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HomeMy WebLinkAboutPoyant Sign Documents CAPE 5 COD April 10, 2023 RE: New Signage Permits Cape Cod 5 514 Station Avenue South Yarmouth,MA 02664 To Whom It May Concern: I Christopher W Raber as the Chief Real Estate Officer at Cape Cod 5,the owner of the subject property noted above, hereby give consent to Poyant Signs, Inc. to act as an agent on my behalf pertaining to the permitting and installation of signs and/or awnings. This includes temporary and permanent signs, in addition to any related improvements to the subject property and to other work required to the existing properties at the following address: Please contact me if you have any questions or require any additional information. Sincerely, Christopher W. Raber SVP/Chief Real Estate Officer craber@capecodfive.com 508-247-2216 1500 Iyannough Road Member FDIC Hyannis,MA 02601-1835•888-225.4636 Member DIF www.capecodfive.com LENDER The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 1/4 2 Avenue de Lafayette,Boston,MA 02111-1750 ay~ www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Poyant Signs Address: 125 Samuel Barnet Blvd. City/State/Zip: New Bedford, MA 02745 Phone #: 774-762-3413 Are you an employer? Check the appropriate box: NII am a employer with 50+ 4. ❑ I am a general contractor and I Type of project(required): employees (full and/or part-time).* have hired the sub-contractors �' New❑ construction ' 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.FT! Other Signs comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Valley Forge Insurance Co. Policy#or Self-ins. Lic.#: WC182091627 Expiration Date: 9/4/2023 Job Site Address: 514 Station Ave. City/State/Zip: Yarmouth, MA 02664 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D. • insurance coverage verification. /do hereby ce un the pains and penalties of perjury that the information provided above is true and correct. Si tune: Date: 5/2/23 Phone#: 4-762-3413 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 2❑Building Department 30City/Town Clerk 4.0 Electrical Inspector 51:i'lumbing Inspector 6.❑Other Contact Person: Phone#: POYASIG-01 LMENDES A41CORL7►` CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/rvvv) 8/31/2022 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 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 License#1780862 CONTACTNAME: Lucia Mendes HUB International New England PHONE AX 222 Milliken Boulevard (A/C,No,Est):(508)235-2210 I(FaC,No): Fall River,MA 02721 E-MAILSS,Lucia.Mendes@hubinternational.com INSURER(S)AFFORDING COVERAGE NAIC U INSURER A:Valley Forge Insurance Company 20508 INSURED INSURER B:Continental Casualty Company 20443 Poyant Signs,Inc. INSURER C: 125 Samuel Barnet Blvd. INSURER D New Bedford, MA 02745 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 1077924068 9/4/2022 9/4/2023 pRA M SES Ea occurrence) $ 100,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT X LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: A $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO BUA1077924040 9/4/2022 9/4/2023 BODILY INJURY1Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident). $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 EXCESS LIAB CLAIMS-MADE CUE1077924054 9/4/2022 9/4/2023 AGGREGATE $ 10,000,000 DED X RETENTION$ 10,000 $ A WORKERS COMPENSATION y AND EMPLOYERS'LIABILITY X PER ERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC182091627 9/4/2022 9/4/2023 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (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) Ref:#WO 2164917 Eversource Energy is listed as an additional insured on the general liability policy as respects to operations of the named insured when required by executed contract prior to the loss/claim. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Poyant Signs,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 125 Samuel Barnet Blvd ACCORDANCE WITH THE POLICY PROVISIONS. New Bedford,MA 02745-0000 AUTHORIZED REPRESENTATIVE giS9?;47- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure Board of Budding Regulations and Standards Constticit06 (Skfix,rvisor CS-091480 17:- ires: 09/16/2024 JASON GREGORY FREDETTE 32 SUMNER ST TAUNTON MA 02780 1r aL, C onstrtgction SuperAllsor Linrostricted - Buildings of any use group-,ikeniT,h contain than 35000 cubic feet(991 cubic meters) of enclosed space. Failure to possess a current edition of the M3ssachusetts state Building Code is cause for revocation of this license. Fc.lr thir;Call (617) 727-3200 or visit www.rnass.govidpi