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HomeMy WebLinkAboutBCOI-23-1761 2024 2 / a) Z Q \ \ 2 ¢ ^ a) a) / � 4- a) a / ® c r C) cc / \ / 3 / $ = .I. ƒ R k II ae \ j \ C ) . O 2 e 0 2 0 = \ / 0 ) / 3 § z % % % % ? a — a a) a ¢ Cl c \ 3 0 0 & 0' rp f \ / q ° § ) \ 00 / o o 2 S ( m $ @ § , \ R o e 2k g - k ® c7 / ■ _ ■ r ® o . i\ k f � « � \ ƒ \ $ c � I � � k 203 2 k t .c k d \ , 2 L ul k / / 15 \ ( 2_ C 0 E oeE © 00 a) S / § O 01 k t a5 It \ < �. U ■ _ « % ° > � _ � ¥ � £ 2 � ° R © / \ E ] c » @ & n k k f co a "2 k § \ k / \ \ # k 3 . d a E Q = ■ o 2 \ a s = R 5 2 $ § \ 00 lo \ § \ k U . 10 = e e 0 0 0 o 2 7f2 m22 ® * 2 , 2 I- 2 2 o E # E o $ \ \ \ } \ ƒ/ c >a 2 _a as c / . d a) -0 /e§ @- m 2 'a -D 2 a) / .6 ƒ �ƒ 0 3 / I ) § / . = 0 a) o -0 < \ a a) ) @ .- / k ) m 2 CD k / / . £ R : g % c 'a.") = = 2 / ° $ = \ a \ § Q 0 3c \ c S 2 � g 2 7 \ / ] % 2 2S ] » 00al 2 0 2 / ƒ $ % § * ^ k \ / c 'e fog- "' 01 'NG EPA _ , ,x A v,' 1146 Route 28, South li arntotith, MA 02664 11 -3 1'-2 3 7.. EIvED APPLICATION FOR CERTIFICATE OF INSPECTION 1 OCT 0 2 2023 September 1, 2023 PAYABLE UPON RE flullitANG DEPARTMENT (X) Fee ( ) 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: II VD P� '1 SW" :....Av Name of Premises: (cif r-l*,(1): ).--"Ilit Tel: 121/. S ' )4 72 Purpose for which permit is used: .es License(s) or Permit(s) required for the premises by other governmental agencies: I .;7 License or Permit Agency l0 r e e : Certificate to be 'ssued ;, vL ea AtAddress: II ill ,�!i111L AA flit' 0 73 Owner of Record of Buildin: rAf . Address I iAiiil y n Il M �!• ii Present Holder of Certificate . . P. It�A; 1 61Vrir---------s i natur o rson to whom Title Certifica is sued or his agent Date Email Address: see I� oeAvi3OM f Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth,MA 02664 Return this application to: Building Inspector's Office for each Please note: Application form with accompanying fee must be submitted d be ore the certificate will be ssuedn The building official shall uildig or structure or part thereof to be certified. Application must be receive be notified within ten (10) days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION CANE OF INSPECTION. INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR CEP Certificate of Inspection# h b 12/31/2023-12/31/2024 �..1140 ROURTOP-01 ALLCOI ACOREP DATE(MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 9/11/2023 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). CONTACT PRODUCER NAME: Salem Five Insurance Services,LLC PHONE 781 933-3100 I FAX No):(781)933-9048 445 Main Street (A/C,No,Ext):( ) Woburn,MA 01801 ADDR E-MAILESS:insurance.services@salemfive.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Central Mutual 20230 INSURED INSURER B: Rourke's Top Of The Cove LLC INSURER C: 183 Main Street INSURER D: West Yarmouth,MA 02673 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THE INSURED NAMED ABOVE FOR THE PE ITHIS IS TO CERTIFY THAT THE NDICATED. NOTWITHSTANDING POLICIES Y R QUUIREMENTT,, TERM STED OR CONDITION OF ANY CONTRACBELOW HAVE BEEN ISSUED TT OR OTHER DOCUMENT WITH RESPECT TOLW ICY ICHR OS 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. ADDL SUBR POLICY EFF POLICY EXP LIMITS INSRLTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDD/YYYY) (MM/DD/YYYY) 1,000,000 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE X OCCUR CLP 8971494 4/7/2023 4/7/2024 ?ERa occur ence) $ 300,0005,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1'000'000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ General Aggregate $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ - ANY AUTO _ OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY _ AUTOS PROPERTY DAMAGE HIRED NON-OWNED (Per accident) $ _ AUTOS ONLY _ AUTOS ONLY 1,000,000 A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE CXS 8971495 4/7/2023 4/7/2024 AGGREGATE $ 1,000,000 DED X RETENTION$ 0 PER OTH- $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y/N E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE N I A OFFICER/MEMBERt EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ !f yes,describe under E.L.DISEASE-FOLLY LIMIT $ 550,000 DESCRIPTION OF OPERATIONS below 4/7/2023 4/7/2024 Blanket Coverage A Property CLP 8971494 A Liquor Liability CLP 8971494 4/7/2023 4/7/2024 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 Rourke's Top of The Cove LLC ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ) 88-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AC IC) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/1'YYY) (ir....►�, 09/18/2023 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 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 00509-001 CONTACT Scott Duplissis—RG Baldwin Krystyn Sherman Partners LLC dba RogersGray Inc, RogersGray Inc PHOONNE.EXt): (800)553-1801 FAX No.: 410 University Ave. ADDRESS: mail@rogersgray.com Westwood, MA 02090 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Associated Employers Insurance Company 11104 INSURED INSURER B: Rourkes Top Of The Cove LLC INSURER C: 183 Route 28 INSURER D: West Yarmouth, MA 02673 INSURER E: INSURFR F' I 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. NOTVNTHSTANDING 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. ILTR NSR TYPE OF INSURANCE IANSRSWVD• POLICY NUMBER !(MM/DDNYYI� (MMIDD/WYY) LIMITS GENERAL LIABILITY ! EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 'PREMISES(Ea occurrence) CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG $ � POLICY PRO- JECT LOC I AUTOMOBILE LIABILITY !COMBINED SINGLE LIMIT $ I (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS II'BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED ',, PROPERTY DAMAGE $ AUTOS , I(Per accident) UMBRELLA LIAB OCCUR ! I •EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE ' AGGREGATE $ DED RETENTION $ $ yypR{K�EERRgs poMM gq77��pNN I WC STATU OTH- ANNyD ERMpPLROIY YR IIARB7ILIETRY/E� X i TORY LIMITS ER A OFFICER/MEMBER EXCLUDED?ECUTIVE YN" N/A WCC-500-5024258-2023A 4/7/2023 4/7/2024 E.L.EACH ACCIDENT $ 100,000.00 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00 If es describe under E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS below _ _ , DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) "Proof of Coverage" Worker's Compensation Coverage Applies to Massachusetts Employees Only Kathryn Gianno is covered by the workers compensation policy. CERTIFICATE HOLDER CANCELLATION Rourkes Top Of The Cove LLC 183 Route 28 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE West Yarmouth,MA 02673 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD