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HomeMy WebLinkAboutBLDCI-23-004465 The Commonwealth of Massachusetts ,, iCity\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: Natalie Mason BLDCI-23-004465 Trade Name:Seafood Sam's Identify property address including street number,name,city or town and county Certificate Expiration Located at 1006 ROUTE 28 11/30/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 97 A-2 Nightclub/Restaurant/Bar/Banquet Hall 97 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 ingegalEMBESt Name of Municipal Mark Grylls Date of r. SC�w n f� Fire Chief �o Building Commissioner Inspection O`�"�/`�3 7t s- Signature of Municipal Signature of Municipal Date of Fire Chief Building Commissioner Issuance Z./0 Fee:$100.00 BLD_Certofl nspection.rpt BUILDING DE PARTMENT 1146 Route 28, South Yarmouth, NI iik 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2023 NAME: Seafood Sam's ADDRESS: 1006 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 R Date Comments Approved for License Issuance /// 3 [4001,- - 0 No Fire Department Rep. Date Comments Approved for License Issuance /J. _ ( 2 2 /.23 —s ❑ No Board of Health Rep. Date Comments Approved for License Issuance I i Yes L1 No Plumbing/Gas Inspector Date Comments Approved for License Issuance Yes ❑ No Electrical Inspector Date Comments Approved for License Issuance I l Yes ❑ No Taxes Paid ❑ Yes ❑ No Rev.Sept.2003 . y TOWN OF YARMOUTH i 1� BUILDING DEPARTMENT . . o . 1146 Route 28, South Yarmouth, MA 02664 508-398-223 exact (lE E APPLICATION FOR CERTIFICATE OF INSPECTION Fij EB Z�Z3 BUILDNE'a'�'MENT February 1,2023 PAYABLE UPON REC " (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: /06(e Zr ' Name of Premises: a j St 'S Tel: Cam/ Purpose for which permit is used: ,Sovrac,t L&a "!se_ /A.secc.17 0-r License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency RAS 4-?a,( 11 g�,�oi Ii res•� Certificate to be issued to AJcd-uai.,e_ AiSUY) Tel: 7 7-/— -9/1a Address: 3510 avit c Lr �,( vu { j�u eat T- -CimL.uMU4 J-tA c is 3/ Owner of Record of Building ,0 E.(..aa Address Present Holder of Certificate lj ,t )%4 0 r Signature of person to whom Title Certificate is issued or his agent Z�f 3/ Dat Email Address: ,2krIjedgz s arena i-i —76r71 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# a/Xi-t;?3-0W(S-- 04/01/2023-11/30/2023 0 DATE(MWDDIYYYY) ACc3RD� CERTIFICATE OF LIABILITY INSURANCE 1/30/2023 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 RogersGray, Inc.-Kingston Branch PHONE 1 FAX 63 Smith Lane IA(c,No.Extr.508-746-3311 (ac,No):877-816-2156 Kingston MA 02364 E-MAIL mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Arbella Protection 41360 INSURED SEAFSAM-02 INSURER B:Massachusetts Retail Merchants Seafood Sam's of S.Yarmouth, Inc. dba Seafood Sam's INSURER C: 1006 Rte 28 INSURER D: South Yarmouth MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1850592341 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP(MMf LIMITS LTRINSD WVD POLICY NUMBER (MM/DD/YYYY) DOIYYYY) A X COMMERCIAL GENERAL UABIUTY 8500054782 3/20/2022 3/20/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY ECOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) A X UMBRELLA UAB X OCCUR 4620091340 3/20/2022 3/20/2023 EACH OCCURRENCE $2,000,000 EXCESS LAB CLAIMS-MADE AGGREGATE $2,000,000 DED X RETENTION$in,nn $ g WORKERS COMPENSATION 014005032775122 1/1/2023 1/1/2024 X PER ERH •AND EMPLOYERS'LIABILITY Y(N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED? NIA (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 A Liquor Liability 8500054782 3/20/2022 3/20/2023 $1,000,000 $2,000,000 - I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 POUCY PROVISIONS. Town of Yarmouth 1146 Main Street South Yarmouth MA 02664 Au i48IQDREPRESENTATIVE 1/3116414.4 "-----.....--- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD'25(2016/03) The ACORD name and logo are registered marks of ACORD • 11 • • • L ... .. • . . • • m. � • �;�... .•may •.., __ va--` -• • m rT J t t. k • • • • • •