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_ 1146 Route 28, South am-tooth, MA02664 08-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
September 1, 2023 PAYABLE UPON RECEIPT
(X) Fee Requikki$150-
( ) 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: /3 vC M
`c . So - h Yarm0z'A
Name of Premises: Gra ay
PA9 0 S/ Tel: 508-0958 - C9 a 7a,
Purpose for which permit is used: f( "- /.L O 1(' I L e s
License(s) or Permit(s)required for the remises by other governmental agencies: RECEIVED
/ tT
License or Permit Agency OCT 1 8 2023
5-C -
B L I P %-.
-N'-11.
BY:-- ---
Certificate to be issued to 7 1-U rj 0 E p S 74 A Lr s Tel: .a8-e5270-.1-- 7
Address:
Owner of Record of Building S ?
Address /3f9 ,e IY SDLe itVarh-r o u M._
Present Holder of Certificate Sa. t,U1.-e. r4 `►
Signatu of person to whom Title
Certificate is issued or his agent _ /O / _ t 3
Date
Email Address: Pa fr.(a dot 4 5 "5-07a-d-
1i ce' S mot iI . Co 'v')
r0
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# ,g /a3-
12/31/2023-12/31/2024 /7 7�
AcoRL) CERTIFICATE OF LIABILITY INSURANCE
64,..r/ DATE(MM/DD/YYYY)
10/10/2023
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 Erica Barrett
OLDE CAPE COD INSURANCE AGENCY INC NAME:
PHONE
(A/C.No,Ext): (508)771-3300 I FAX
E-MAIL ericab (a/c,No):
300 WINTER ST ADDRESS: @occia.com
INSURER(S)AFFORDING COVERAGE NAIC#
HYANNIS MA 02601
INSURED INSURERA: AIM MUTUAL INS CO 33758
TATA INC INSURER B
INSURER C:
26 PINE GROVE AVENUE INSURER D:
HYANNIS INSURER E
MA 02601 INSURER F:
COVERAGES CERTIFICATE NUMBER: 938561
REVISION NU
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEBER: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
COMMERCIAL GENERAL LIABILITY (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
CLAIMS-MADE I I OCCUR EACH OCCURRENCE $
DAMAGE TO RENTED
PREMISES(Ea occurrence) $
N/A MED EXP(Any one person) $
GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $
POLICY I I JECOT I I LOC GENERAL AGGREGATE $
OTHER: PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY $
ANY AUTO
COMBINED SINGLE LIMIT
(Ea accident) $
OWNED SCHEDULED BODILY INJURY(Per person) $
AUTOS ONLY AUTOS N/A
HIRED NON-OWNED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE
(Per accident) $
UMBRELLA LIAB OCCUR $
EXCESS LIAB CLAIMS-MADE N/A EACH OCCURRENCE $
DED I I RETENTION$ AGGREGATE $
WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY V I PER OTH-
ANYPROPRIETOR/PARTNER/EXECUTIVE Y/NSTATUTE I ER
A OFFICER/MEMBEREXCLUDED? IN/AI N/A N/A VWC10060253242021A E.L.EACH ACCIDENT $ 100,000
(Mandatory in NH) 04/27/2021 04/27/2022
(yes,describe under E.L.DISEASE-EA EMPLOYEE $ 100,000
If DESCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT $ 500,000
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to
pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy
precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-
Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/.
CERTIFICATE HOLDER
CANCELLATION
THESHO ULD ANY OF EXPIRATIION THE DATEBVPOLICIESE DESCRIBED CANCELLED BEFORE
THEREOF, NOTICE WILL BE DELIVERED IN
Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS.
230 South Street
AUTHORIZED REPRESENTATIVE
HyannisTh, r r i
MA 02601 L..,'< >�--
Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA
1988-2015 ACORD 25(2016/03) The ACORD name and logo are registered mo arks of ACORD ORD CORPORATION. All rights reserved.