HomeMy WebLinkAboutBLDCI-16-005427-07 The Commonwealth of Massachusetts
City\Town of
...1_," YARMOUTH
h s,
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: SKIPPER RES I AURAN i BLua-lb-UU5421-Ut
Trade Name: SKIPPER RESTAURANT
Identify property address including street number, name, city or town and county Certificate Expiration
Located at
152 SOUTH SHORE DR 11/30/2023
SOUTH YARMOUTH, MA 02664
Use Group Floor Occupancy Use Group
Classification(s)
Other
A-2 01st Floor 80 A-2 Nightclub/Restaurant/Bar/Banquet Hall
Up to 80 Persons
Allowable 02nd Floor 24 A-2 Nightclub/Restaurant/Bar/Banquet Hall
Occupant Load 24 Upstairs Bar
Other 60 A-2 Nightclub/Restaurant/Bar/Banquet Hall
Outside Deck
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 Jon Sawyer Name of Municipal Mark Grylls
Fire Chief �Y Date of
Building Commissioner Inspection -5--3-'23
Signature of Municipal Signature of Municipal bate of
Fire Chief Building Commissioner `
Z X G Issuance /rA
Fee: $150.00
BLD Certoflnsnartinn mt
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, ETA 02664
508-308-2231 ext. 1260 Fax 508-398-0836
LICENSE INSPECTION APPROVAL LOG - 2023
NAME: Skipper Restaurant ADDRESS: 152 South Shore Drive
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 C mments Approved for
f /3 License Issuance/ �-23 Li No
Fire Department Rep. Date Comments Approved for
License Issuance
Va.645-3
3 _� c�, 2> es H No
ILTI•
Board of Health Rep. Date Comments Approved for
License Issuance
❑ Yes LI No
Plumbing/Gas Inspector Date 3/il'a3 Comments Approved for
License Issuance
❑ Yes I I No
Electrical Inspector Date Comments Approved for
License Issuance
Ll Yes I1 No
Taxes Paid ❑ Yes ❑ No
Rev.Sept.2003
TOWN OF YARMOUTH
o �`" 1^1If BUILDING DEPARTMENT
': "" "j`' 7 1146 Route 28, South Yarmouth, MA 0266 5()5-398-2231 ext. 1260
r
RECEIVED
APPLICATION FOR CERTIFICATE OF INSPECTION FEB 27 2023
February 1, 2023 PAYABLE UPON RE ILO NG DEPARTMENT
(X) Fe e�urre150.00 _
( ) 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: )5' _S/v J\ K)o iDe SflXeleivag--\
Name of Premises: fp,..--.41. pfp Tel: 77 it g�4 9- Z�
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29'y -29-0-‘-i
Purpose for which permit is used: ki=s-r-4ty,eiArr
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to GAlV d> d Tel:7 4( 076 2 2-9-
Address: f CZ Sow t/ np.� .._S7
Owner of Record of Building n) Q ^/J
Address ), LD✓�� � , o Ol-t,
Present Holder of Certificate t, i tVrti
Signature of person to om Titl
Certificate is issued r his agent -1.-
k Date
Email Address: r p--e-ilic2 eAcz-. 4.12 4i
1
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# 6Z-ZrZ -/6- ad 5127 2,5jv p 7
04/01/202 3-11/3 0/2 02 3
1
NOTICE NOTICE
TO - =� y! TO
yY
YYYYi Yi��
EMPLOYEES e=' = EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE,BOSTON,MASSACHUSETTS 02111
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we)
have provided for payment to our injured employees under the above-mentioned chapter by insuring with:
MA Retail Merchants WC Group Inc.
NAME OF INSURANCE COMPANY
PO Box 859222-9222, Braintree, MA 02185-0000
ADDRESS OF INSURANCE COMPANY
014005032678123 01/01/23 - 01/01/24
POLICY NUMBER EFFECTIVE DATES
Deland Gibson Insurance Associates Inc. 36 Washington St, Wellesley Hills, MA 02481 (781) 237-1515
NAME OF INSURANCE AGENT ADDRESS PHONE#
The Skipper Restaurant 152 South Shore Drive, South Yarmouth, MA 02664-0000
EMPLOYER ADDRESS
01/18/2023
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to
furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers'
Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may
select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by
the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring
hospital attention, employees are hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER