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HomeMy WebLinkAboutBCOI-23-1753- \ uU U / N — ® c „ . k b k ° e m § ° & o = £ 2 0 o ff / / � i if \ § _ = I07 £ a 6r / / Sa/5.-6•C - 2R ƒ Zi o » o 0 0 2 § k / r a 0 t 2 = = co c k E 2 / / 729 / ® / / _c / \ # ƒ E22 & '5n5 ® f \ / 2 C L. J � \ ) \ k �\ � 2 ) HU \ § I ƒ £ a D / § k■ E r \ / 0 cb t a) \ in. al « U) a_ o " < — 2 ° 0 � � � < 2 Ifi . ° � 2 $ / � Q ) 6 ® V ( � 1. � I k � � n \ \ � � k k k 7 v £ § \ _ \ § >- » $ Z ) \ E / 2 E / /_ \ \ � �( / / / \ co cl. c 0 . C § coE / kk0 § ■ \ k ¥ J 0 \ / \/ ■ m 0 ) 2 flu _ ° _ F % zoe/ / 0 / $ U �i \ + _ _ CO d C RR " @ - 8 § 2 S f u .. % o = '2 = ^ r / \ \ \ ƒ / / ) 'NNt % LLG c = § > \ . Cl) 2 e i� . / Pi) g Cl) it @ - 7 3 2 § / 2 e / 2 g % c } \ = 2 ■ § o - o = \ 2 G o \ 7 \ j S 2 0 g w \ \ . .e % @ k S 25 2 f ® 2 % \ \ \ © \ J i_ E / c ° ® =3 _ a) z mo ;6, f BUILDING DEPA T, ENT AT ?°` 1146 Route 28, South Yarmouth, MA 02664 50 -398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION September 1, 2023 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) 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: kutih j f,� v -j R E C E I V F 0 Name of Premises: ( PoY, 5 �'v._f Tel: - y - SEP�f2o 2023 Purpose for which permit is used: ji10 ,A,a 7/-( g Pti/hl> 8;,;,d,1 L►1 ) License(s) or Permit(s) required for the premises by other governmental agencies: BUILDING DPgfiMNY By License or Permit Agency J • 4.1z;1:: 10/ 1914 Certificate to be issued to �tu,�{�j /0.. Q5Jey,� �e-a. LcC. P&4 Tel: Soe -axle,-3,9341 $At Address: 2 { t - 0 Owner of Record of Building ) '-d C �an✓►u.- Address i) Lone ( t,,,wo!)ri,, Pee,-1M/3 69107S Present Holder of Certificate L tort tl �:—,(1 a.�14✓ / -,�,�d- r i�r �� ma;et) °(01(11-A 01A3v),e,/ gel/ cleft' Signature of person to whom Title Certificate is issued or his agent 91(o/ ?6?3 Date Email Address' 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# (3CD /7 12/31/2023-12/31/2024 �1 DATE AC�o® CERTIFICATE OF LIABILITY INSURANCE 02/24/2023 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: Megan Wright Wright Insurance Agency PHONE FAX (A/C.No.Exo: (508)619-3586 (Am,No): (508)619-3847 23 Whites Path Unit G2 E-MAIL ADDRESS: megan@wrightinsagency.com INSURER(S)AFFORDING COVERAGE NAIC# South Yarmouth MA 02664 INSURERA: ASSOCIATED INDUSTRIES OF MA MUT INS 33758 INSURED INSURER B: Osteria Mota LLC(Leonessa Restaurant) INSURER C: 43 Route 6A INSURER D: INSURER E: Yarmouth Port MA 02675 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (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 $ PRO- POLICY PRO- P 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 PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? y N/A WCC-500-5028208-2023A 01/02/2023 01/02/2024 (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE LOr kjht ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD