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UT o, IraBUILDING DEPARTMENT "! 9 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION April 1, 2023 PAYABLE UPON RECEIPT (X) Fee Required$226.00 ( ) 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: l`� R0k ` ° / k YcW/noten-- d144` a'ZcV Citk 1 Name of Premises: iyls1t) !f Y��9 .- � Tel: V-1-1 ,-ZCt I -3 Purpose for which permit is used: /Ta License(s) or Permit(s) required for the premises by other governmental agencies: RECEIVED License or Permit Agency MAY 1 Q 2029 BUILDING DEPARTMENT By ---- - ---------/ Certificate to be is ed to C4 Tel: r k ( C� Address: / (I� i— y�'(c t,(yl'C—(11,4 - .?- Owner of Reco d,4 f Building Address Xi Ocrhd nfe 6,C/4" N ih—i Q �J \ Present Holder of Certificate givultyerst flaAA-e' vto.e4,-- Signature of person to whom Title Certificate is issued or his agent ( '! �'1 'C 67)-4A,i/ Date Email Address: fief /)/)adJ l�g- -C9?v- 6 h acI r /�/ T 4 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# ,(3CQ/-.3 3- /7/-, 05/06/2023-05/06/2024 A CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 05/18/2023 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 CONTEA E:ACT Maureen Raymond NAM The Hilb Group New England,LLC PHONE (800)640-1620 FAX (A/C.No.Eat): (NC,No): dba Dowling&O'Neil ADDRESS: mraymond©hilbgroup.com 973 lyannough Road Hyannis INSURER(S)AFFORDING COVERAGE NAIC if MA 02601 INSURERA: Northern Security Insurance Co,Inc. 25992 INSURED INSURER B: Vermont Mutual Insurance Co 26018 CAPE WINDRIFT MOTEL INC INSURER C: Associated Employers Insurance Co 11104 115 RTE 28 INSURER D: INSURER E: WEST YARMOUTH MA 02673-8154 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2351873422 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY 2,000,000 �/ EACH OCCURRENCE $ CLAIMS-MADE X OCCUR DAMAGE TO RBNTED 50,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A BP21063238 03/28/2023 03/28/2024 2,000,000 PERSONAL&ADVINJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY n RO- J LOC PRODUCTS-COMP/OPAGG $ 4,000,000 PECT OTHER: Hired/borrowed $ 2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ $ X UMBRELLA LIAB OCCUR 3,000,000 EACH OCCURRENCE $ B EXCESS LIAB CLAIMS-MADE CU11006204 03/28/2023 03/28/2024 AGGREGATE $ 3,000,000 DED X RETENTION$ 10,000 WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY X PER OTH- Y/NANY STATUTE. ER C OFFICER/MEMBER EXCLUDED?ECUTIVE Y N/A WCC50050267562023A 03/28/2023 03/28/2024 E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) 500,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below 500,000 - - - E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) ***Workers Compensation*** The following Officers are excluded from coverage:Ankit Patel;Shailesh Patel;Bhadresh Patel Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions 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. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 M 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD