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HomeMy WebLinkAboutBCOI-23-1715 2024 d w/� c w1 i ^ •Q o 00 as• 0) If N N a) N 0 oD 0 a) II 43 C) a D w •_al C N. 0 r- N sw m N 3 mm2� a) co N Tx'O aa)) C a e o � vo c s -aL. 2 cS O 0) a) mCI' a) Q V . y a N m G ay c 'C y 0 c 0) a) a) v 0 C ` a) oaf v � � V Ia r' ti Q) 1‘1:,:' 1,1 G. i.. -) co 46 a R' a) 2 _m w fN w ►O. cL0 c O b - (0) In o „c Oo to yU• U H• wy � > ft o d a O £ Na) ycr0iX Hi �j ``o Et L 7 r ,_ cf6 c r >` O O O r �' Z N 3 I' -p si a) F. m EE ~ C DIN O m �p U r la N r' 2 O C = H V N a) C 0 O c m N l0 � "0 0) Q • 0 0 0 . 3 0 a) a) 0 a)) ' wE .° 'O _ E E c E O Q. OO ZU (�U U 0) O = N � ;0 m c n v_) m' ac) M 't t- aa)) co`o c� c O = 0 . m ~ 2 N � 0 .0 Q O .07 0 o C Co as m a) a+ v '5 C a) a) !a _ .c — .5 fA 07. "6 C '6 LL N A ) o UTsi v a) y O IL c J A a cU co"ag) 10 m C t N 0 7 Q ~ C c P ,2'40 TO N OF YARMOUTH BUILDING. EPA �a \MRTTAL.t LSE/Th .. ,. 1146 Route 28, South Yarmouth, MA 02664 508 :. APPLICATION FOR CERTIFICATE OF INSPECT I MAY12023 May 1, 2023 PAYABLE UPON REC IIU1'LDING !DEPARTMENT ( ) 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: UP 1&7i 02g 50011 y 'biota t fn.A 002,�'4 Name of Premises: �-I+iD I y1<O Tel: 6n Purpose for which permit is used: Y lo ‘e,e. License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency v� Certificate to be issued to i 0T Ca) v r,Wi)14 Tel: 50g ' 3 cie-ozgli ✓ C�Gi i Address: f)°/ kariTa24 SozL' 'l Zer ie Jf. _ -�- (� j (9t_ Owner of Record of Building S(.44 /E Address h6( -2OL/ . c,28 La!! Y�1W7O tz- C?c Presen older of Certificate CA-PE CO ) V QA N( k 0 oboite( Si n re of person to whom Title Certificate is issued or his agent Dat Email Address: CCVV /V g 67qmareG, G - C.C.Vern n cL ot fY1 rvz Jc4 01 w i Instructions: Make check pa able to: Town of Yarmouth PY t 4 JC-C> 1146 Route 28, South Yarmouth, MA 02664 4 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# 3CO/-t .3-.' /7ls- 06/08/2023-06/08/2024 ACQRD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 414k..." 06/02/2023 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 Maureen Raymond The Hilb Group New England,LLC PHONE (800)640-1620 FAX ((EA/C No,Ext): I(A/C,No): dba Dowling&O'Neil ADDRESS: mraymond@hilbgroup.com 973 lyannough Road INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Northern Security Insurance Co,Inc. 25992 INSURED INSURER B: Cape Cod Veranda LTD DBA Beach N Towne Motel INSURER C: 1261 Route 28 INSURER D: INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: CL236278319 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 AUUL'SUttk POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR DAMAGE TO RENTED 50,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A BP21052448 10/17/2022 10/17/2023 PERSONAL&ADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPUES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n JEC7 pi LOCR PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Hired/tx)rrowed $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea acddent) 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) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? n N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 Rte 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 _.w• I ©1988-2015 ACORD CORPORATION. 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