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TOWN OF YARM()UTII
tk•
'41rVI -4) BUILDING DEPARTMENT RECEIVED
" 1146 Route 28,South Yarmouth. 1A 02664 508-398-2231 ext. 1260
UN 01 2023
APPLICATION FOR CERTIFICATE OF INSPECTION
BUILDING DEPARTMENT
By._-----
M"13+24 2023 PAYABLE_UPON RECEIPT
(X)Fee Requved S220.00
) No Fee Requinal
In actladance with the orortstons of the Maasachoscits State 13uilding Code,Section 1.10.7,I hereby apply for a
51111
Certificate of Inspection for the below-narnoi premises located at the folknving
Street and Number: i )1 Ki .1)0-Y4-
)3111
i
Narac uf Pm:raises: rrie-PC(te &rnri L-titiy4 Tel.: LE2 .„f-
PuipoLsc for which permit is u*xi L , .c.. Lrf )4
License0 j or Plarrnt(s)required for the prendscs b other governmental agericics:
License or Permit
Agency
_
Certificate to be islued to eat_ e cjI d Tel:54. -
Address: q z. cf,th Sh Cr< ."1(Vrr7
Owner of Record cif Building -Se rn 901ike:t Address (43caLcn IY14 _
Present Holder of Certificate
Ihc
Si re of person to whom
Tale
Certificate is issued or his agent Sj _
Date
464 01 siva rnai, 14/i7 keice IS.. Lcryl a/r V- hfrki
Instructions: Make check payable try Town of Yarmouth
1146 Route 28,South Yarmouth,MA 02664
Muni dm application to_ Building Inspector's Off=
Please note: Application tone with acoompanyinli foc must be subtrairtoLl for each Inn-Wing in structure or pan tbena.1
to be eirtitlecL Applicatinni mina be retched before the certificate will be Issued The building ahead than he
notified within ten(JO)days of any change in the above information_
PLEASE SEND US A COPY OF YOUR WORKER'S OCIMPENSATION ENSURANCE FORM WITH THIS
APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION_
Certificate of Inspeetam
0691/2022-06`01,2023
OC-0/-073—/7/ks
9os:0-n2114009h:,:m.,,,itragt.ofzI
Nip...7 01
A`�D® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
5/4/2023
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 CONTACT
Eastern Insurance Group LLC NAME: Mary Donovan
233 West Central St PHONE FAX
(Am.No.EMI:781-261-2012 (A/C,No):781-586-8244
Natick MA 01760 E-MAIL
ADDRESS: ITldonovan@easteminsurance.Com
INSURER(S)AFFORDING COVERAGE NAIC 0
INSURER A:MEMIC Indemnity Company 11030
INSURED WINDJAM-01
Horizon Engagement LLC INSURERS:
192 South Shore Drive INSURER C:
South Yarmouth MA 02664 INSURER 0:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:1632924722 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 WIT14 PELT 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
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP
(MMIDD/YYYYI (MM/DD/YYYY) LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $
CLAIMS-MADE OCCUR DAMAGE TO RENTED
PREMISES(Ea occurrence) $
MED EXP(Any one person) $
PERSONAL&ADVINJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY PRO-
JECT LOC
PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accident) $
$
UMBRELLA LIAB OCCUR
EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE
AGGREGATE $
DED RETENTION$
A WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY 3102809471 3/1/2023 3/1/2024 I STATUTE I ER
ANYPROPRIETORMARTNER/EXECUTIVE Y/N
OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT
(Mandatory in NH) $500,000
If yes,describe under E.L.DISEASE-EA EMPLOYEE $500,000
DESCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks
Evidence of Insurance Schedule,may be attachedspace;r more Is remarked)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
TOWN OF YARMOUTH BUILDING DEPARTMENT
1146 Route 28
South Yarmouth MA 02664 AUTHORIZEDREPRESENTATIVE
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