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HomeMy WebLinkAboutBLDCI-23-002957 PAPA GINOS • The Commonwealth of Massachusetts } rr, 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: Papa Gino's BLDCI-23-002957 Trade Name: Papa Gino's Identify property address including street number,name,city or town and county Certificate Expiration Located at 932&940 ROUTE 28 12/31/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 98 A-2 Nightclub/Restaurant/Bar/Banquet Hall 98 Person Totally 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 Municipals Name of Municipal Mark Grylls Date of /a � Fire Chief Building Commissioner Inspection Signature of Municipal Signature of Municipal Date of Fire Chief Building Commissioner Issuance /0..p Fee:$100.00 BLD_Certofi nspection.rpt 4° YRR TOWN OF YARMOUTH o= ( BUILDING DEPARTMENT Y "Z':`.:"�""_' 3 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 tea. _;,� REcEH .' D APPLICATION FOR CERTIFICATE OF INSPECTION LNOV 2 8 2022 November 18, 2020 PAYABLE UPON RECEIPT (X)Fee Require t#IOLO®ING .,RTMENT ( ) No Fee Requi 6 --- 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: 9 go lt✓i,q /J T, J-f Name of Premises: / /41 PA 6' /()Pi s Tel:50?— g--J/yb Purpose for which permit is used: g ,,S--,UM/i License(s)or Permit(s) required for the premises by other governmental agencies: License or Permit Agency , p 1 6r�� c,P �t L r(,w„U 4f/Yf.4i L/f eAm r/J ) t,`,411 ic1-- f3 or.(.5('�j ;'t Certificate to be issued to OW -,t /,1,,t�ArTkuirle. E s Tel:76-1/47"0// Address: Liz()O eliCVOck)Cf.- W 1.6-,/i't )- 2)9/(4/1 ,Lt7 D W o 6 Owner of Record of Building (2,4 cic A 111 rL (c_4( I Address 1/3 etOnAir iefcz r soJT (1.0 CU'7b /i4 02,60 Present Holder of Certificate CAM (i goL2 -6))11/(\1?(W2 - heifiell*Witek Signature of person to whom Title Certificate is issued or his agent //—/7' Date Email Address: t/C _,1JSE ® Ctg ril 6 l3O(S. e- 0M 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# — 12/31/2020—12/31/2021 Acc•R o® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDT ) 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 CONTACT The Plexus Groupe LLC PHONE Certificates FAX 21805 W. Field Pkwy, Suite 300 (A/C,No,Ext): (NC,No): Deer Park IL 60010 ADDRESS: certificates@plexusgroupe.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:United States Fire Insurance Company 21113 INSURED NEWENGL-01 INSURER B:North River Insurance Company 21105 New England Authentic Eats LLC dba Papa Gino's/D'Angelo INSURER C:Crum&Forster 42471 _ 600 Providence Highway INSURER D: Dedham MA 02026 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:5465465 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP TYPE OF INSURANCE LTR (NOD wVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y 543-231131-4 2/11/2022 2/11/2023 EACH OCCURRENCE $2,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $1,000,000 MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $10,000,000 PRO POLICY X JECT LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea 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) $ B X UMBRELLA LIAB X OCCUR 5821183881 2/11/2022 2/11/2023 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION 408-742746-3 2/11/2022 2/11/2023 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A LiquorLiabiiity 543-231131-4 2/11/2022 2/11/2023 Per Occurrence $1,000,000 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Excess Liability: Policy Term:2/11/2022-2/11/2023 Policy Number:US00089484L122A Carrier:XL Insurance America,Inc. Limit:$10M x$5M Named Insured Schedule: New England Authentic Eats LLC(DBA Papa Gino's/D'Angelo's) See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: NEWENGL-01 LOC#: ACO ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED The Plexus Groupe LLC New England Authentic Eats LLC dba Papa Gino's/D'Angelo POLICY NUMBER 600 Providence Highway Dedham MA 02026 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE WC PG Franchising LLC(Papa Gino's Franchising Corp.) WC DA Franchising LLC(D'Angelo Franchising Corp.) D'Angelo Sandwich Shops Advertising Fund,Inc. NEAE Card Services LLC ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD