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v`'4' 1146 Route 28, South Yarmouth, MA 0266 505- 8-22 I x
APPLICATION FOR CERTIFICATE OF INSPECTION MAR 312023
March 1, 2023 PAYABLE UPON RECEIPT By:BUILDING DEPARTMENT
(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 premises located at the following address:
Street and Number: 5 V ' 'G\V\ S T Cy- ar
Name of Premises: Cr\ Co NO T,d 1 \'I ex''11- Tel: \ s-- S LI 0�—
Purpose for which permit is used: O�e
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
�n�
Certificate to be issued to $&h`fl V7 Pr`Q- G T TIC Tel: ON 3 '7 S' S L1°
Address: S I 1Ma vh v M I() '7 3
Owner of Record of Building lj 4 NO 0)A 1 }0k�1 bS
Address S I VVZ G h S W \ ci(1,vv 4,t 1.,, M 4 0 )- 7 3
Present Holder of Certificate (t 'ix A i? V AG`� p 'C
Si ature person to whom Title
ertificate is issued or his agent 313 II 23
n Date
Email Address: J 6 e , M a f Cc; W oK r ' J emu,L, Calm
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# �J
04/15/2023-04/15/2024 �/5T
4 •
AcoRI) CERTIFICATE OF LIABILITY INSURANCE DATE
111
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 poiicy(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 N 'Z"~CT Brian Allaln
Choice Insurance Agency PNo ,,E„U 978,'143-4853 11.v.leek 978-345.1007
376 Summer Street may; bailainOCholCednsurance.com
Fitchburg,MA 01420 NAIL I
INSURER(S)AFFORDING COVERAGE
INSURER A: AniGuard Ins Co 42390
INSURED INSURER a:
Sandbar Management Inc/Sandbar Holdings LLC INSURER C:
Caps Cod Inflatable ParkfShark Bites Cafe MSURER0:
100 Wood Ave S,Suite 209
Iselin.NJ 08830 INSURERE:
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 HSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTEICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NTR imuLeuTYPE OF INSURANCE YYIND POLICY NUMBER I0 IDIVYYYY) ( MfOWYY�Y1r)._ LOOTS
COMMERCIAL OBIERAL LIABILITY EACH OCCURRENCE S
DAMAGE TO RENTED
I CLAMS-MADE 0 OCCUR PREMISES Mu occurrence) S
MED DIP(Any one person) S
—1 PERSONAL&ADV INJURY S
GEHL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S
POLICY❑PJPCTC ❑LOC PRODUCTS-CO/AP/OP AGG S
oT� s
AUTOMOBILE UABp rY COMBINED t)SINGLE UNIT $
(Ea acciden
ANY AUTO BODILY INJURY(Pat person) S
—OYYNED SCHEDULED BODILY INJURY(Per accident) S
_,AUTOS ONLY _AUTOSHIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accident) S .
$
—
UMMIREU.A UAS OCCUR EACH OCCURRENCE S
— EXCESS L y� CLAIMS-MADE AGGREGATE S
DEO I 1 RETENTION$ S
WORKERS COMFENSATION 1 STATUTE I XI ER
AND EMPLOYES,OR UAR N EY YIN E.L.EACH ACCIDENT $ 1,000,000
A �E� ❑ N/A SAWC374351 10/01/22 10/01/23
EL.DISEASE-EA EMPLOYEE S 1,000,000
M S _,ram OF RATIONS bedew _ EL DISEASE-POLICY LIMIT S 1,000,000
DESCRWTION OF OPERATIONS I LOCATIOIM I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B more specs Is requted)
Opotations of Insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Sandbar Management,Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
P.O.Box 409
Iselin,NJ 08830 AUTHORIZED REPRESENTATIVE
t y �C 1088,2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo ere registered marks of ACORD
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i;-----
44;----__ TOWN OF YARMOUTH BUILDING DEPARTMENT
to+ ht 7, Certificate of Occupancy
)
.... MA 4 FESS /
/ In accordance with The Commonwealth of Massachusetts Building Code
it No. Location
Type of Building
Has been inspected and occupancy is approved.
,
Date 65---- 7--- :5> Building Commissioner ..", ,„,,.
.This certificate certificate must be posted in a conspicuous place. .. .... • •••'
7 /'2,',.)/ 7r*--/-.2---1°1-2 7 7