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Home My WebLink AboutBLD-23-000571 0111ed g13)72,- j of.1-AR RECEIVED Office Use OnlyO Permit# �2- C LIU ,0 o . AUG 012022 Amount ` MATT M , ``°" �'"�' Permit expires 180 days from BUIL _G / T issue date By: EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 ( ,� (508) 398-2231 Ext. 1261 yCONSTRUCTION ADDRESS: "7 jg- l L W 4 (G✓� - - t p/ I,}-) fn Y" +� ASSESSOR'S INFORMATION: / Map: Parcel: OWNER: (rI242J a l C1 Pin NAM} PRESENT �/"/�'SS TEL.1# ` �P ��d� CONTRACTOR: /<4`7 S/Ofi'? —f W)C-C,, JCj f G41- .<`'7or-),-.fAn/0 Ua&6 1-1 COE, l to c`'7 Uo1 NAME MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ ea Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 1 am the sole proprietor have Worker's Compensation Insurance Insurance Company Name: ✓1/)C57i (6. 1,--Jr/�"`Ce Worker's Comp.Policy# Lit CC —S 0 0"S 0 I I2d/ — ?OZ,4 W71 by Fr( WORK TO BE PERFORMED g1-l-- (I . -- Tent . Duration (Fire Retardant Certificate attached?) Wood Stove E Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. {Q)Replacing like for like Pool fencing I I *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revo n of m/y�Jlicense d fo pro �: under M.G.L.Ch.268,Section 1. / Applicant's Signature: �� 'Nv / Date: y l//� z Owners Signature(or attachment) , ( l 1-1. :::: • . l`: 1"2 ' 6?-3-2 2._.Building O ' ( signee) EMAIL ADDRESS: Zoning District: . Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No �)0 s ides i (10 IcJe v, , The Commonwealth of Massachusetts Department of Industrial Accidents << - Office of Investigations Lafayette City Center 4 2 Avenue de Lafayette, Boston,MA 02111-1750 .ID www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:Bayside Tent Address:40C Whites Path City/State/Zip:S.Yarmouth, MA 02664 Phone #:508-760-4025 Are you an employer? Check the appropriate box: Business Type(required): 1.I: I am a employer with 7 employees (full and/ 5. ❑Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, Tent Rental with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:Mcshea Insurance Insurer's Address: ` ` P City/State/Zip: t G am' GA I A" 1 4 °—7'5 Policy#or Self-ins. Lic. #WCC-500-5013321-2021A Expiration Date:5/22/22 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§ 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 DIA for insurance coverage verification. I do hereby certify, u er the pains and penal r;. o perjury that the information provided above is true and correct. �WV, � 'I"' Date r /'�/ 22 Signature: -/`�� 40 Phone#: 508-246-6 28 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): 1.❑Board of Health 2.❑Building Department 30 City/Town Clerk 4.DLicensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia r"----- Noccol CERTIFICATE OF LIABILITY INSURANCE DATE `~ ) 05/23/2022 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 pollcy(tes)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 endorsements). PRODUCER CTACT NAME: Joseph Dupuis McShea insurance Agency, Inc Pa",,, (508)420-e011 FA7( t508);20-9010 1645 Falmouth Road,Rt 28 BLDG D t=iikeD RD jos®mcshesinsurartce.com Centerville,MA 02632 INsURm ls)AFFORDINGCOVERAGE tulle INSURER A: PENN AMERICA INSURED -- INSURER 11: Progressive Casualty 11770 Baystde Tent&Table,Inc. NesuRERc: AiMillutua_l 40c Whites Path INSURER D: South Yarmouth,MA 02664 INSURER*: INSURER F: COVERAGES CERTIFICATE NUMBER: 0000217E-0 REVISION NUMBER: 1 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 ay PAID CLAIMS. TRR TYPE OF INSURANCE DM MIVD POLICY NIBMIER IMWDOIYYYY) memogYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY PAV0380B64 0511712022 0611712023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED ]CLAMMS44ADE X OCCUR PREktISIS(FA +Le—_ $ 50,000 MED E V(An tenon) $ 5,000 — PERSONAL 6 ADV INJURY $ 1,000.000 GENT AGGREGATE UNIT APPLES PER: GENERAL AGGREGATE $ 2.000,000 X 1 POLIO 1! (LOC PRODUCTS-COMP/OP AOG 9 INC $ ()Twit COMBINED SINGLE UNIT a B AUTOMOBILE LIABILITY 02711576-6 1w2612021 10(2612022 (Eaeceideral ANY AUTO BODILY INJURY(Par peen) a 100,000 H __., OWNED __. SCHEDULED BODILY INJURY(Per accident) a 300.000- I_ AuToil ONLY OS HIRED NON-OWNED • PeOP DAAMAGE $ �,000 AUTOS ONLY AUTOS ONLY $ Lepagu.ALMB OCCUR EACH OCCURRENCE �S sxca UM IXADAS#MADE AGGREGATE $ DED 1 RETENTIONS $ C R UA4T OO Y WCC-500-6013321-2022A 0512212022 05122r2023 X I s sure 1 0T- OFF RPRIETawPARTNERrEXECUTlvr Y'N E.L.EACH ACCIDENT c 500.000 OFFICER/MEMBER EXCLUDED? [� NI A EL DISEASE-EA EMPi OYEt3 a 500,000 1MandalaY In NH) $Egy�R p 500,000 Nyynnss dosed under .L.DISEASE-POLICY UAW IPTION E OF OPERATIONS beRW, { DESCRIPTION CF OPERATIONS LOCATIONS I VEHICLES(ACORD 101,Ade:tonal Remarks ScA.IS I.may be attached Ir mare spice Is rpatred) Workers Comp:Corporation owner Ryan Ginis is not included for coverage under the Workers Compensation policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WLL SE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. If 46 Route 28 South Yarmouth,MA 02664 AuTNOID REPRESENTATIVE 1/0114..*••••••••••.•,••••••••••••.-. ' . . (JFD) 4: I 01988-2015 ACORD d- ORATION. An rights resarva •ACORD 2S(2018/031 The ACORO name and lone are re red marks of ACORD Printed by JFD on 05/23R022 at 01:52PM Certificate of Flame Resistance * REGISTERED test sY Date atMtaveetteeme FAERteZER JOHNSON OU DOORS SRC. Il• ao.oi I �IGNAliTef.NEW YORK 13002 ]At�tiJARY 199R ► ere*RAW Tanr '[ts to to certify that the products herein have been manufacturedMott materiel bistreali#y flame retardant as here otter opedfled by the motorist supplier, NAME: RAYSIDE non cry„ SAND ViC MN Certekation is hereby masts tbst The on Ofs radiscato have been manufaduted ear an aperomd team tetenters dwelt* etesh C Necia Code t�'A-701', ryas Labor ry of ce .end rove c ee testesFedora Ted Mood Spear end meet or mese the mossy Rolm specneseensat Noi.- . T ype � o T 1401 �8LOGK+ EJI deem GENESIS 24t MID 40 SECTION 1 Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Cif The Fabric Snyder M fng tutactur .Ire. _�.. .+! ibmtseaser of rta c Retardant WA ICNT DEFAitttKVT � a • Certificate of Flame Resistance REGISTERED ISStED este Maisubsobat FABRIC JOHNSON OUTDOORS NC. NUWER DING tAbill V, YtiRif 13902 JANUARY 1998 F-1410.01 Usnufactoort of dre newt Temp Desatrad Alvah 'This is to certify that the products!heroin have been manufactured from malvrial*f • ter~erre retardant as here aftctr specified by the material supplier. NA a AY5Tt3 t M' _ . ary SANIDW ii,MA/ csrtifbs tiara itr harrshyrnsds Mat ma sodas,.described on cue 1 V been ntertilatzeett yai�r+worn-void N ts4vrd a ctsnsks� in t rpdpos Cartiernta Stffs s MarshalCo* PA 7AS•. hdenmrrer$tabOrdaty Corwin,end NW*b rt to the SAei "stt or mimeo the faits/ROO Sperat 4.o rr Type,eciWend weight ofmalisilit 14 OZ.VMti1TE SLOCIOIDUr DeSatidan OfIteft O fOsst GEN&CIS 40140 2PC 1D 'r Flame Retardant Process Used Wi l Not B Removed By W shing And Is Effective For The Life Of The Fatet0 Snydrer Manufacturing,In ;40',4 r' , Varralocirevi at name....... getavdart♦(o-�f(Lazomes TINT( + 4.c.r.0 lagneopa a;...� • 40x60 tent 6 60" round tables 5 8' tables 8 high top tables EXIT 0 Stage 0 0 0 0 0 0 0 EXIT You are currently running an experimental version of Learn more Send few'' Earth. X 4. \ ---— a r l • p y ...._ ,. xd. u - x- e ® a 0 t Google Earth Imagery date: 10/6/... I 20 m Camera: 97 m 41'42'23"N 70'13'4... Clarke, Kristin From: JAPA (Jamie Pastiglione) <japa@novonordisk.com> Sent: Wednesday,August 3, 2022 9:25 AM To: Clarke, Kristin Cc: ryan@baysidetent.com; cheeseman.patrick@gmail.com; jamiepast@gmail.com' Subject: FW:444 Route 6A Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Hi Kristin, I am the homeowner and give permission to Ryan at Bayside Tents to obtain a permit for the tent. Please let me know if you need anything else. Best, RECEIVED Jamie Pastiglione -._..._.�_.._. AUG 03 2022 BUILDING DEPARTMENT Forwarded message By -- From: Clarke, Kristin<KClarke@yarmouth.ma.us> Date:Tue,Aug 2, 2022 at 3:15 PM Subject:444 Route 6A To: Ryan Gillis<rvan@baysidetent.com> Hi Ryan, Can you have the homeowner send me an email giving you permission to obtain a permit for their residence? Thank you, Kristin Clarke Office Assistant Building Department 508-398-2231 X 1261 1