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HomeMy WebLinkAboutBCOI-24-28 The Commonwealth of Massachusetts Town of 'IL.) YARMOUTH New and Renewal Certification of Inspection In accordance with the Massachusetts State Building Code,Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name:The Pancake Man BCOI-24-28 Trade Name:The Pancake Man Identify property address including street number,name,city or town,and county Certificate Expiration Located at 952 ROUTE 28 November 30,2024 SOUTH YARMOUTH,MA 02664 Use Group Classification(s) Floor Occupancy_ Use Group Other 01st Floor 185 A-2 Restaurants,Night Clubs,or 185 Person Allowable Occupant Load similar uses 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 line safety features.This certificate shall be framed behind clear glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned.Failure to post or tampering with the contents of the certificate is strictly prohibited. Name of Municipal Building I: D.e of Inspection 3'f3 y Name of Municipal Chief Enrique Arrascue Commissioner ark G ry� Signature of Municipal Firt�-- Signature of Municipal Building Chief �— Commissioner '�y �/� 7,, .ate of Issuance Z�/ a o�AR�� , a TOWN OF YARMOUTH of . - BUILDING DEPARTMENT ` MATTACn ._;,._'4' 1146 Route 28, South Yarmouth, MA. 02664 508-398-2231 ext. 1260 a �09a�R�T LO J. ,- APPLICATION APPLICATION FOR CERTIFICATE OF INSPECTION January 5, 2024 PAYABLE UPON RECEIPT (X) Fee Required $150.00 ( ) 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: q 2 ?04-r.104 2y Name of Premises: IV1 '' ?(XN Ga1ik :n Tel: 6 64- 5q �{-01S 3 9- 1 Purpose for which permit is used: pc 5T , IC-P --VCfRni:.1 License(s) or Permit(s) required for the premises by other governmental agencies:License or Permit Agency 051014 BUILDING DEPARTMENT f�;i re, 04, 4 hi- ill fiy mki-4 0 0 et r� lv -1- 1 , t) • Certificate to be issued to t, lIs Tel: i 'b 'd - le- t a -)._._ R 4 Address: 'C. 'fie As- 59. A r iv oG T/ Owner of Record of Building 401.if.sies4. p ' FR A t,/ jel C I Address , 9dv /194 ,,),/ , 4 rf -OA 0269 7 7/11 Present Holder of-Certificate 5' ? \ 44 A.14 e r7 yi Signature of person to whom Title / / Certificate 's issued or his agent 1 .::/ Date,/ Email Address: ti\p/ Lpkh.� CA14 ' ittAk, idr i'4 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 # / (]/? Y- p- 04/01/2024-11/30/2024 t r . . AP t, . r9. , . - , •A I's, .' , . . . ,.. . .,. . ‘ '` . ..- N . . . . , . . , .., . .. . . , . . ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MMroomYY) 03/01/2024 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 Erica Barrett NAME: OLDE CAPE COD INSURANCE AGENCY INC (PHONE Ertl: (A/C,771-3300 FAX No): EMAIL ADDRESS: ericab occia.com 300 WINTER ST INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INsuRERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: PANCAKE MAN LTD INSURER c: INSURER D: PO BOX 148 INSURER E: HYANNIS PORT MA 02647 INSURER F: COVERAGES CERTIFICATE NUMBER: 982878 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ,INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDDYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED S CLAIMS-MADE OCCUR PREMISES Ea occurrence) , $ MED EXP(My one person) $ N/A PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JPERCOT- LOC PRODUCTS-COMP/OP AGG S OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE N/A AGGREGATE S DED RETENTION S S WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY ANYA OFFICEORJMEMB EXCLUDED? N/A N/A WA N/A VWC10060160112023A 08/01/2023 08/01/2024 E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Main St AUTHORIZED REPRESENTATIVE Yarmouth MA 02664 Daniel M.Crowley,CPCU,Vice President-Residual Market-WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD --� PANCA-1 OP ID: EB ACORO DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 03/01/2024 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 508-771-3300 CONTACT Martha J Findlay Olde Cape Cod Insurance PHONE FAX Martha Findlay (A/C,No,EXt):508-771-3300 (AIC,No):508-775-3821 300 Winter Street E-MAIL marthaf@occia.com Hyannis,MA 02601 ADDRESS: Martha J Findlay INSURER(S)AFFORDING COVERAGE NAIC• INSURER A:Arbella Mutual Insurance INSUR D INSURER B: The ancake Man Ltd And/Or Marshall Farley INSURER C: P 0 Box 148 Hyannisport,MA 02647 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYYI IMM/DOIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE X OCCUR 7520094518 AMA RNTD 04/01/2023 04/01/2024 °R (SEsiEaEoccEu r nce) $ 50,000 INCLUDES LIQUOR LIABILITY 04/01/2023 04/01/2024 MED EXP(Any one person) $ 10,000 LIMITS ARE THE SAME PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY jEIT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ NED AUTOMOBILE LIABILITY (Ea ac deentStNGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRE� ONLY _ AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS yy��p ONLY (�OPE ent)AMAGE $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFa CCER/Mry in NM)EXCLUDED' N I A E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I 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 Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Main Street Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE IJUJC11Z,R , ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD