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Oco (.) 0O j TO Jam- co E c x� # c z in TOWN OF YARMOUTH .:: Y . 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION January 1, 2023 PAYABLE UPON RECEIPT (X) Fee Required$181.00 ( ) 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: 9 Street and Number: I agi,� 5h o l C Dr \ R V E D Name of Premises: SU(14"5&rA 3eauhI!L6 l Tel: I 1 FEB 0 3 2023 Purpose for which permit is used: 6 B u i License(s) or Permit(s)required for the premises by other governmental agencies: °.- TnnE►vT License or Permit Agency Certificate to be issued to fl fl SG l& 5 FYIr( i�1 L CTel:56g 3q g a3�/ Address: 711 66M S hod° .Pry.-e `lCrYvo l ✓hh- G 244 G t Owner of Record of Building , i1 5 c 5 T D r vv r L L e Address PO 1%&C 3'1. ) S laxr,2c-A0 63.— Present Holder of Certificate 91Va`-C a 5 q b OV—( Sig ature of person to whom Title Certificate is issued or his agent o2-1'o.. Date Email Address: S PCl 5 het in V a c 1 i ( O''" 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# 6£(2/-073-(YjL/Y/0 02/17/202 3-02/17/2024 •,4ec CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/01/2022 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(ies) must be endorsed. If SUBROGATIONIS 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 THE OCEANSIDE INSURANCE GROUP CONTACT NAME: 08084400 Ext PHONE (508)771-1660 FAX (A/C,No, (508)775-1135 PO BOX 38 )' (A/C,No): WEST DENNIS MA 02670 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAILS INSURER A: Hartford Accident and Indemnity Company 22357 INSURED INSURER B: SKP1 M,LLC.,731 MAIN STREET LLC,277 S.SHORE INSURER C: DRIVE LLC DBA SKIPPY'S PIER 1 PO BOX 370 INSURER D: SOUTH YARMOUTH MA 02664-0370 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 ADDL SUBR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP INSR WVD (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE (CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY PRO- I I LOC JECT PRODUCTS-COMP/OP AGG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) BODILY INJURY(Per person) ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED AUTOS AUTOS PROPERTY DAMAGE (Per accident) OCCUR UMBRELLA LIAB EXCESS LIAB CLAIMS- EACH OCCURRENCE MADE AGGREGATE DEDI IRETENTION$ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY x [SPER TATUTE i IERH ANY Y/N A PROPRIETOR/PARTNER/EXECUTIVE I- N/A 08 WEC AD1A4A 05/30/2022 05/30/2023 E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? (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 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION 277 South Shore Drive,LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Surf and Sand Motel BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED Sandra M DiGiovanni IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 370 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 (� V L G7Ot2 ' ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD