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Home My WebLink AboutBld-19-007045 l/tiyC Uk Only �V Og,Yq ..' l s» i O O �€ H Amount —1 �' i,'�,,,w,�,.' "dux Permit expires 180 days from c-' issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1 146 Route 28 J U N 12 2019 South Yarmouth, MA 02664 (508) 98 22 1 FYI. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 325 Main Street, Rt 28, West Yarmouth,MA By: ASSESSOR'S INFORMATION: Map: 30 I Parcel: 251 OWNER:- Kounadis,..Eyangelta Tr 85 TradersLane,_West Yarmouth,MA .__.__ SQ8-Z94 . 7Q NAME PRIEST Nf ADDRESS TEL M CONIRACIOR: Rodgers Ski & Sport, Inc,P.O. Box 68, Lincoln,NH 03251-0068 603-745-8347___ NAME MAILING ADDRESS ILL.# CI Residential XCommercial Est.Cost o#-C'onstruction$ Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) I am the homeov+net I ant the sole proprietor X I have Worker's Compensation insurance Insurance Company Name:The Hartford __ ..__. ._-__. ._____._—_—_.__Worker's Comp. Policy# 41 WECAB3AGJ WORK TO BE PERFORMED Tent X Duration (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 ssdt r (of at: Location of Facility I declare under pert; - ,,miry II t to statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) mill be just cause fo.i.tn,al or reco ti n of my license and for p osc ion under M.G.L.Ch 268,Section I Applwvut's Signature. Date 419/Io /f/ Owners Signature(or atta nt) Date: )JI ✓ f gApproved 13y -._ � f Date. _— t?widi Uflicia (or do. eel FM.AII ADDRESS: -Zoning District: l listorical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District Within It/0 ft. of Wetlands: , Yes No Yes No name •Z1P.'� EUREKA! TENTS/a div. of Johnson Outdoors Inc. �`� BINGHAMTON, NEW YORK 13902 ofihe St Iluf�res�s Tent Products Described Herein f 7 1 ± N1 : LAKES REGION TENT ADDRESS: 26�I LEE RD ADD.ESS: BOW NH 03304 CITY: STATETT P: ♦ ♦ ♦ This is to caddy that the products herein have been menrdacbued from material inherently flame rtardMas here after specified by the rrotmeriel supper. Certification is hereby made that The articles described on this certificate have been manufactured will an approved flame retardant=mica that was tested and passed the following codes:Ca omia State Fire Marshal Code,*PA-701,Underraiiers Laboratory of Canada(ULCS1094487),and have been tested in accordanoe with the Federal Test Method Specticalora and meet orweed the May Flame Specificadons of MIL-043006G and hence superseded by A-A 65308. 40'X 40' 2 PIECE GENESIS POLE TENT IN 16 OZ WHITE BLOCK OUT VINYL Desairlan dam collet Flame Retardant Process Used Wit Not Be Removed By Washing And Is eve For The Ube Of The Fabric TENT DEPORTMENT, • '• ♦ .$ INCsows .• Aire _ The Commonwealth of Massachusetts ► `` ey, Department of Industrial Accidents c =4= 1_ I Congress Street, Suite 100 `• 411— Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Rodgers Ski & Sport, Inc. Address: P.O. Box 68 City/State/Zip: Lincoln,NH 03251-0068 Phone#: 603-745-8347 Are you an employer?Check the appropriate box: Type of project(required): 1.®I am a employer with 20+ employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.) 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.)t 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.MI Other Tent Sale 152,§1(4),and we have no employees. [No workers'comp.insurance required.) *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. lithe sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: The Hartford Policy#or Self-ins.Lic.#: 41 WEC AB3AGJ Expiration Date: 4/15/2020 Job Site Address: 325 Main Street, Rt 28 City/State/Zip:WYarmouth,MA02673 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the ns and penalties of perjury that the information provided abo is ue and correct. Signature: bAu 1D Rdd ui Date: l e IO 1' Phone#: Official use only. D of write in 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. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ACC,RD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 5/14/2019 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 Phone: (952)944-2929 CONTACT Linda Bregel,CISR Fax: (952)944-3091 NAME: PHOHorizon Agency,Inc. (A/C.No.E ); (952)914-7133 No): (952)956-3311 6500 City West Pkwy#100 ADDRESS: Linda@horizonagency.com Eden Prairie,Minnesota 55344 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Allied Property And Casualty Insurance Company 42579 INSURED INSURER B: Hartford Casualty Insurance Company 29424 Rodgers Ski and Sport,Inc. INSURER C: Great Stone Face Skier,LLC. INSURER D Box 68 Lincoln,NH 03251 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 SUBR POUCY EFF POUCY EXP LIMITS LTR INSD WVD POUCY NUMBER IMM/DD/YYYY) (MM/DD/YYYY) 1 COMMERCIAL GENERALLIABIUTY ACPBPRC3047102890 4/15/2019 4/15/2020 EACH OCCURRENCE $ 1,000,000 A DAMAGE TO CLAIMS-MADE ✓ OCCUR PREMISES(EaENTED occurrence) $ 300,000 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT PRO v LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE UABIUTY ACPBAPC3047102890 4/15/2019 4/15/2020 Ea acctrer t?INGLE LIMIT $ 1,000,000 A ✓ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ✓ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ ✓ UMBRELLA LIAB ✓ OCCUR ACPCAP3047102890 4/15/2019 4/15/2020 EACH OCCURRENCE $ 2,000,000 A EXCESS UAB 2,000,000 CLAIMS-MADE AGGREGATE $ DED / RETENTION$ ° $ WORKERS COMPENSATION 41WECAB3AGJ 4/15/2019 4/15/2020 ✓ STATUTE ERH B AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 NIA A OFFICER/MEMBER EXCLUDED? Y 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If es,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Additional Insured (Applies to General Liability Coverage Only) : Yarmouth House Restaurant Solely as to the respect of negligence by the named insured regarding Cape Cod Tent Sale event from July 25, 2019 to August 11, 2019. CERTIFICATE HOLDER CANCELLATION Holder's Nature of Interest:Certificate Holder SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Yarmouth House Restaurant THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 335 MA-28 West Yarmouth,MA 02673 AUTHORIZED REPRESS TIVE kf ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD