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HomeMy WebLinkAboutBLD-19-001395 O4; R $Office Use Only . '$:.. t 'r0:. 1Pennit# / i 0 � H Amount (Q - c�`Y'' ?Permit expires 180 days from '. BL6— h"—{7 U 13 9 S i issue date EXPRESS BUILDING PERMIT APPLICA C E I V E D TOWN OF YARMOUTH Yarmouth Building Department AUG 22 2018 • 1146 Route 28 South Yarmouth, MA 02664 B UIL rEi y-"rr.,� NT (508) 398-2231 Ext. 1261 �M ' ONSTRUCTIONADDRESS: /35 So Shore f)r. S. lfarm(s v+' m '} ASSESSOR'S INFORMATION: C Sea S Cat Ccs+tt.CS') i: AME Parcel: OWNER: 42er GZ/ , Same, (-1-08)377.-02,5:0 PRESENT ADDRESS EL. # CONTRACTOR: gel Y., S tkr • in C • 2,q5 2- "at jyy)uuthi RSI (X-Irrrille, V)1 } 77'f 443 NAME MAILING ADDRESS TEL.# p 1 9 1 1� 0 Residential ,fit Commercial Est.Cost of Construction S /r1.O 0 1 t/...- Home Home Improvement Contractor Lie.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) 0 I am the homeowner ,. 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name:Nbr-Foil t bed him Worker's Comp.Policy# IJ I LIDOS—Oa-1 17 S i I g-- e WORK TO BE PERFORMED 20YHO t CA/27/i& - ✓ Tent3(L DurationC /go/ )R' (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: /,//,{�' ', //_ Date: g¢' 2:2 / ' Owners Signature(or attach nt) � (/.'7 i1yData 52 cY�- /P Approved By: Date: / D - /p Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No /1 CANAFIS-01 DATTRIDGf: ACORO' CERTIFICATE OF LIABILITY INSURANCE 001/17/2018ATE Y) `•� at/1nzo16 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(les)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 NAME; Deland,Gibson Insurance Associates,Inc. i 36 Washington Street s"c°,"o,Ext):(781)2371515 (Nc,N0):(781)237.1805 Wellesley Hills,MA 02481 Miss.info@delandgibson.com INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Norfolk&Dedham Insurance Company 23965 INSURED INSURER B:Mass Retail Merchants Workers Comp Group_ Canal Fish&Lobster,Inc. INSURER c:Underwriters at Lloyd's London _ 2952 Falmouth Road INSURERD: Osterville,MA 02655 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. I INSRRTYPE OF INSURANCE ADDLNSUBR POLICY NUMBER (MM/DDY/YYYY1 IMM/DD//YYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1.000.000 CLAIMS-MADE El OCCUR ND-P-011810891 01/12/2018 01/12/2019 DAMAGMISEES(TO Fe RENTEDacanencel $ 300,000 PRE MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY A 1.000.000 — GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _ $ 3.000,000 X POLICY !Elf 0 LOC PRODUCTS-COMP/OPAGG $ 3,000,006 OTHER' $ A AUTOMOBILE LIABILITY F&BecadeentSINGLELIMIT $ 1,000,000 _ ANY AUTO 91764265A 01/12/2018 01/12/2019 smut INJURY(Per person) $ _ OWNED AUTOS X AUTOSULEOBODILY INJURY(Per accident) $ _ X AOS ONLY X ANOOD ppactDGE S $ A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1.000.000 EXCESS LIAR CLAIMS-MADE U1706602A 01/12/2018 01/12/2019 AGGREGATE $ 1,000,000 DED X RETENTION, 0 $ B WORKERS X TRME OTH- ER EMPLOYERS'LA UTY 014005034175118 01/01/2018 01/01/2019 500,000 pOANYFF PROPRIETORni NIA RIEXECUTIVE E L EACH ACCIDENT $ (Mande YnNH)EXCLUDED? 500,000 E L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ C Comm Lines Package QSRMA11073 01/12/2018 01/12/2019 see remarks • DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Commercial Property(Norfolk&Dedham)policy:P011810891-0 Deductible$1,000 Location#1 2952 Falmouth Rd.,Osterville,MA Business Personal Property:$80,000 Business Income with Extra Expense:$600,000 SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE a verification THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN coverage ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i Deo ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:CANAFIS-01 DATTRIDGE -----"°., LOC#: 1 A�O ADDITIONAL REMARKS SCHEDULE _ Page 1 of 1 AGENCY NAMED Fish&Lobster,Inc. Deland,Gibson Insurance Associates,Inc. 2952 Falmouth Road POLICY NUMBER Osterville,MA 02655 SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Description of Operations/LocationsNehicles: Location#3 10 Jan Sebastian Dr.,Sandwich,MA Improvements&Betterments: $100,000 Business Personal Property: $200,000 Location#4 10 Jan Sebastian Dr.,Unit#2,Sandwich,MA Building: $10,000 Business Personal Property: $50,000 Commercial Property(Lloyds)policy:QSRMA11073 Deductible$2,500 Location#1 275 Millway,Barnstable,MA Business Personal Property:$80,000 Business Income with Extra Expense: $80,000 4 ACORD 101 (2008/01) "' ©2008 ACORD CORPORATION. All rights reserved. The ACORD name anlogo are registered marks of ACORD ) C ertificute of Blame iReointance § ( ,...,tb? REGISTERED USEMENT Ono Rerun or d, APPLICATION ANVAS wavraYwK Zi Y"� CONCERN Ne. #37827 y;ee UTFITTERS ( °' �•' F-410.01 tent Fencers supply November 2015 i., f1 JtIt� 1 SODS Hanna Ave.Tampa,R33610 870/865-5064 Fax 813/7408370 1 ( This is to certify that the materials described on this certificate have been flame- y } retardant treated or are Inherently nonflammable and were supplied to: it ((} NAME: Canal Fish&Lobster AT_?.Sfi2Falln4uth.8d 1 CITY Osit tville STATE MA)02655 Certification is hereby made that i> The articles described on this Certificate have been treated with a flame-retardant approved (. ) chemical and that the application of said chemical was done in conformance with Federal �. Specification NFPA 701/CSFMF ASTM E84-81A/CAIl1LC-S109!CPAI 84/MVSS302 Method of appiication:JUF1FRFNTf V Ft AMP RESISTANTti Trade name of flame-resistant labric or material used __6it.Gt.OSS Cham.Reg.No._F419.01 ,' ( I) i The Flame Retardant Process Used WILL Be Removed By Washing t;`; (*WI al wen nor) i and is good for the life of the fabric. Renewal Certification unnecessary. ) l Color and weight of fabric:.Sunblock.whitr 18.oz p ( i, Description of item certified: (4)30e Y60'Airs F4ip Roof_ErameSeatIopa4Caabe_usedas-a30.t$, Jeff Sucher 30'x 45'and 30'B ) PRODUCTION SUPERVISOR },7 C " _. Na .0 h•a I Aortar 1Ynssckoa SuY'a+""ndrwe )/M ' We hereby certify this to be • trite copy of the original "CERTIFICATE OF FLAME RESISTANCE" lasted to us, "original copy" of which has been riled with the California State Fite Marshal. Signed by Walla ka r ilio uez In a "`..- i "ter' " ,-••���--`�. - r. Tertiftrate of Nlitme Resistance ,sTz . Itatinallit _ ( �'.~w`4 AMLlCATtOfI AftYAZiMT e.~w.nw.crbested og vee { �''- + Mani Fla T TIMS #28166 on .f MARCH 2011 Tent Renters Suer* W t .”:4'''r . . IF 419.01 soon E Hanna Ave.Tamps,R 336610 o S00/863.5064fax 813/740.8370 N .� This Is to certify that the materials described on this certificate have been flame m retards tre In ntly nonflammable a '�an�� i��i Lo ss er "¢�fld. " NAME: AT IVIA 02655 W di ary Oster/Elle STATf Certification is hereby made that: Ct The articles described on this Certificate have been treated with a ttame-retardant approved y 11i chemical and tR1V Q,Mplication of said chemical was done in conformance with Federal t )) specification IVFPA �7 ( Method of application: Inherently Flame resistant U) tLO ) Trade name of flame-resistant fabric or material used Hi-Gloss - l s _ ) - t Cham.Reg.Na r 1 t The Flame Retardant Process Usedwill not Be Removed By Washing t a oat nod W and is good for the life of the fabric. Renewal Certification unnecessary. E I (( Sunblock White 15-16 oz. psy E Color and weigh of fabric CC l, r scrip rano st• r: tri is v nii6llsa ' q(/kJ., Thomas Sdortino as Production Supervisor )l o it`1 Mame S Aorta*'at P+oAXrbn Si no1uadem i tt N 't Ws hereby earNb Ms le be a tree copy of the ousel "CSRUPICATE OF PLANE No RE$4TAMCA" Issued le re, "WOW ropy of which has been Med WO the Ca arms N Stele Fire h fL'r' '`' Signed by Waleska Rodriguez • i The Commonwealth of Massachusetts G"--'=fri Department of Industrial Accidents _=n�=e I Congress Street,Suite 100 ,r Boston,MA 02114-2017 ?.4'444- www mass.gov/dla Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:Bakes Etc Inc Address:2952 Falmouth Rd City/State/Zip:Osterville MA 02655 Phone#:774-413-9191 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with 30 employees(full and/ 5. 0 Retail or part-time)." 6. ❑RestaurantBar/EatingEstablishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8• ❑Nora-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]" 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.0 Other Tent *Any applicant that checks box HI must also fill out the section below showing their worker'compensation policy information. s•trths corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box HI, Jam an employer that Is providing work en'compensation insurancefor my employees. Below Is the policy Information. Insurance Company Name:Deland, Gibson Insurance Mac. Inc Insurer's Address:36 Washington St#40 City/State/Zip: Wellesley, MA 02481 Policy#or Self-ins.Lic.#014005034175117 Expiration Date:1/1/2019 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year Imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for Insurance coverage verification. I do hereby -rdfy n the pains nr�d pen Isles of perfu that the Information provided above is true and correct $ienature: /lL -7< Date: �i f.2a-//8 Phone#:774-41 9191 Official use only. Do not write to this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone it: www.mass.gov/din ® a�mm mmm -w._-arm•17,1114 p Nig mmy TI 31. tCt ❑DO❑®O�mBBB� ,�;, p [NOW a lr e r S� R figliiiiill 1 01 �r fi alg"ll Its - s 4 !is 1 � 'j• Cpl M ;k d t 1,,,: s , E Q? .�p r o dayYuS�11 l .'k $rr r� {� U 0 r X ft '", '.' ' Li II P tl1 r V Vi mi kir , f 04 .♦ �{ '. ♦,y���°q Ftp -.({,h �(( , }�j4 ky; t'Ifrta" Ort '11‘ ay,. :.i_:, : f AI» 0' k. D F rw a 4 ��' t r •4A, r r t T i 2 r ff,, rt' , �-ii. • +, K µ i,:�r _ ,+y�5rt t. O 1 ♦ wt �ty�j t \Y `. by p - •ti .a Jj-4-,ef is • 'apt t n �' j D 4 t 1 4, r ' j }t'Lh� \ � �;ccT w �' . 04, • yet • . `✓ My yi , 4 1, y �i , , 4' 1. 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