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HomeMy WebLinkAboutBldci-16-003280-05 The Cottimtmwealth of Massachusetts 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: OLD YARMOUTH INN BLDCI-16-003280-05 Trade Name: OLD YARMOUTH INN Identify property address including street number,name,city or town and county Certificate Expiration I Located at 223 ROUTE 6A 12/31/2022 YARMOUTH PORT, MA 02675 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 0i t Rut), 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 Grylls Date of f , Fire Chief Building Commissioner Inspection Signature of Municipal Signature of Municipal Date of �j Fire Chief — Building Commissioner C •� Issuance A, e* L Fee: $150.00 RI fl r.artnflncngrtinn rnt BUILDING DEPARTMENT NT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2022 NAME: Old Yarmouth Inn ADDRESS: 223 RTE 6A This log is to be signed by the appropriate inspectors upon a satisfactory inspection of your building/premises. When all signatures are obtained, this log shall be presented to the License & Permits office and/or the Health Department in order to obtain your license. Licenses will be withheld until all inspectors have signed. Building Commissioner Rep. Date Comments Approved for License Issuance 4172 /45/e.;;r// 1 AtZ79, dial0" No Fire Department Rep. Date Comments Approved for L' e Issuance �j � II ^,� - Ye No _W�V 1 Board of Health Rep. Date Comments Approved for License Issuance Yes No Plumbing/Gas Inspector Date Comments Approved for e j // /y(Z( Lic se-.ISsuance / 1Q__Te_s___I No Electrical Inspector Date Comments Approved for License Issuance Yes No Taxes Paid Yes No Rev.Sept.2003 0 °�aYgR TOWN OF YARMOUTH o. '� . a BUILDINGDE �yy PARTMENT 4aauLoaC 1146 Route 28, South Yarmouth, MA 02664 508-348-2231 ext. 1260 LI RECEIVED APPLICATION FOR CERTIFICATE OF INSPECTION - -- October 1, 2021 PAYABLE U OrMC21 (X)Fee Requir ( )No Fee,uire l ECt b--) In accordance with the provisions of the Massachusetts State Building Code, Section 110.7,I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: '2 3 Leo+t. (... Name of Premises: ©k c\ k--- (-NL f rn)0--y-v--, 1 .v1 n Tel: SO: • 3L0 Z Q1 q L e_ Purpose for which permit is used: r 0_ V1 - License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to 01 a L(k,(fro v 1 L1�.0 Tel: (SO$�3� 'pZ 9 Address: Z Z 3/pit lQ Owner of Record o Building'4rf C ,l�V v =7--'f' Address ZZ'.� C�lA , L �y 'c:�.7 -- (�(\A C -Cy 1 Present Holder of Certificate UU s L , Src4-- Net a_ i ,,UST X624f-362(Q—___ P—Rtt-I't _x_Ai-N-A5-. IL.Pcils Ck.,--s f Signature of person to whom Title Certificate is issued or his agent lr� \\ 70Z Date Email Address: ►L;,c Ls (6)_ (.cpy-\c . n`L--' -" 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# 13(,[}C/--/(o-.06,3%/80—Qt' 12/31/21-12/31/2022 NOTICE NOTICE TO TO EMPLOYEES =• _MOM 4c EMPLOYEES The Commonwealth of assachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER,2 AVENUE DE LAFAYETTE,BOSTON,MASSACHUSETTS 02111 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30,this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222, Braintree,MA 02185-0000 ADDRESS OF INSURANCE COMPANY 014005032709121 01/01/21 - 01/01/22 POLICY NUMBER EFFECTIVE DATES RogersGray,Inc 434 Route 134, South Dennis, MA 02660 0 NAME OF INSURANCE AGENT ADDRESS PHONE# Old Yarmouth Inn 223 Route 6A,Main Street,Yarmouthport, MA 02675-0000 EMPLOYER ADDRESS 01/21/2021 EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER