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HomeMy WebLinkAboutBCOI-24-77 2026 The Commonwealth of Massachusetts %gYA Town of ` yo YARMOUTH 3 j '_� `-S'PPORAiEO\E,/ 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:Jack's Outback Trade Name:Jack's Outback BCOI 24 77 Identify property address including street number, name, city or town, and county Certificate Expiration Located at 161 ROUTE 6A YARMOUTH PORT, MA 02675 February 1, 2026 Use Group Classification(s) Floor Occupancy Use Group Other 01 st Floor 54 A-2 Restaurants,Night Clubs,or 54 SEATS 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 7 Name of Municipal Chief Commissioner Mark ry Date of Inspection p 3 Signature of Municipal Fire Signature of Municipal Building Date of Issuance Chief Commissioner l� S ', YA TOWN OF YARMOUTH f, :' �.�,_ �. Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 N --:- 508-398-2231 ext. 1260 Fax 508-398-0836 4,C�R E� b� PpRAt , � APPLICATION FOR CERTIFICATE OF INSPECTION January 02, 2025 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: f € I ( T G A 5 L Cr- 0% Name of Premises: J ct G IC `S o a+b a(K Tel: S o eL 3 0\ 66 i 0 Purpose for which permit is used: (126g� v IZA.v7` ef-// / /7L/- R S,j. -_--/& License(s) or Permit(s)required for the premises by other governmental agencies: / RECEIVED License or Permit Agency JAN 22 2025 BUIL N NT Certificate to be issued to �C 0 dT ,l-c_ Tel: $"�'' 3 6 26 '''o —��~ `.— Address: /6 / 6L T 4_ 4A. / L.�$2 Owner of Record of Building Liars - G4 L L i . Address 5-5-0f,/7-e- r/41 S'��7X y.4 ti T'1 o IA /14 A- 4, el-i Present Holder of/Certificate g,4 e-ks b a 7) 4 C k... ..1,,:, f � Q co %A-)2 Signature of person to whom Title Certificate is issued or his agent o/— 2 2- 20 -5' Date Email Address: L U15 TRSNSC o 9 HOT/A'1AIL . C°, '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 ISSUEY rOIJR CERTIFICATE OF INSPECTION. Certificate of Inspection# et,b':,`i v.7-) 02/01/2025-02/01/2026 C�® DATE(MM/DD/YYYY) A C CERTIFICATE OF LIABILITY INSURANCE 1/17/2025 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 RFI OW. THIS CFRTIFI(_ATF OF INSURANCE OQFR NOT (:QNSTITIITF A CONTRACT RFTWFFN_THF,ISSUING_ INSIIRFR(S1_, AIITHORI7F11 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 CI IRR.f:AT1/1N IS WAIVE. fn fhe ..... .n.nnnrfittnno .t fhn nnriny, nerf.In nntiniee mw rnnniru Mn nn.I.r..m.n4 A .fe.fmm..nf�n this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: RogersGray SBC Rnnarct;rav Ralriwin Risk Partner PHONE FAX _. . r,i A__..-. (A�_No.Ext):781-208-8400 I(A/C,No): 410 University Ave E-MAIL Westwood MA 02090 ADDRESS: rgsbc@rogersgray.com INSURERS)AFFORDING COVERAGE NAIC# License#:PC-514062 INSURER A:AmGuard Insurance Company 42390 - INSURED JACKOUT-01 INSURER B:Citizens Insurance Company of 31534 Jack's Outback, Inc. INsuaeac: 161 Route 6A Bldg 2 Yarmouthport MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:621299861 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 SUBR POLICY EFF POLICY EXP LIMITS ,LTR INSR WVD POLICY NUMBER (MWDLYYYYYI (MWDD/YYYY) A X COMMERCIAL GENERAL LIABILITY JABP552755 2/1/2024 2/1/2025 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTE CLAIMS-MADE X OCCUR PREMISES(Ea occur ence) $50,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY PRO- JECT J LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY n AUTOS HIRED NON-0''.NED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ g WORKERS COMPENSATION W8NJ641337 2/1/2024 2/1/2025 X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 un DESCRIPTION OF Oder PERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth Port 1 146 Route 28. South Yarmouth, MA 02664 AU�T ¢ED REPRESENT ATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD