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Home My WebLink Aboutbldci-17-002046-03 The Commonwealth of Massachusetts _ 4,,ifi City\Town of ` YARMOUTH i ..., ,_ if , ,sti, 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 BLDCI-17-002046-03 Business Name: BAYSIDE RESORT Trade Name: MOBY DICK PUB Identify property address including street number, name,city or town and county Certificate Expiration Located at 225 ROUTE 28 12/31/2021 WEST YARMnI ITH MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 36 A-2 Nightclub/Restaurant/Bar/Banquet Hall 36 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 with the contents of the certificate is strictly prohibited. Name of Municipal Philip Simonian Ill Name of Municipal - \ Mark Gryli 7 Date of �� Fire Chief Building Commissioner \ /;//' Inspection `T/.��0 Signature of Municipal Signature of Municipal (/ Date of Fire Chief , Building Commissioner Issuance (7X9 e:$10 Z` ` Fee: $100.00 DI r r`rrfnfl ncnor+inn rn+ BUILDING DEPARTMENT 146 Route 28, South Yarmouth, MA 02664 508-3 8-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2021 NAME: Bayside Resort-Moby Dick Lounge ADDRESS: 225 Route 28 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 /4 7 cf !4SI► No Fire Department Rep. Date Comments Approved for License Issuance C-A ice` 1 . /�U� �� -�-Z � Yes 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 !_ o TOWN OF YARMOUTH o -y BUILDING DEPARTMENT y '��':c 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION October 1, 2020 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: -Z25 r c- 2S Name of Premises: F7CtIC Id e 12-es 00(f I+13711.. Tel: Cj `77 5 5-61 Purpose for which permit is used: I—��L - `- � Vl� lt�(� . �—1 License(s) or Permit(s) required for the premises by other governmental agencies: it _—" h" I ! OCT 1520 License or Permit Agency 20 Gt3 , Certificate to be issued to rct v;.N t 5 A el\v\ 1 IV L Tel: ct) 9 -7) j - S Cvc,cj Address: ZZ -F 2& GO .. '- Q.✓ln oUZL4 Owner of Record of Building v t4 S I a0 PQr• i PS L L Address "? '2 c f 2-c )7-e 2g Present Holder of Certificate A-TAc Si nature of person to whom Title Certificate is issued or his agent U v IS '7 Date Email Address: R-S V .i S Id Q 1Q S O(€ . Co ✓l,A 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# 6Uic/ /7-adog&,..,Ige,n-O,3 12/31/2020—12/31/2021 I • WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICY NO. WMZ-800-8003721-2020A PRIOR NO. WMZ-800-8003721-2019A ITEM 1. The Insured: Travis Hospitality Inc DBA: Bayside Resort Hotel Mailing address: Rt 28 FEIN:"-""7972 225 Main Street West Yarmouth, MA 02673-0000 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 04/01/2020 to 04/01/2021 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: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 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 and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 000362922 INTER SEE CLASS CODE SCHEDULE Minimum Premium $281 Total Estimated Annual Premium $14,638 GOV GOV Deposit Premium $3,799 STATE CLASS MA 9052 State Assessments/Surcharges $15,825.00 x 3.5100% $555 This policy, including all endorsements, is hereby countersigned by 03/10/2020 Authorized Signature Date Service Office: Rogers & Gray Insurance Agency 54 Third Avenue 434 Route 134 Burlington MA 01803 South Dennis, MA 02660 WC 00 00 01 A (7-1 1) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. f -