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" 1146 Route 28, South Yarmouth MA 02664 50 -398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION March 1, 2023 PAYABLE UPON RECEIPT (X) Fee Required$757.00 ( ) 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: / g 3 m ,i1 y Name of Premises: l�.e C v� et 7 eue-rvb:3 i4in Tel: 3D =1 1 1- 3t4,(e Purpose for which permit is used: 1.-0€45 1n 'i(V)3-kJ License(s) or Permit(s) required for the premisdby other governmental agencies: Rt F. C F A V F. D License or Permit Agency APR 0 3 2023 P l 4Se.01/4. 8j u BUIL6INc; DEPARTMENT By J -1- Certificate to be issued to MC C31.2. ...vmoL+ its Tel: 50 8 - -? -7 1- St(a (, Address: Owner of Record of Building Address Present Holder of Certificate Sig ture o erson to whom Title i Certificate is issued or his agent 31/ J 23Z3 Date Email Address: ityLccA(/..�C r�S Gt� C;43vt,4,4 ;u- ry, 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 CANNO ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# 04/15/202 3-04/15/2024 A ' RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4/5/2022 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 RogersGray, Inc.-Kingston Branch P 63 Smith Lane PHHOONNE: INC.No.Eat):508-746-3311 FAX No):877-816-2156 Kingston MA 02364 E-MAIL ADDREss: mail©rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:The Cincinnati Specialty Underwriters Insurance Co 13037 INSURED COVEATY-01 INSURER B:MAPFRE Insurance Company 23876 The Cove at Yarmouth Resort Hotel Owners Association, Inc. 183 Main Street INSURER C:Allied World Insurance Company 22730 West Yarmouth MA 02673 INSURER D:Massachusetts Retail Merchants WCSIG,Inc. 0 INSURER E: National Fire Insurance Company of Hartford 20478 INSURER F: COVERAGES CERTIFICATE NUMBER:72707266 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY CSU0185688 4/1/2022 4/1/2023 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $0 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY X !ERa X LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: B AUTOMOBILE LIABILITY BJGMTM 4/1/2022 4/1/2023 COMBINED SINGLE LIMIT $1,000,000 ANY AUTO (Ea accident) BODILY INJURY(Per person) $20,000 OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $40,000 X HIRED X NON-OWNED PROPERTY DAMAGE — AUTOS ONLY AUTOS ONLY (Per accident) $ $ C X UMBRELLA LIAB — OCCUR 0313-0691-1792725 4/1/2022 4/1/2023 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$n $ D WORKERS COMPENSATION 014000014047122 4/1/2022 4/1/2023 X ;MUTE EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICERJMEMBEREXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 E Boiler&Machinery 7033730991 4/1/2022 4/1/2023 Limit Per Breakdown , Commercial Property Blanket Building $35,470275 Blanket Contents $175,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) 229 Total Units Replacement cost coverage applies Special form Building Deductible-$50,000 Building Wind/Hail Deductible-2%TIV$100,000 min Named Storm Ordinance or Law Coverage—Coverage A Included,B&C Limit$5,000,000 Blanket Business Income-$6,100,000 Business Income Waiting Period 72 Hours See Attached... 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. Route 28 South Yarmouth MA 02664 AU .'4111111111111111%DR`EPRESENTATIVE 4• r I Y,r . ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD