Loading...
HomeMy WebLinkAboutBLDCI-17-002993-06 (2) c The Commonwealth of Massachusetts } w= City\Town of == i 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: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 01st Floor 31 A-2 Nightclub/Restaurant/Bar/Banquet Hall 28 Persons-Tables& Chairs 6 Persons-Stools Allowable 31 Seats-TOTAL OCCUPANCY PER BOH 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 -Phtttp-Stmvnianif Name of Municipal Mark Grylls Date of /l /� �^ Building Commissioner Inspection ll iV` Fire Chief J p,% S Gs--s.tf— Date of Signature of Municipal Signature of Municipal Building CommissionerIssuance ///Z/ALFire Chiefi---6- Fee:$100.00 BLD Certoflnspection.rpt BUIL INGi ARI `T l 1 6 Route 28, South Yarmouth, MA 02664 508 39 -2231 ext. 1260 Fax 50 -39 -l 36 LICENSE INSPECTION APPROVAL LOG - 2023 NAME: Yarmouth Pizza by Evan ADDRESS: 559 Route 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 Commissioner Rep. Date Comments Approved for /7,4' License Issuance 7e2zi No Fire Department Rep. Date Comments Approved for License Issuance L� - 2_ ' il--2 2 -2? 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 Of.16'4N TOWN OF YARMOUTH o y,1.-y BUILDING DEPARTMENT • 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION September 16, 2022 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: a " F C ,'T F V E D Street and Number: 55 9 R rto A OCT 1-3 2022 Name of Premises: ygui lotA t4 Pr2Z4- y EV4'J Tel: S08 - a— LI�:G JEPAR I MENI- Purpose for which permit is used: cOoD SECIJte- License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency ao A 4 c.o HoL « t36vEte.44, ©CA aL e. ESA Certificate to be issued to 'ytmiii c.&"tf P(2 4 By 6J4 4.) Tel: Gob - 3a- 717 i Address: Rr6.4 Owner of Record of Building C 4 r Address 5`5cr (�TteA Present Holder of Certificate .T&C4 LC-C. D& %4, tc cA. H Pr22a 6y l4 N Gev 446 2 Signature person o w om Title Certificate is issued or is agent !b l `� `az- Date Email Address: C4)(KC- 4. et) — 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# &L)C/--.�7 �'/C/3 te_e 11-- 06 1/01/2023 — 12/31/2023 A Worker's Compensation and Employer's Liability Policy •!/Berkshire Hathaway NorGUARD Insurance Company - A Stock Co. Policy Number 30WC216993 t GUARD CompInsuaance nies RenewalNCCI No. [5844]- I p 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 P.O. Box 1990 C/O Botsini Corp Hyannis, MA 02601 South Yarmouth, MA 02664 Agency Code: MADOWL10 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 (12/30/2021 - 12/30/2022) [2] Policy Period From December 30, 2021 to December 30, 2022, 12:01 AM, standard time at the insured's mailing address. [3] Coverage 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 a [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ 4,438 Total Surcharges/Assessments $ $166.00 Total Estimated Cost $ $4,604.00 INTERNAL USE XX Page - 1 - Information Page MGA : ]OWC216993 WC 000001A Date : 11/25/2021 MANOTE Issuing Office: P.O. Box AH, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com I-