HomeMy WebLinkAboutBldci-20-002812-02 The Commo lth of Massachusetts
it / City\Town of
ul '� . YARMOUTH
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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: KE=L I IC Kit CHEN t3LUGI- U-UU1t511-U1
Trade Name: KELTIC KITCHEN
Identify property address including street number, name, city or town and county Certificate Expiration
Located at
415 ROUTE 28 12/31/2022
WEST YARMOUTH, MA 02673
Use Group F!oor Occupancy Use Group Other
Classificate(s)
A-2 01st Floor 75 A-2 Nightclub/Restaurant/Bar/Banquet Hall 75 Persons
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 withthe contents of the certificate is strictly prohibited.
Name of Municipal Name of Municipal Mark Grylls Date of �s��
Fire Chief Building Commissioner Inspection R7 APQ
Signature of Municipal Date of
Signature of Municipal 9 P
Fire Chief Building Commissioner l�G - Issuance /.7 ' (./
ee: $100.00
BLD_Certofl nspection.rpt
M:Zrmm ,
� YaR TOWN OF YARMOUTH
�; ! ).91 ECEIVED
t°; t �� BUILDING DEPARTMEN --
Fn�MHTTHtM LS[/ 1
1.1.46 Route 28, South Yarmouth, MA 02664 508-398- 2 1 1
N 0E-2022
BUILf� �DEPAT�vi}�/NT
APPLICATION FOR CERTIFICATE OF INSPECTION BY
December 3, 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: 1'1�j (�( DS
Name of Premises: k& t1( - I Cri S Tel: -77/ 67 --
Purpose for which permit is used:
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to 1(O r 120Lk1 el: )g 771- 3��
Address: 4/S as toft f -m(
f i"tV0961 3
Owner of Record of Building .Vl I 'W..&
Address I() W1L6N R0 S ft\O) lit et C 66L(_
Present Holder of Certificate °AU(1J D MPJLl
. I
_ ONO
Signature of person t who Title
Certificate is issued or a ent la-0� -00 9-
Date
Email Address: ,(�(CW 1I e_coftim sth C�
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# a LLC/-aO-Opd*/,1-b)_,
1/1/22-1/1/23
NOTICE -*--- NOTICE
To =- TO
EMPLOYEES 7r, EMPLOYEES
Vd
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/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:
NorGUARD Insurance Company
NAME OF INSURANCE COMPANY
P.O. Box AH, 39 Public Square, Wilkes-Barre, PA 18703-0020
ADDRESS OF INSURANCE COMPANY
DAWC321881 01/01/2022 01/01/2023
POLICY NUMBER 150 Sawgrass Drive EFFECTIVE DATES
PAYCHEX INSURANCE AGENCY Rochester, NY 14620 877-266-6850
NAME OF INSURANCE AGENT ADDRESS PHONE#
David Valentine 415 Main Street West Yarmouth, MA 02673
EMPLOYER ADDRESS
12/02/2021
8
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
0
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