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HomeMy WebLinkAboutBLDCI-16-005425-07 �. The Commonwealth of Massachusetts --ti, , ; City\Town of . , ` , -__ :y YARMOUTH Y 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 BLDCI-16-005425-07 Business Name:OLYMPIA FISH HOUSE Trade Name: OLYMPIA FISH HOUSE Identify property address including street number, name,city or town and county Certificate Expiration Located at 1341 ROUTE 28 12/31/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 95 A-2 Nightclub/Restaurant/Bar/Banquet Hall 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 Name of Municipal Mark Grylls Date of 4 �.} Fire Chief I.Qt.6�> .'Lµ-4et-Cif, Building Commissioner Inspection 3 / .25 Signature of Municipal Signature of Municipal ( / Date of Fire Chief i Building Commissioner Issuance 4'/,72. Fee:$100.00 BLD_Certofl nspection.rpt [MVO) v F BUILDING DEPARTMENT �MT „t:X .* •a* a 1146 Route 28, South Yarmouth, VIA 02664 508-398-2231 ext. 1260 i APPLICATION FOR CERTIFICATE OF INSPECTION February 16, 2023 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 addressl: 1 Street and Number: 1 t'} 1 R i a x GO ` ���N 21 Z_� + 1 Name of Premises: 0 I NICA, iZe3 1 Tel: (�f�- 9 L -t26 12. Purpose for which permit is used: License(s)or Permit(s) required for the premises by other governmental agencies: CEIVED License or Permit Agency I-FEB 23 2023 Lao(4 LlaIfts 4-6C_ BU E RIME T By Certificate to be is ued ' e vi12+rioS S 6, Tel: Sf)i 394(--XX(, (2 Address: 9 vU ot/ (4,t( �.YU S f-th . evvio�-I P1 0?L4I o Y r� Owner of Record of Building YYstnykk6e PCNIC ,0 0 6+ Address oPS" \•erroce Unvc `wort. r (el Present Holder of Certificate Dv mpl 005 4c o rI e 5 1 Ovine( Sig ature of person to whom Title Certificate is issued or his agent a ..2.37)0)5 Date Email Address: er5 k 0 rCl 3 7 g 6 I m a l I , coal 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# C/ -/4' 1 2Y 142-,S`-1G,)p7 —104 2023 ,2434 242.3/3PDa3 INFORMATION PAGE (Continued) Policy Number: 08 WEC AL3CMX 3.A.Workers Compensation Insurance: Part one of tie 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 $100,000 each accident Bodily injury by Disease $500,000 policy limit Bodily injury by Disease $100,000 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 $203 Expense Constant $250 Terrorism Risk Insurance Program Reauthorization Act Cisclosure Endorsement $7 Other Miscellaneous State Premiums $20 Estimated Annual Premium (before Surcharges) $480 Total Estimated Surcharges $8 *See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $488 Deposit Premium: Policy Minimum Premium: $211 MA Interstate/Intrastate Identification Number: Refer to Schedule of Operations NAICS: 722110 Labor Contractors Policy Number: SIC: 5812 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 03/10/22 Policy Expiration Date: 04/19/23 (Policy Provisions: WC000000C) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Twin City Fire Insurance Company q ONE HARTFORD PLAZA HARTFORD CT 06155 ,r THE ;.., HARTFORD NCCI Company Number: 14974 Company Code: 7 Suffix LARS RENEWAL POLICY NUMBER: 08 WEC AL3CMX 16 Previous Policy Number: 08 WEC AL3CMX 1. Named Insured and Mailing Address: OLYMPIA FISH HOUSE RESTAURANT, INC. (No., Street, Town, State, Zip Code) 1341 MAIN ST, RTE 28 S YARMOUTH MA 02664 FEIN Number: 04-2519368 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Full-Service Restaurants Other workplaces not shown above: 1341 MAIN ST, STE 28 S YARMOUTH MA 02664 2. Policy Period: From 04/19/22 To 04/19/23 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: GUARD INSURANCE AGENCY INC 279 MOUNT AUBURN ST WATERTOWN MA 02472 Producer's Code: 08080603 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (866)467-8730 Total Estimated Annual Premium: $488 Deposit Premium: Policy Minimum Premium: $211 MA Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9©8.33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by �4<-a C 03/10/22 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 03/10/22 Policy Expiration Date: 04/19/23