HomeMy WebLinkAboutBCOI-24-1 2026 The Commonwealth of Massachusetts
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YARMOUTH 3iiE EO '�'�
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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: Keltic Kitchen
Trade Name: Keltic Kitchen BCOI-24-1
Identify property address including street number, name, city or town, and county Certificate Expiration
Located at 415 ROUTE 28 January 1,2026
WEST YARMOUTH, MA 02673
Use Group Classification(s) Floor Occupancy Use Group Other
01st Floor 75 A-2 Restaurants,Night Clubs,or 75 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 Chief Name of Municipal Building
P Mark G I Date of Inspection
Commissioner ry p
—
Signature of Municipal Fire Signature of Municipal Building /Q 2 j.--
Chief Commissioner ' Date of Issuance�'
i
�7 0,g _A� TOWN OF YARMOUTH
--IS Office of the Building Commissioner
( 1146 Route 28, South Yarmouth, MA 02664
, ,� 508-398-2231 ext. 1260 Fax 508-398-0836
MATTACHUSE-
t \CORP0RATE�„c'% ,
`" _. ~'' APPLICATION FOR CERTIFICATE OF INSPECTION
December 02, 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: 4/C (L-r a' w \ getiot i if
Name of Premises: /c tL-fl C- k Tat 60 Tel: 64-17/_1463 _ - 74i - i a 7-1 y 47 5
Purpose for which permit is used: gat k f6 S7/GUP at STi}e4rsT
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to UPkVin D 4PS ,-( Tel: 77:J- /37- (VS-
-Address: 4--jj( 'fi f (Lj a� J Z.Mo�a
Owner of Record of Building A'J1D 64P5E`(
Address ( b W 1 tf,N NAD 5 qikoyTR-
P sent Holde of Certificate 0}�V 1 .P 56`( RECEIVED
°NNW— DEC 112024
Signature of person t who Title BUILDING DEPARTMENT
Certificate is issued or hi ent a-(0' a�Lr, By: ______ —
Date
Email Address: Ti C-1W ct e11 e Co,ttce4.ilu
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# X.,0/ U .j
01/01/2025-01/01/2026 l
%/1, -a/i4 ,S doCec(
EMPLOYERS Workers' Compensation and Employers Liability
Insurance Policy
EMPLOYERS PREFERRED INS. CO. Policy Number From olicy PeriodTo
A Stock Company
EIG 5450446 01 01/01/2025 01/01/2026
12:01 A.M.Standard Time at the address of the
Insured as stated herein
Transaction
RENEWAL DECLARATIONS
NCCI Carrier# 31283 WCIRB CARRIER# PRIOR POLICY NUMBER EIG545044600
1. Named Insured and Address Agent
DAVID VALENTINE DEMPSEY DBA KE PAYCHEX INS (SMALL COM SALES) 7334300
415 MASSACHUSETTS 28 225 KENNETH DR
YARMOUTH MA 02673 ROCHESTER, NY 14623
Telephone: 8004720072
Customer# Carrier# FEIN# Risk ID# Entity of Insured
31283 043231737 INDIVIDUAL
Additional Locations:
2. The Policy Period is from 01/01/2025 to 01/01/2026 12:01 a.m. Standard Time at the Insured's mailing address.
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 3A.
The limits of our liability under Part TWO are:
Bodily Injury by Accident $ 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease $ 1,000,000 each employee
C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here:
All states except ND, OH, WA, WY and states listed in item 3.A.
D. This policy includes these endorsements and schedules: See attached schedule.
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.
SEE EXTENSION OF INFORMATION PAGE
Minimum Premium $ 201 Expense Constant $ 338
Premium Discount $
Assessments and Taxes $ Total Estimated AnnualPremium $ 2,588 2
❑ This is a Three Year Fixed Rate Policy
Premium Adjustment Period: E Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly
a
e.
Countersigned this Day of ,
Issued Date: 11/22/2024 Authorized Representative
Issuing Office EMPLOYERS PREFERRED INS. CO. 2
P.O. BOX 539003
HENDERSON, NV 89053-9003
Issued Date 11/22/2024 INSURED COPY
WC990630 (5/98 Ed.)
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