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HomeMy WebLinkAboutBldci-15-004597-05 l The Com L� ealth of Massachusetts City\Town of F YARMOUTH I. , 1: 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: BLDCI-15-004597-05 • Trade Name: BLUE ROCK CLUB RESTAURANT Identify property address including street number, name, city or town and county Certificate Expiration 39 TODD RD 11/30/2021 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group p Other A-2 Basement/Lower 78 A-2 Nightclub/Restaurant/Bar/Bantauet Hall MEETING ROOM Allowable 01st Floor 110 A-2 Nightclub/Restaurant/Bar/Banquet Hall 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 Ill Name of Municipal Mark G Fire Chief rY Date of Building Commissioner Inspection 3 �-��j Signature of Municipal Signature of Municipal " Date of Fire Chief i ., Building Commissioner (2G• ��7(�� Issuance ./70/ Fee: $150.00 BUILDING f . 146 Route 28. South Yarmouth, NIA 02664 50 -39 -2231 ext. 1260 Fax 50 -39 -0 36 LICENSE INSPECTION APPROVAL LOG - 2021 NAME: Blue Rock Club Restaurant ADDRESS: 39 Todd 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 License Issuance No Fire Department Rep. Date Comments Approved for Lice se Issuance es 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 ° 'YqR, TOWN OF YARMOUTH ~4 `' c BUILDING DEPARTMENT ' 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 ' APPLICATION FOR CERTIFICATE OF INSPECTION February 4, 2021 PAYABLE UPON RECEIPT j 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: 39 Todd Road Name of Premises: Blue Rock Club Tel: 508-398-6962 Purpose for which permit is used: Liquor License Inspection License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Common Victualler Food Service Certificate to be issued to Blue Rock Resort Tel: 508-398-6962 Address: 39 Todd Road, South Yarmouth, MA 02664 Owner of Record of Building Davenport Realty Address 20 North Main Street, South Yarmouth, MA 02664 Present Holder of Certificate Blue Rock Resort Assistant Controller Signature of p rson to whom Title Certificate is issued or his agent February 4, 2021 Date Email Address: mpurrierAdavenportcos.com 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# WC8196035 Lea.. 3/7/2021 - 11/30/21 DAVEREA-01 OKAY ;4.`O/ CERTIFICATE OF LIABILITY INSURANCE DATE 1YYY� 2/3/2021 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). CT NTA PRODUCER N C ME: Valley Forge Captive Advisors PHONE 610 458-3659 FAX 484 965-9627 630 Freedom Business Center Drive (NC,No,Eat):( ) (A/C,No):( ) Suite 203 ADD RESS:SS: King Of Prussia,PA 19406 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Zurich American Insurance Company 16535 INSURED INSURER B: Kingsbury Management LP,DBA Blue Rock Resort INSURER C: 20 North Main Street INSURER D: South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 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 LIMITS LTR TYPE OF INSURANCE INSD MD POLICY NUMBER IMM/DD/YYYYI IMM/DD(YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR GL08196255 3/1/2021 3/1/2022 DAMAGE TO RENTED 1,000,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 1,000 PERSONAL 8 ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: S OM A AUTOMOBILE LIABILITY ((EaBI EDSINGLE LIMIT S 1,000,000 ANY AUTO BAP8196256 3/1/2021 3/1/2022 BODILY INJURY(Per person) $ — — OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S — {{Q�WN PROPERTY DAMAGE AUTOS ONLY — AUUTOS ONLY (Per accident) $ S _ UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS S A WORKERS COMPENSATION X STATUTE _Err - AND EMPLOYERS'LIABILITY YIN WC8196035 3/1/2021 3/1/2022 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S OFFICER/MEMBERHani EXCLUDED? NIA 1,000,000 NH) E.L.DISEASE-EA EMPLOYEE S It yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached H more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 47/agi ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD