HomeMy WebLinkAboutBldci-17-002993-06 The Commonwealth of Massachusetts
I~ = ! 4 City\Town of
;! YARMOUTH
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l 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-17-002993-06
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 12/31/2022
YARMOUTH, MA 02675
Use Group Floor Occupancy Use Group Other
Classifications(s)
A-2 01 st Floor 31 A-2 Nightclub/Restaurant/Bar/Banquet Hall 28 Persons-Tables&
Chairs
Allowable 6 Persons-Stools
Occupant Load
31 Seats-TOTAL
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 ark Grylls Date of /
Fire Chief Building Commissioner `/oc.?.Ipspection ' 7
Signature of Municipal Signature of Municipal & =e
dti->*.vi - fi.p.0
Fee: $100.00
YaR T WN OF YARMOUTH
(oA ,) BUILDING DEPARTMENT
it_• , 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: ES c gr 4
Name of Premises: 44eNk,u b1 P 1 ZLA u y U•4,i(1 Tel: 5 D8 - 36.2-79
Purpose for which permit is used: coot) scev,C-
License(s) or Permit(s)required for the premises by other governmental agencies: f RECEIVED
License or Permit Agency NOV 05 2021
4 C_Cci i4Dc-4c f3EUseAa� Buy -
By
Certificate to be issued to p BA yAigeptetcr4 P(ZZA 8,£tA4, Fe1: 5o8 -3Ga-79 7
Address: 5 Set QT4 A
Owner of Record of Building CAS'
Address S S I 12 T A
Present Holder of Certificate .J GCA L LC , p a r4 y44 efri vtT N Pie24 y 1U44)
A ' Ggiv_ /yi&2
Signs hom Title
Certificate is issuedIis agent 1/ 3 a 1
/ 1
Date
Email Address: U4NO r CO 4C-4 S`T nirr
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( TIFI ATE OF INSPECTION.
Certificate of Inspection# zo //J C'73- A.er7_ 0
12/31/21-12/31/2022
�/j Worker's Compensation and Employer's Liability Policy
AV! Berkshire Hathaway NorGUARD Insurance Company - A Stock Co.
CAA I Policy Number J0WC193300
i� GUARD Insurance
RCINWal of NEW
NCCI No. [25844]
Policy Information Page
[1]Named Insured and Mailing Address Agency
JOCA, LLC DOWLING & O'NEIL INSURANCE AGENCY
DBA/TA Pizzas by Evan 973 Iyannough Road
450 Station Ave
C/O Botsini Corp P.O. Box 1990
South Yarmouth, MA 02664 Hyannis, MA 02601
Agency Code: MADOWLIO
Federal Employer's ID XX-XXX1292 Insured is Limited Liability Co. (LLC)
•
Additional Names of Insured
(N2) Pizzas by Evan
Locations on Policy
(L2) 559 Route 6A , Yarmouth Port, MA 02675-1915
•
(12/30/2020 - 12/30/2021)
[2] Policy Period
From December 30, 2020 to December 30, 2021, 12:01 AM, standard time at the insured's mailing
address.
[3] Coverage -a _..._.______.___.� _
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident each accident $500,000
•
Bodily Injury by Disease - each employee $500,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page Schedule of Forms
[4] Premium -
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, V i Classifications, Rates, and Rating Plans. All required information is subject to verification and change by E
audit. (Continued on another page)
Total Estimated Policy Premiump —
4,438
Total Surcharges/Assessments
$Total Estimated Cost $140.00
.00 l .
$4,578578
INTF_RNAt USE 72275 ,,
MGA : J0WC193300 nd
°age 1 - I
Date : 12/22/2020 Information Page
MANCTF WC 000001A
Issuing Office: P.O. Box AH, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1260 Fax508-398-0836
LICENSE INSPECTION APPROVAL LOG - 2022
NAME: Yarmouth Pizza by Evan ADDRESS: 559 RTE 6A
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 Co issioner ep. Date Comments Approved for
License Issuance
2„
/-7: , No
Fire Department Rep. Date Comments Approved for
Q t ? (4 U QC 1 t-Zq a( Lie e Issuance
CC es No
Board of Health Rep. Date Comments Approved for
License Issuance
Yes No
Plumbing/Gas Inspector Date Comments Approved for
/
V is/7ff/Z/ Li Issuance
I ._._) No
Electrical Inspector Date Comments Approved for
License Issuance
Yes No
Taxes Paid Yes No
Rev.Sept.2003