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HomeMy WebLinkAboutBldci-17-006523-05 The Commonwealth of Massachusetts et 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 Certificate No. Issued to Business Name: GRAND CAFE BLDCI-17-006523-05 Trade Name:GRAND CAFE Identify property address including street number, name,city or town and county Certificate Expiration Located at 80 ROUTE 28 12/31/2022 WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 92 A-2 Nightclub/Restaurant/Bar/Banquet Hall 92 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 Grylls Date of Fire Chief Building Commissioner Inspection Signature of Municipal Signature of Municipal ; Date of Fire Chief Building Commissioner { tr Issuance Fee: $100.00 BLDCertoflnspection.rpt BUILDING DE T NT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2022 NAME: Grand Café ADDRESS: 80 RTE 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 Re . Date Comments Approved for kLicense �� � L./ Issuance 4) No Fire Department Rep. Date Comments Approved for "� L. -nse Issuance k°k\I Id 1 - aI No Board of Health Rep. Date Comments Approved for License Issuance Yes No Plumbing/Gas Inspector Date Comments Approved for `� � Lic Issuance Yes No Electrical Inspector Date Comments Approved for License Issuance Yes No Taxes Paid Yes No Rev.Sept.2003 TOWN OF YARMOUTH �a) BUILDING DEPARTMENT S 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 •z ' r' APPLICATION FOR CERTIFICATE OF INSPECTION October 1, 2021 PAYABLE UPO IPT (X) Fee Requir d 100.00 ( )No Fee Re 'red 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: g Street and Number: ,/o (J (� � ! /�(,t//� �/�/ (7(71-613 Name of Premises: Gc b--onLI C fi V 1: _50 e otgd-P 8z/ Purpose for which permit is used: [ RECEIVED License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency (;OV 22 2021 • L1C3I1.1(b L- � BUi LIJT BY _. Certificate to be issued to G rQ rC C-+� .. $+G(AYC4 n1- Tel: `J Address: _ Owner of Record of Building 2 re.r CI CcA ' Address S-O I�-+-<- 7 E' Present Holder of Certificate I q,.`S p Q d -e- WY2rdp- ignatu ers whom Title Certificate is issued or his agent II/ /20 21 Datc Email Address:)4/6 p&5 iioy 9,5 gbet al cow 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# /—�7=C) 3 _ " " 12/31/21-12/31/2022 U� ��"...41 PAGUA-1 OP ID:JA '`����� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/22/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 508-775-6060 NAME CT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-775-6060 FAX 508-790-1414 88 Falmouth Road (A/C,No,Ext): (A/C,No): Hyannis, MA 02601 E-MAIL Bryden&Sullivan Insurance ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Scottsdale Insurance Company 41297J INSURED INSURER B:The Hartford Grand Cafe Restaurant Inc. 80 Rte 28 INSURER C: _ West Yarmouth,MA 02673 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MA"HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LTR INSD NIVD (MM/DD/YYYYI IMM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000 000 CLAIMS-MADE X OCCUR CPS7341849 04/25/2021 04/25/2022 DAMAGE TO RENTED SE 100,000 PREMIS(Ea occurrence) $ MED EXP(Any one person) $ 5,000 x Liquor CPS7341849 04/25/2021 04/25/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- LOC 2,000,000 JECT PRODUCTS-COMP/OP AGG $ OTHER: $ - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT fEa accident) $ ANY AUTO , BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident). $ , HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B AND EMPLOYERS'ERS'LIABILITY RS COMPENSATION X PER H STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N OEWECAA2S20 05/04/2021 05/04/2022 500,000 OFFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION TOWN-02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 S. YARMOUTH, MA 02664 AU D REPRESENTATIVE B den Sul 'van Insurance j _ i r� ACORD 25(2016/03) 1 �( /1l1 A _ ���� 1 , ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are regtst d marks of ACORD (Policy Provisions: WC000000C) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Hartford Accident and Indemnity Company ONE HARTFORD PLAZA HARTFORD CT 06155 THE ' HARTFORD NCCI Company Number: 10448 Company Code: 5 Suffix LARS RENEWAL POLICY NUMBER: 08 WEC AA2S20 5 Previous Policy Number: 08 WEC AA2S20 1. Named Insured and Mailing Address: GRAND CAFE RESTAURANT INC. (No., Street, Town, State, Zip Code) 80 ROUTE 28 WEST YARMOUTH MA 02673 FEIN Number: 82-5130974 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Limited-Service Restaurants Other workplaces not shown above: 80 Route 28 WEST YARMOUTH MA 02673 2. Policy Period: From 05/04/21 To 05/04/22 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: BRYDEN &SULLIVAN INS AGCY INC/PHS 88 FALMOUTH ROAD HYANNIS MA 02601 Producer's Code: 08082523 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (866)467-8730 Total Estimated Annual Premium: $1,256 Deposit Premium: Policy Minimum Premium: $261 MA(Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: Twelve Pay(8.33%Down+11@8.33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by if �2 03/25/21 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 03/25/21 Policy Expiration Date: 05/04/22 INFORMATION PAGE (Continued) Policy Number: 08 WEC AA2S20 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 our 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: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT-WC 99 03 68 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. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premium $933 Expense Constant $250 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement $36 Estimated Annual Premium (before Surcharges) $1,219 Total Estimated Surcharges $37 *See the attached Schedule(s)of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $1,256 Deposit Premium: Policy Minimum Premium: $261 MA(Includes Increased Limit Min. Prem.) Interstate/Intrastate Identification Number: Refer to Schedule of Operations NAICS: 722211 Labor Contractors Policy Number: SIC: 5812 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 03/25/21 Policy Expiration Date: 05/04/22 • The Commonwealth of Massachusetts Print Form Department of Industrial Accidents MOM �1 Office of Investigations ' 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 6 tccI -o, i' 1 e f j-ov Address: 8() fo vAC as Wif t� ui-L I fl� ©d-6�3 )fac/ City/State/Zip: We) 1- Yck4V,YO c/� 0 )- &3 Phone #: $D 8 J.-.- g D L/ Are ygu an employer?Check the appropriate box: Business Type(required): 1. I am a employer with t employees(full and/ 5. ❑ Retail or part-time).* 6. [7jRestaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees.[No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: -7-%€ igie T Fps D Insurer's Address: 41/6'e " fie- c)74` 4ed City/State/Zip: /14w / hGo e /V / /3y/3 Policy#or Self-ins.Lic.# 9 a C ,4A d,(20 Expiration Date: (5— t/' ? Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 7/7/672_ 2.( Phone#: $ 0 d 9)— 575 O I Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia s R ; -- - i