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BLDCI-17-003192-04 The Commonwealth of Massachusetts h1 r City\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: M.A.A.M. CORP. BLDCI-17-003192-04 Trade Name: LONGFELLOW'S PUB Identify property address including street number, name,city or town and county Certificate Expiration Located at 182 OLD TOWNHOUSE RD 12/31/2021 ISOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 66 A-2 Nightclub/Restaurant/Bar/Banquet Hall 20-Bar Stools 6-Standing 40-Main Dining Room 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 Grylls Da of �/�p�^O Fire Chief Building Commissioner Inspection j O( Signature of Municipal Signature of Municipal Date of / +� �� Fire Chief �i� Building Commissioner Issuance /1,/V *, E-��/ , ! Fee: $100.00 BUILDING DEPA TN1 l 146 Rotate 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2021 NAME: Longfellow's Pub ADDRESS: 182 Old Townhouse Road 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 14- License Issuance �—� No Fire Department Rep. Date Comments Approved for CA TT T U G L License Issuance C -�'ZO Yes 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 ° .YgRo -f tTOWN OF YARMOUTH r c o li -y BUILDING DEPARTMENT '`-' :::.,',1 ., (�MAT �.E Route28, SouthYarmouth, 1146 MA 02664 508-398-2231 ext. 1260 p 1 4W APPLICATION FOR CERTIFICATE OF INSPECTION October 1, 2020 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: /f)p cX Q 7&04.1Oo E / L Name of Premises: ()iA/1? itUC. Me4 r-EaDt, 5 Tel: 5Od J1 Purpose for which permit is used: P65740 License(s) or Permit(s) required for the premises by other governmental agencies: R F License or Permit Agency rout icy 2on C tl✓ Certificate to be ' suppedd to lJ K Rt)S50 Tel: 6a - 731)- SIG Address: / 1 �/'Np C' K 6 FQ 657 9'.E , ifi 0 49 Owner of Re ord of Building f�� 4LU, Address /k 04D ] ;rc.till ViE 106 Present Holder of Certificate J1 f1xi le l cd5S 3 ,eQ4.0 PneiaLceet4 Si ture of person to whom Title -y' Certificate is issued or his agent id �l2"cC,,.� Q Date Email Address: i K Imo- 0 #0 T/oi9/e_ , echi 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# &'J1-17-033/9 2 -fr3eo ov 12/31/2020—12/31/2021 a � ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `..•/ 11/06/2019 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 Ray Travers NAME: The Oceanside Insurance Group PHONE (508)771-1660 FAX (508)775-1135 (A/C,No,Extl: (A/C,No): 411 Route 28 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# West Yarmouth MA 02673 INSURER A: Scottsdale Ins Co. INSURED Twin CityFire Insurance Company INSURER B: P Y MAAM Inc.,DBA:Longfellows Pub INSURER C: 182 Old Town House Rd Unit A INSURER D: INSURER E: West Yarmouth MA 02673 INSURER F; COVERAGES CERTIFICATE NUMBER: CL1911607350 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HA\'E 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) S 5,000 A CPS3269313 10/19/2019 10/19/2020 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT PRO LOC PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE _ ER B ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA O8WECC69655 02/23/2019 02/23/2020 100,000 OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT S (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,ODD DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Each Occurrence 1,000,000 Liquor Liability A CPS3269313 10/19/2019 10/19/2020 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitation's and endorsement of the policy. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage prDvided 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 5 ro tfr 3- r N �' - , n + '4i' r ,� 9 u r •.Y T s k.,9 �;:.. � , '�,1,..s3..