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HomeMy WebLinkAboutBldci-16-004965-05 The Commonwealth of Massachusetts 1 City\Town of UMi _ z_MN s YARMOUTH i 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:AZZARO YARMOUTH, LLC BLDCI-16-004965-05 Trade Name:THE LOBSTER BOAT Identify property address including street number, name,city or town and county Certificate Expiration Located at 679&681 ROUTE 28 11/30/2016 WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 334 A-2 Nightclub/Restaurant/Bar/Banquet Hall 314 PERSONS 20 BAR STOOLS 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 Date of �o�/l Fire Chief Building Commissioner Inspection 3 Signature of Municipal Signature of Municipal / Date of � Fire Chief Building Commissioner /f Issuance 9 9 ?4 ee: $150.00 RI rl Cprtnflnsnprtion rnt BUILDING _ . MEN. 1146 Route 28, South Yarmouth. NIA 02664 508-398-2231 ext. 1260 Fax 508 398-0836 LICENSE INSPECTION APPROVAL LOG - 2021 NAME: The Lobster Boat ADDRESS: 681 Route 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 Rep. Date Comments Approved for License Issuance c""Yeses No I/ Fire Department Rep. Date Comments Approved for License Issuance Ye 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 = TOWN OF YARMOUTH K . BUILDING DEPARTMENT 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: Street and Number: g/ )1eefiz. '20 lidgylarmoug, 1774 ca4K5 Name of Premises: 4 _ae • Tel: ,.50,g 7 D JJ Purpose for which permit is used: ay,e'-� -fGQ5 O�-Gx��r-�ipx� (r�2 t ,4vica.giyvu) License(s)or Permit(s)required for the premises by other governmental agencies: 'G�% License or Permit Agency ..k Certificate to be issued to l: ��' '": 16 2021 Address: s i Owner of Record of Building • — Address UILDIIJG GrFARTIviEiJl Present Holder of Certificate Sign a of person to whom Title Certificate is issued or his agent , ate Email Address: 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 I SUE YOUR CERTIFIC OF INSPECTION. Certificate of Inspection# L,. _ - Dp2 21)—( 4/1/2021 —11/30/21 Azzaro Yarmouth,LLC The Lobster Boat Restaurant 681 Main Street Route 28 West Yarmouth,MA 02673-0000 l .a' Workers Compensation and Employers Liability Insurance Policy Insurer ID No (s): 34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 014005030290121 01/01/2021 to 01/01/2022 Braintree, MA 02185-0000 Information Page Renewal Policy FEIN: 200666393 Carrier Prior Policy#: 014005030290120 Item 1: Named Insured and Address Agency Azzaro Yarmouth, LLC Dowling &O'Neil Insurance Agency The Lobster Boat Restaurant PO Box 1990 681 Main Street Hyannis, MA 02601 Route 28 West Yarmouth, MA 02673 . Other Workplaces Not Shown Above: See Schedule of Operations Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation Federal ID#: 200666393 Risk ID: 000000000 NCCI/Bureau#: 34355 Unemployment ID#: File#: 014005030290121 Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2021 to 12:01AM on 01/01/2022 based on the insured's mailing address time zone. Item 3.Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $500,000.00 each accident Bodily Injury by Disease $500,000.00 policy limit Bodily Injury by Disease $500,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15),WC000414A(01/19),WC000422B(01/15), NOE(01/01),WC200102(01/14), WC200301(04/84), WC200302A(09/08), WC200303D(08/10), WC200306B(06/13),WC200405(06/01), WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $261.00 $2,549.00 $2,549.00 $0.00 $0.00 Issuing OM 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: Braintree MA 02185-0000 01-14-2021 I/1 Form#WC 00 00 01 C (Ed.) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Panes 1 of 1 et i s,' 1.. _. ;_ , Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 014005030290121 01/01/2021 to 01/01/2022 Braintree, MA 02185-0000 Information Page Renewal Policy FEIN: 200666393 Carrier Prior Policy#: 014005030290120 Item 1: Named Insured and Address Agency Azzaro Yarmouth, LLC Dowling &O'Neil Insurance Agency The Lobster Boat Restaurant PO Box 1990 681 Main Street Hyannis, MA 02601 Route 28 West Yarmouth, MA 02673 Schedule of Covered Workplaces Other Workplace Azzaro Yarmouth, LLC Effective Date: 01/01/2021 The Lobster Boat Restaurant NAICS Code: 722511 679-681 Main Street Division#: 0 Route 28 Workplace#: 0000000001 West Yarmouth, MA 02673 State Risk ID#: 000154319 Mailing: 681 Main Street Route 28 West Yarmouth, MA 02673 Form#WC 00 00 01 C (Ed.) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1 • Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 014005030290121 01/01/2021 to 01/01/2022 Braintree, MA 02185-0000 Information Page Renewal Policy FEIN: 200666393 Carrier Prior Policy#: 0140.0503.0290120 Item 1: Named Insured and Address Agency _ Azzaro Yarmouth, LLC Dowling &O'Neil Insurance Agency The Lobster Boat Restaurant PO Box 1990 681 Main Street Hyannis, MA 02601 Route 28 West Yarmouth, MA 02673 Schedule of Classifications : MA Code No. Classification Payroll Rate Premium 8810 Clerical Office Employees Noc $48,700.00 0.06 $29.00 01/01/21-01/01/22 9079 Restaurant Noc $318,698.00 0.92 $2,932.00 01/01/21-01/01/22 Description Percentage Factor Amount Manual Premium $2961.00 Rate Deviation (9037) 15.0000% $444.00 Increased Employers Liability Limits(9807) 1.0000% $50.00 Merit Rating (9885) 0.9500 $2,439.00 Standard Premium $2,439.00 Normal Premium $2,439.00 Expense Constant(0001) $0.00 Domestic Terrorism (9740) 0.0300 $ 110.00 Annual Premium $2,549.00 DIA Assessment 1.4400%/ $40.00 1.4400% Total $2,589.00 Merit Rating Effective Date 0.9500 01/01/2021 Form#WC 00 00 01 C (Ed.) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. 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