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I . 0 DEPA ' .. -' �s'= =t� 9 1146 Route 28, South Yarmouth, MA 02664 50 -39 -2231 ext, 1260 APPLICATION FOR CERTIFICATE OF INSPECTION \/19 Q September 1, 2023 PAYABLE UPON RECEIPT ,\ . (X) Fee Required$100.00 ( ) 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: �/r ; Street and Number: ' Name of Premises: (rill 6,1- 'J3-s> (,trsW Tel Purpose for which permit is used: ris{-e,) 1.,.4‘id `L LJCr 5g\1 License(s) or Permit(s)required for the premises by other gornmental agencies: " 1 License or Permit Agency OCT 2 3 2023 a L1r .; v- L,a[a..1 r 104 4 - By Will Certificate tocseL"ss�uo �,e ,,, a, (5,"S S , ,,L't;,r Tel: - -� _ 14 50 �� Address: �rr eNr• viz. fief (N1,na A.r cx -� ., Owner of Record of Building r'L,,,s k of 44 l,. , Address 1+-v, b - ...i ,Set,1�,I ii�c ,,-(1► PM 6"aut�y Present Holder f Certificate Z 1r63,0 Ari-+ f Signatur f person to whom Title Certifica e is issued or his agent 1 1 0 l i 1 ,3 Date Email Address: `\L; e L :sp i bt i' •COS 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 abrve information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CAN OT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# L� )3,__/7F. 12/31/2023-12/31/2024 CHEZHOS-01 AMCCORMACK •a►�o�RL7 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDmYY) 10/20/2023 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 Haberman Insurance NAME: --. - - _ PHONE 95 Ashley Ave (ac,No,Ezt):(413)781-7000 FAX FAX No):(413)733-9545 West Springfield,MA 01089 E-MAIL info h ADDRESS; abermanmsurance.Com INSURER(S1AFFORDING COVERAGE NAIC# INSURER A:Sentinel Insurance Company_ 11000 INSURED _. -. - -- - INSURER B: Chez Hospitality LLC INSURER C: PO Box 498 — East Windsor,CT 06088 )NsuRER D 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 LTR TYPE OF INSURANCE ADDL SUBR{ POLICY NUMBER POLICY EFF POLICY EXP - - -- - - - - - INSD wVD (MM/DD/YYYY1 (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED - - - - ---- - PREMISES(Ea occurrence) $ MED EXP(Ajy oneperson) $-.--- PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY -_ JEC PRODUCTS-COMP/OP AGG $ -- - - - -- OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _(Eaaccident) $ ANY AUTO OWNED _ SCHEDULED BODILY INJURYjper person $. __-_AUTOS ONLY _ AUTOS - --- -- - -- HIRED BODILY I Per accident) $ NON-OWNED PROPERTYTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB — - ---- - -- CLAIMS-MADE -- - - --- AGGREGATE DED RETENTION$ --- - -$ -- - A WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY �,/N _X STATUTE ' ERH _ ANY PROPRIETOR/PARTNER/EXECUTIVE —- 08WECAL1FGD 3/29/2023 3/29/2024 - _ OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT 500,000 (Mandatory in NH) -Y N/A, $ If yes,describe under E.L.DISEASE-EA EMPLOYEE $ _ ___ 500,000 DESCRIPTION OF OPERATIONS below - 500'000 E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Marc Sparks is excluded from workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The Grille at Bass River THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 62 Highbank Road ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) The ACORD name and logo are registered marrks9ofACORDCORD CORPORATION. All rights reserved. AC R CHEZHOS-01 AMCCORMACK 4........ � CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD/YYYY) 10/20/2023 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 Haberman Insurance . NAME:._ ..—__. PHONE shley Ave (A/c,No,Est): (413)781-7000 FAX West Springfield,MA 01089 E-MAIL ADDRESS: (a/c,No).(413)733-9545 Info@habermaninsurance.com INSURERS AFFORDING COVERAGE_ INSURER A:Sentinel Insurance Com INSURED — — — — — — pan Y 1.1000 INSURER B:Ch -- - — ez Hospitality LLC PO Box 498 INSURER C East Windsor,CT 06088 INSURER D INSURER E: -- - _--- INSURER F COVERAGES CERTIFICATE NUMBER: BER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMOED N N ABOVEn 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 — — ----- LTR TYPE OF INSURANCE ADDL SUBR. POLICY EFF POLICY EXP INSD WVD POLICY NUMBER IMM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED -- — - --- PREMISES(Ea occurrencej $ MED EXP_LAny one_erson)_ $ PERSONAL&ADV INJURY $GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PE� LOC GENERAL AGGREGATE . PRODUCTS-COMP/OP AGG $ OTHER: ---- AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT ANY AUTO _ a accidentl. $ OWNED AUTOS ONLY SCHEDULED BODILY INJUR perp_ersorj1 $ AUTOS ---- — --- HIRED NON-OWNED BODILY INJURY(Per accident AUTOS ONLY .AUTOS ONLY PROPERTY DAMAGE -- -$ ------ _Ter accidentL $ UMBRELLA LIAR OCCUR $ EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $ $ DED RETENTION$ ,_AGGREGATE A WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY X PER OTH- ANYPROPRIETOR/PARTNER/EXECUTIVE Y/_N 08WECALIFGD 3/29/2023 3/29/2024 STATUTE ER (Manda(MaOFFICER/Mndatory in ER EXCLUDED? Y N/A E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE'$ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Marc Sparks is excluded from workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE —. ,'" ACORD 25(2016/03) /.{ 988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD