HomeMy WebLinkAboutBldci-17-002993-05 The Commonwealth 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: PERIKLIS, INC. BLDCI-17-002993-05
Trade Name:YARMOUTH PIZZA BY EVAN
,
Identify property address including street number, name,city or town and county Certificate Expiration
Located at
559 ROUTE 6A 12/31/2021
YARMOUTH, MA 02675
Use Group Floor Occupancy Use Group Other
Classifications(s)
A-2 01st Floor 31 A-2 Nightclub/Restaurant/Bar/Banquet Hall 28 Persons-Tables&
Chairs
6 Persons-Stools
Allowable 31 Seats-TOTAL
Occupant Load OCCUPANCY PER BOH
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 /� ��
Fire Chief Building Commissioner Inspection
Signature of Municipal Signature of Municipal Date of
Fire Chief Building Commissioner �' Issuanceii zots
ix/ „vinerx:_____:__„
s Fee: $100.00
BLD_Ce rtofl nspection.rpt
TOWN OF YARMOUTD
BUILDING DEPARTMENT
1.146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1260 Fax 508-398-0836
LICENSE INSPECTION APPROVAL LOG - 2021
NAME: Yarmouth Pizza by Evan ADDRESS: 559 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
�/'• Yes) No
Fire Department Rep. Date Comments Approved for
LieeIssuance
i t/1 1).) 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
,_ o TOWN OF YARMOUTH
ti -y BUILDING DEPARTMENT
MATTA n CSE4'
`�,'��•••• °° 3 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. 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: SS-9 R i 6/1
Name of Premises: Q11oukT14 P Cr.Z/4- fly Eclan./ Tel: 5-08— 36.2 -7 9'7
Purpose for which permit is used: `p D SeQs0i
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
13o6i
ALcoUOLLG i3F(WI,aG-E__
Certificate to be issued top 4,4 P y E vetn/ Tel: 508—36a— 4 �!7
Address: S 5 j RT G A
Owner of Record of Building C L L. C. .
Address SS`t RT C44
Present Holder of Certificate ,�QC,4 LL,�. A �t
RECEIVE ;
Alai:
Signa u - o person . hom Title ZD�f
Certificate is issued *This agent /j
Date By.
Email Address: T/V ANo C.0 AST 1 iCl E�
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 # 6U) /-/7 b64g93_A.efi_as-
12/31/2020—12/31/2021
�a
c
TRAVELERS WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6HUB-7H82900-6-19)
RENEWAL OF (6HUB-7H82900-6-18)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
NCCI CO CODE: 13439
1.
INSURED: PRODUCER:
JOCA LLC DBA PIZZAS BY EVAN DOWLING & 0 NEIL INS
C/O BOTSINI CORP 973 IYANNOUGH RD
450 STATION AVENUE HYANNIS MA 02601
SOUTH YARMOUTH MA 02664
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 1 2-30-1 9 to 1 2-30-20 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
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: $ 500000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 500000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 1 2-1 0-1 9 WC
ST ASSIGN: MA
OFFICE: RMD POOL 161 22LGR
PRODUCER: DOWLING & 0 NEIL INS