BY -- V
Certificate to be issued to 1 '! I; Vat IJ LA-k C M!)(A) Tel: 5 4 3 c1 - �3 2
Address: rf5 Z 1{
Owner of Record of Building M A v- P
Address P s b P2 a 1 3-� 4,i a n l I S Vo r t Wl 4 o x b`41
Present Holier of Certificate Dire OP r, M A
'+1� V V'A J A -�
Signature �=rson to whom Titl
Certificat- is issued or his agent a- d-1 13,
Date
Email Address: VtA A iu,k- rJ l j N c,A 'N/L p I\3,, C h
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. d
( Ge 1rLL� 4
Certificate of Inspection# CC b �� 1 1.1 .,� \N A
4/1/2021 -11/30/21
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i CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATiVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 3Y THE POLICIES 1
I t3Fi(1W THIS CFRT7FICATF OF il1ti ilarairs= news 11t 1T CONSTrri ITF A cowymirrr tiFTMI,F,F1y1'IMF :RAI mon n1<ti:RFR1at At ITtmnR:7Pri I
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on I
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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at w ruicnay I .. ......50S-77i-3300 i Pa x, f rgS-i 7S-ii'sti 1 ii
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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 REQUIREMLNT. TERM OR CONDITION OF ANY rCO I
US TRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T
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!i EXCLUSIONS AND CONDITIONS OF SUCH POLiC;IES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CiAifsiS. I
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i LIABILITY INCLUDES UQUOR eery i12ti D112D u- �� - person),
D4/0 20104! 2`1 I,' r•EXP(Anv o• .. $ 10,0001
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I I. I'L AOGPFGATE LIM R APPLIES PER I I I i LLiENERAL AU iiii tiA i E +--_I ai. ,I3�J01
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Dittaeraftinti OF OPERATIONS t LOCATIONS t venc6i4!ACoRD lel.Additional Rantarips isle.My De bitched I9 more mess le toliiledl
Ivuls ue aeaung Area with a term,will include the Liquor Liauiihy coverage I
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CERTIFICATE HOLDER CANCELLATION. •,___ � ._
I ACCORDANCE WITH TH POLICY PROVISIONS.
Town Of Yarmouth
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REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to i
. z eC•�':=^^^-•••.:_i::•, •"- N.-Y :e.pilli.1IAA may reouIra an endorsement, A statement on this certificate dries not canter riuhts to the
1! certificate holder in lieu of such endorsement(s). I
IPRODUCER I ONTACT I
..zr . Martha Findlay r
1300 WINTER ST INSURE RIS)AFFORDING COVERAGE NAIC s
HYANNIS MA 02601 I INSURER A: AIM MUTUAL INS CO 33758
IINSURED
{INSURER 8 I PANCAKE MAN LTD
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I HYANNISPORT MA 02647 j INSURER F: I
COVERAGES CERTIFICATE NUMBER: 626972 REVISION NUMBER:
iTHIS IS I)CER .r. 7 p ::: v r Ein r_-uN .T IN nrz 1 NtArvirrp ABOVE FOR THE POLICY PERIOD I
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDMON OF ANY CONTRACT OR OTHER flcCUMEN1 WIIH RESPECT TO WHICH THIS i
I CERTIFICATE MAY tit ISSUED OR iMAr PERTAIN, THE INSURANCE AFFORDED DY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO Al i THE TERMS. I
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I Wnrkers•Compensation benefits will be Daid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no author nation is given to pay I
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issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage VeI ification
Search tool at www.mass.govilwdlworkera-compansationtinvestigetionst.
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