HomeMy WebLinkAboutBldci-17-002233-05 The Commonwealth of Massachusetts
City\Town of
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: MID-CAPE RAQUET CLUB BLDCI-17-002233-05
Trade Name: MID-CAPE RAQUET CLUB RESTAURANT
Identify property address including street number,name,city or town and county Certificate Expiration
Located at
193 WHITES PATH 12/31/2022
SOUTH YARMOUTH, MA 02664
Use Group Floor Occupancy Use Group Other
Classifications(s)
A-2 ()1st Floor 34 A-2 Nightclub/Restaurant/Bar/Banquet Hall 18-Bar Stools
16-Movable chairs
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
Fire Chief Building Commissioner Inspection "be
Signature of Municipal Signature of Municipal Date of
Fire Chief ' Building Commissioner Issuance Z. 0 ,
Fee: $100.00
BLD_Certofl nspection.rpt
4-a,a� 1t).) TOWN OF YARMOUTH
�` BUILDING DEPARTMENT
Mat" 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 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: it ,3 1(� Ym1 tom-&
Name of Premises: n'A C\WR D Tel: Ebb-3+' 3K)it
Purpose for which permit is used: - couorpo&
License(s) or Permit(s) required for the premisesby other governmental agencies: RECEiVE7
License or Permit Agency F. s
NOV 24 2021
BUie N
Certificate to be issued to IL1oe. Tel: 508.1-31-91406 /-Get t
Address: _
Owner of Record of Building `3tjAe_ CCl._1 utk
Address 13/� Q oce ` .
Present Holder of Certificate
Z. -Pre k kix
Signature of person to whom Titl
Certificate is issued or his agent
iJd YYY
Email Address: CLjvv
-,
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# B(acJ-.*17— DO 3--jam
12/31/21-12/31/2022
NOTICE NOTICE
TO MIMI=
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rl■_
Mau TO
111111111111
EMPLOYEESmi,row EMPLOYEES
r S
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111
(617) 727-4900 — www.mass.gov/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:
Technology Insurance Company, Inc.
NAME OF INSURANCE COMPANY
800 Superior Avenue East, 21st Floor, Cleveland, OH 44114
ADDRESS OF INSURANCE COMPANY
TWC3898983 9/20/2021 to 9/20/2022
POLICY NUMBER EFFECTIVE DATES
Maguire Insurance Agency, Inc. One Bala Plaza, Bala, Cynwyd, PA 19004 (855)516-1776
NAME OF INSURANCE AGENT ADDRESS PHONE#
Mid-Cape Racquet& Health 193 Whites Path, South Yarmouth, MA 02664
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER(1r 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 ser-
vices 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
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1260 Fax 508-398-0836
LICENSE INSPECTION APPROVAL LOG - 2022
NAME: Mid Cape R.C. ADDRESS: 193 Whites Path
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
C4(1 C License Issuance
2 -9 - ` 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