HomeMy WebLinkAboutBldci-22-002577 •
The Commonwealth of Massachusetts
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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
Issued to
Business Name: 99 WEST, LLC BLDCI-22-002577
Trade Name: 99 RESTAURANT& PUB
Identify property address including street number, name,city or town and county Certificate Expiration
Located at
14 BERRY AVE 12/31/2022
WEST YARMOUTH, MA 02673
Use Group Floor Occupancy Use Group Other
Classifications(s)
A-2 01st Floor 142 A-2 Nightclub/Restaurant/Bar/Banquet Hall 142 persons-tables&
chairs
01st Floor 28 A-2 Nightclub/Restaurant/Bar/Banquet Hall 28 Bar Stools
Allowable
Occupant Load
Total Occupancy limited
to per Board of Health
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 Grylls Date of /��
Fire Chief Building Commissioner Inspection
Signature of Municipal Signature of Municipal Date of
Fire Chief � Building Commissioner Issuance
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Fee: $150.00
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BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1260 Fax 508-398-0836
LICENSE INSPECTION APPROVAL LOG - 2022
NAME: 99 Restaurant ADDRESS: 14 Berry Ave
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 Commissio Rep. Date Comments Approved for
//- ow License Issuance
No
Fire Department Rep. Date Comments Approved for
Lic Issuance
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
V,y•1 �,
ACi YqR TOWN OF YARMOUTH
fo - - - .)�) BUILDING DEPARTMENT
1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
October 1,2021 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: 1 rhetiri3 Ate.
Name of Premises: Il � at(( ps 4'1R4 42-t.Tel: .spg- *2-q`1•
Purpose for which permit is used: I, _ Sect/1 C-e s+ac(ia
License(s)or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
'IPC(114,14‘ k o
0444,
Certificate to be issued to
�. Tel: (CIS-2So 1
Address:SO g S aLO D r., n)a,S .I Al T1 31 Wit
Owner ofRecord of uilding
Addres I Pk'
Present Holder of Certificat
Signature o p n to hom Title
Certificate is is ed or his agent �J I l k1 2 _,_ _ _ _^
Date
Email Address l ( ie c - r
1 V _cesrvi to .Lvr—
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#
12/31/21-12/31/2022 B"-4.C. /,.a2— byl_c .."4/ /
RECEIVED
NOV 0 2 2021
BUILDING DEPARTMENT
SAFETY NATIONAL CASUALTY CORP Workers' Compensation and Employers' Liability
1832 SCHUETZ ROAD Insurance Policy Information Page
ST. LOUIS, MO 63146
(888)995-5300 i Policy Period
Policy Number From To
LL-::4055543 _' /01/202 L - - -
12:01 A M Standard Time at the address of
the Insured as stated herein
Prior Policy Number LE - "=4
Transaction
Renewal i _u
1. Named Insured and Address*see below Agent
RESTAURANT GROWTH SERVICES, LLC STEPHENS INSURANCE, LLC. c_
3038 SIDCO DRIVE 111 CENTER STREET
NASHVILLE, TN 37204 LITTLE ROCK,AR 72201
Teleph:ne:
Customer# Corner# 1 FEIN# Risk ID# Entity of Insured
1E3-4-9 - _ `01-% -9-1-7tt5 I'.1.
LLB
• If applicable. Item 1 is continued on attached Named Insured andfor Additional Locations Page:
2. The Policy Period is from 08/01/2021 to 08/01/2822 12:01 a.m. Standard Time at the Insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here:
AL AR CT FL GA IL IN KY LA ME MA MN MS MO NH NY NC RI SC TN VT VA WV
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 a 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease 8 1,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to states,if any, listed here:
All states ::oeft NE, -, V1, P , t: an: states designated in Item ?.A.
D. This policy includes these endorsements and schedules: See attached Schedule of Forms and Endorsements.
4. The premium for this policy will be determined by our Manuals of Rules. Classifications. Rates, and Rating Plans. All
information required below is subject to verification aid change by audit
SEE EXTENSION OF INFORMATION PAGE
Minimum Premium Total Estimated Annual Premium
Expense Constant 8
Assessments and Taxes Premium Discount 8
(Taxes not applicable in Puerto Rico)
Deposit Premium
This is a Three Year Fixed Rate Policy
Premium Adjustment Period: Annual _ Semiannual _ Quarterly _ Monthly
Countersigned this Day of
Issued Date: 09/0=/20=1 Authorized Representative
Issuing Office: Safety National Casualty Corporation
WC 99 00 00 (07 17)