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Home My WebLink AboutBCOI-23-1790- 2 Z 0 / / a> - 2 2 Q _ o q a k Q ¥ coca- o o 0 . co .E" d 2 E • % c 1 . 0 co a) ® .0 - 0 \ co _ $ ) } 0_ / E 0 � a) \ j \ C 5 0 ° om ƒ $ / -- - - u u , , q 2 k E O Q yO . } I- ' 2 2 / 2 / ) » ƒ / c22 \ c \ O. Co U) � / � 0 o � ] g ] g0. , @ 2 ) ƒ ƒ / o § S U ■ G . NECNA. E /_ / fkill\,11‘.- -P.2 C 2 £ � � < 2 < 5La) •U £ © e m $ E °$ % / / k � \ � I & � § k2 2uk k/ / 2 2 % / / § % / § \ \ �� Q % � � 2 / R 0 $ < > m % k k q £ \ $ O U CL § S k < Ioc$° ® E co Z ® f t _ £ \c . f@ % - }-. I'll I 5® 2§ \ / k \ I. ECL ■ om 2 2 = o k U § c / / \ k \ § CD 03 k / \ /\ �\ e _ \ 0 [ ] 2 ) a j ƒ \ zk 0 a. J \ \ _ 0) \ a) Ram 0 2 $ S f �� / ) . § / j � / / I _ hIf cr 2 / \ \ 2 ■ v ° . 0 0_ % � 1,5 Q o \ c k / 0 m k 2 =a .0 a e \ > co 2 m E % Z t q I $= E &ƒ z 70 , ‘N ROI P-3R r {1G EPA . ENT c °" �`rt vt,y' 1146 Route 28, South it armouth, NIA 02664 08-39S-2231 ext 1260 ; !RECEIVED APPLI C FICATE OF INSPECTION September 1, 2023 OCT 2 5 2023 PAYABLE UPON RECEIPT BUILDING DEPARTMENT (X) Fee Required$100.00 By _ ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address:� � D NIA' Street and Number: et0 ti y 4)QU 1 ' t l O b+-C� I Name of Premises: C,Q ��5 7 0 Tel: S i Vi g 0 Purpose for which permit is used: License(s) or Permit(s)required for the premises by other governmental agencies: 41t V(\ License or Permit Agency �`�.. Certificate to be issued to CIO Tel: ci0 t -3°C g--eto 8 0 Address:ClOst rf\Pa`b ©O b 6 sr- Owner of Record of Building 1 . ` 1 (2.F J 1 Address c(©? M r A- O 66 q Present Holder of Certificate 010% \N _- Signature of person to whom itle Certificate is issued or his agent OCy !3( 1) (� Date Email Address: otOA\ �� r© C� V 1''''t o t• LA,rh Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth, MA 02664 Return this application to: Building Inspector's Office Please note: Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified. Application must be received before the certificate will be issued. The building official shall be notified within ten(10) days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE C OT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# �0C0�-oZ 3-/7'(� 12/31/2023-12/31/2024 Workers Compensation And Employers Liability Insurance Policy WC 00 00 01 A Coverage as Provided WE- Pokey Number 1 liberty csua secuntv Insurance Company IWS(24)64 Tr n n Mutual. XW$Prior Poky Number Ms4n22-n NCI Co No L19291 Workers Compensation and Employers Liability Insurance Policy Information Page ITEM 1:The lamed&Mailing Adams Agent Mailing Address&Phone No, 908 BISTRO. INC. (0171 648-5 ItiO I FILLMORE RD INTERCONTINENTAL INSURANCE WEST YARMOUTH, MA 02673 BROKERS LLC 70 FEDERAL ST STE 310A fk/STON, MA 02110.1974 • *divides' Partnership X Corporation or FEN:XXXXX2460 ANCL1225 *bar workplaces not shown thieve: ITEM 2 The policy period is horn 05 1 7 2023 to 05,1712024 12:01 am StandanITimeat the trisureirsiriailingaddrea . ITEM 3 A.Winters Cumetesatioa Winans.: Part One of the PoNCY SPOkes to the Workers ComPentleon Law of the states listed. here MA IL Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3 A The limas of our Inability under Part Tyro are Boialy Injury by Accident $300 0.00 each accident Bodily Injury by Disease $500 000 policy limit Bodily Iniury by Disease $600 000 each*mpg)** C.Other States Insurance: Part Three of me polici applies to the states it any, listed here See Extension at Information Page D.This policy includes those endorsements and schedules: See Policy Forms and Endorsements Summary ITEM 4 The premium for this policy will be determined by our Manuals of Rules Classifications Rates and Rating Plans AS irilorrnation required below is subject to verification and change by aucla Classifications Code Premium Basis-Total Rate per Estimated No. Estimated Anneal $100 of Annual Remuneration Remuneration Premium See Extension at Information Pageisl Total Estimated Annual Premium $2,049.00 Total Surcharges and Assessments $70.00 Minimum Premium $259 00 MA Total Estimated Cost $2,119.00 .n.ilicaleitt below interim adjustments of premiums shall be made Depose Premium $2,119.00 Couritersagned by Issue Date To report a clam, call yote Agent or 1-844-325-2467 ('00 00 GI A(WC 30 10 Li 0 19$7 National ('owl on Compensation Insurance. Inc 64772223 POLSCS 45C INSURED COPY 11411,70 PAGE 15 OF 48 Elliott,Ken Subject: Certificate of Inspection Location: 928 Route 28 28 diner Start: Thu 3/31/2022 9:00 AM End: Thu 3/31/2022 3:30 PM Show Time As: Tentative Recurrence: (none) Meeting Status: Not yet responded Organizer: Fallon,Rosa Required Attendees: Inkley,Brad;Elliott,Ken;DiBenedetto,Mark;Huck,Kevin;Bearse,Matt;Renaud,Philip The Building Department is scheduled to conduct a final for occupancy inspection on March 31,2022 at 928 Rte 28, Diner 28. Marcos Andrade 508-360-7498 is the contract person. We would like for you to attend. Please notify me regarding your inspection results.