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HomeMy WebLinkAboutBldci-16-00257-04 (2) o� `�R • . TOWN OF YARMOUTH BUILDING DEPARTMENT c_MATTA CSE �'E'ar.c•nt,*9 ) 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION October 1, 2020 PAYABLE UPON RECEIPT ( X) Fee Require . ( ) 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 premisesse/ located at the following address: Street and Number: 6 ` of 07 Er l f ,4 14l S f,Q Pew Name of Premises: Cr� w c i (K W<<c fr. P I1(_ Tel: 9 77/ S(a)C C Purpose for which permit is used: License(s)or Permit(s) required for the premises by other governmental agencies: License or Permit Agency CA6--* g Certificate to be issued to Tel: Cb 8"--A - F 7a Address: Owner of Record of Building �9 e 4(v- H4 n 11/n Address FL&were -rex. Sd t`'f/i 0;64 Present Holder of Certificate jsdirritieSi 74V gepf,&.'07. -- * n ey ex_ Signature of person to whom Title Certificate is issued or his agent /U G Date Email Address: 6'1,e y /y1 M '►hn 1, l% Ccirt 61S 7 • n 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# BC.IX 12/31/2020—12/31/2021 w� _ Fax:(508)398-0836 Acc DATE(MM/DD/YYYY) �, CERTIFICATE OF LIABILITY INSURANCE 10/16/2020 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 CONTACT NAME: Elaine Donoghue McShea Insurance Agency, Inc IN No.FN1• (508)420-9011 ow,No):(508)420-9010 1645 Falmouth Road, Rt 28 BLDG D E-MAIL Centerville, MA 02632 ADDRESS: elaine©mcaheainsurance.com INSURER(S)AFFORDING COVERAGE NAIC A INSURERA: The Hartford Insurance Company 11000 INSURED INSURERB: NATIONAL GRANGE MUTUAL 14788 Captain Parkers Pub, Inc. INSURERC: The Hartford Insurance Company 22357 688 Route 28 INSURER D: West Yarmouth,MA 02673 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000413-218475 REVISION NUMBER: 5 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 LTRINSD WVD POLICY NUMBER IMM/DDIYYYYI IMMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABIUTY 08SBANX5037 04/05/2020 04/05/2021 EACH OCCURRENCE $ 2,000,000 DAMAGE TO CLAIMS-MADE X1 OCCUR PREMISES(EaENTED occurrence) $ 1,000,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 _ OTHER: LiquorLiabil $ 1,000,000 B AUTOMOBILE LIABILITY M 1 T2388U 08/07/2020 08/07/2021 Ea acadeD SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident $ AUTOS ONLY X AUTOS _ ) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY X AUTOS ONLY (Per accident) $ $ A UMBRELLALIAB X OCCUR 08SBANX5037 04/05/2020 04/05/2021 EACH OCCURRENCE $ 1,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ $ C WORKERS COMPENSATION 08WECCM3443 04/01/2020 04/01/2021 PER oTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000 000 OFFIC(Mandatory In ER EXCLUDED? I� N/A E.L.DISEASE-EA EMPLOYEE$ 1,000,000 (Mandatory In NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarrs Schedule,may be attached if more space is required) LIQUOR LIABILITY INCLUDED ONE MILLION PER OCCURRENCE,TWO MILLION AGGREGATE. LIABILITY COVERAGE INCLUDES THE PREMISE ADDRESS,668 ROUTE 28,WEST YARMOUTH,MA,THE PERIMETER AND PARKING LOT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Building Department, Board of Health, Liquor South Yarmouth, MA 02664 AUTHORIZED (ESD) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by ESD on October 16,2020 at 10:55AM