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W- 7 O a) a) C y o C> O v c m `c a) u) O C. co Fr. a) Ts coo ai U ILen Y c4 k,.,i ?:.fin ett, LNG EPA TmENT ` � .�I K t 1146 Route 28,, SouthYarmouth, MA 62664 508-398-2231ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION June 1, 2023 PAYABLE UPON RECEIPT ( ) Fee Required (X) 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: S ZI Y I ` - 1'`� ` 1)'3P Name of Premises: St , Tt lit s X SC*LQO I Tel: S° o 'lq D CI I L Purpose for which permit is used: License(s) or Permit(s) required for the premises by other governmental agencies: iRECEIVPD License or Permit Agency I [ JUN 1 6 2023 i BUILDING DEPARTMENT 6Y. Certificate to be issued to Si S . r; (4 ) X Sao 1 Tel: '5-(c)fi 'Ctl. 6((?- Address: 32( L)Ooc a. Q• i ay V► 'N',Owner of Record of Building 'me_ �.1ma.,, cz:4 1 i c. , t Ler _ &.` W.,'z Address QZ Present Holder of Certificate Signature of person to whom Title �4 Certificate is issued or his agent (6 /7 I CL) f� Date Pi" Email Address: -r C r I WWx SQ-Coot , FD A 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# .� 4_Z3_/7,72,, '" 07/01/2023-07/01/2024 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/27/2023 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 NAME: PHONE FAX (NC.No.Ext): I(A/C,No): Massachusetts Catholic Self Insurance Group E-MAIL ADDRESS: Certificates@Ratiorisk.com 66 Brooks Drive INSURER(S)AFFORDING COVERAGE NAIC# Braintree MA 02184 INSURER A: Massachusetts Catholic Self Insurance Group INSURED INSURER B: INSURER C: St.Pius X School INSURER D 321 Wood Road INSURER E: South Yarmouth MA 02664 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 INSD WVD POLICY NUMBER POLICY EFF POLICY EXP (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 $ 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 AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE - DED RETENTION$ A WORKERS COMPENSATION Approval 03/31/23 03/31/24 X H $ AND EMPLOYERS'LIABILITY Certificate of Y/N Commonwealth of STATUTE OTH- ER A N YP R O P R I ET O R/PARTN E R/EXE C U T I V E OFFICER/MEMBEREXCLUDED? N/A Massachusetts E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) 3000001012023 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 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) Evidence of Workers Compensation Insurance for St. Pius X School for Town of Yarmouth 2023 - 2024 Food License Permit Application. CERTIFICATE HOLDER CANCELLATION St. Pius X School ANY OFBE 321 Wood Road THEULD EXPIRATIIONHE DATEVE THEREOF, NOTIICEDESCRIBEDI WILL CBECELLED DELIVERED BEFORE INACCORDANCE WITH THE POLICY PROVISIONS.South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE Amanda Taillon ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD