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HomeMy WebLinkAboutBCOI-23-1776 The Commonwealth of Massachusetts Town of og __ kI YARMOUTH ° __ _y li "Co„c,RATES TEA, 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: Olympia Fish House Trade Name: Olympia Fish House BCOI-23-1776 Identify property address including street number, name, city or town, and county Certificate Expiration Located at 1341 ROUTE 28 SOUTH YARMOUTH, MA 02664 December 31, 2025 Use Group Classification(s) Floor Occupancy Use Group Other 01 st Floor 95 A-2 Restaurants,Night Clubs,or 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 Name of Municipal Chief Enrique Arrascue Mark G I Date of Inspection % /Q Z Commissioner /Th Signature of Municipal Fire Signature of Municipal Building ! �, Chief SAC -/ .mil— Commissioner �� � Date of Issuance /Z/��Zr r o1 YA � TOWN OF YARMOUTH ,� _ -t, 0, Office of the Building Commissioner 4 ai = •` 1146 Route 28, South Yarmouth, MA 02664 - y 508-398-2231 ext. 1260 Fax 508-398-0836 � `MATTACHEESE .l'� /4, ,,,, .C°RPORATED s APPLICATION FOR CERTIFICATE OF INSPECTION September 23, 2024 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 address: Street and Number: I 3 ( \ 2.2 . 9 tA��cvrrnotAA Name of Premises: O YmQt4 VISv, k65 ILQS\-C'e,vt-- Tel: s D?-sqy-,Z6/rZ Purpose for which permit is used: \_,,Q 1 j n 2 l_t l�v'5-Q D License(s)or Permit(s) required for the premises by other governmental agencies: R E C.. vIC License or Permit q�� Agency [___S_EP 23 2O2i LiRou,r LICe..r� �f�, -- BUILC7`� P T NT '' VV f Rv ------ Certificate to be issued to 0,evrtAr 7� ja5 Tel: sag-3ci1i_2c,/� Address: Na��%ca� Liu So;.�� �ae�ov a i'n 4 0�(vt/ CCILS1\ Owner of Record of Building `(d\a \Aeur 49�e\-� Address a 5 ��rcc c 0 r t v,e VI 0 rc e r vA A 0 /doe/ Present 1 er f C rtificate D 2rne\srtaS ()korokc�5 ©W 41'CilV Signature of person to whom G e Certificate is issued or his agent / V at( Da Email Address: esvO avas 79� a\\ . cnvt/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# 12 31 '2024-12'31 '2025 f c O/—4 3./77, (Policy Provisions: WC000000C) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Twin City Fire Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 fj. HARTFORD NCCI Company Number: 14974 Company Code: 7 Suffix LARS RENEWAL POLICY NUMBER: 08 WEC AL3CMX 18 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 04/19/24 To 04/19/25 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: $287 Deposit Premium: Policy Minimum Premium: $205 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 d-14 ` 03/10/24 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 03/10/24 Policy Expiration Date: 04/19/25 INFORMATION PAGE (Continued) Policy Number: 08 WEC AL3CMX 3.A.Workers Compensation Insurance: Part one of the 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 $99 Expense Constant $159 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement $4 Other Miscellaneous State Premiums $20 Estimated Annual Premium (before Surcharges) $282 Total Estimated Surcharges $5 *See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $287 Deposit Premium: Policy Minimum Premium: $205 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: 03/10/24 Policy Expiration Date: 04/19/25