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HomeMy WebLinkAboutBCOI-23-1763- ) o \ / \ $ 2 \ 7 \ a � a N § \ 111 / / II 2 k § k f C6 U = ) 0 f cc / / ) \ \ - 0k ¥ / -6, a \ k � c 3 $ o• � %Z t @ / G § E §2 a 2 % o \ / 0 § / 2c % % £ — & o a \ § k \ CD 3 a ` ® 6SQ Ch 0 o ) d \ ate\ 0 _ 2 ) ) 0 g 0 V) I ° _ s' ® ^ E -_ 0 LL- •iil c � 0 � / = ke DI \C CD % / 0 k Oo Cl) Oo \ $ \ — > 2t ■ m o t W £ 2 = ■ $ . _ s � § kc � k � \ d \ = J O t f 2 = \ k / E / ) © \ 2 cn 0 2 L , @ 3 k 5 e E ■ o $ / 2a So ° ot 03 f E d % w . o 3 = 0 . C 0 = q \ 2 \ \ 0 0 CO % 2 C) ] / O CD ■ / m qa � % $ ¢ \ I— a) - 2 E c e a E Z k § = k 00 . 0 o a i! z o 0 E >,/ / \ L 10 5 2 ) .- _ a) = tL- @ § Sf e / \ >a § ' co z5 = f / m 2 = ( E, 5 E cn= 2 f \ . \ CA § \ \ 2 0 R f cis q ° f I a $k / 2 D. / 0 % } . . 2 , 0 z \ \ k 2 / k \ c � = _ *C e - m as 2 e8 _ % 2 0 2 \ \ § o : ^ ■ E cy ¥ M � 4) E k} _ z in 421 1146 Route 28, South a -mouth, MA 02664 l - 22 1 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: (D 3 et; ATE Name of Premises: SONS OE E1210 CPr Co Tel: Kok 110 031i Purpose for which permit is used: (R,1 t Et License(s) or Permit(s)required for the premises by other governmental agencies: 1 RECEIVED License or Permit Agency OCT p Eki. - 1,kus 2023 BUILDING DEPARTMENT By Certificate to be issu d to S 5 Q a t t ) C E G Tel: - {0 y U 3 1 Address: 611 K.0( T E. 2-15, ES-rfre,,PtoucT 1 () C13 Owner of Record of Building , .& Oc E2.1, 1%e E Co \\ Address SA!'1' Present Holder of Certificate _�( l� J V- 1Re S (Aktle ign ture of person to whom Title Certi icate is issued or his agent l i 3 d i zwz Date Email Address:`-ttr` .C*.SU; 9413 s� �. "'c►.0.1�� C 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# 3CQ)- 12/31/2023-12/31/2024 '`� RII CERTIFICATE OF LIABILITY INSURANCE DATE'MM'DDITYYYI 10/4/2023 ( 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 end condlUons 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 endoreement(s), PRODUCER CONTACT Sullivan,Garrity&Donnelly PHONEE ._.^_..._ FAX 10 Institute Rd. (M �t Lo s 505-754-1767 1(ly re! 508-754 1885 ' Worcester MA 01609 A MAIL INSURERS)AFFORDING COVERAGE NAIC 9 INSURER A:Markel American Insurance Company 4 28932 INSURED SONSOFE-01 INSURER a:United,States Liability Insurance Company 25895 Sons of Erin Cape Cod Inc P 0 Box 403 INSURER C:Hospitality Mutual Insurance Company South Yarmouth MA 02664 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1398091658 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. VIER 11-TAESITIOrili—LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMPOLICY EFF T POLICyy EXP T lDD/YYYYI (MMlDO/YY YY) LIMBS B X I I COMMERCIAL GENERAL LIABILITY NPP1597755C 9/72023 i 9/72024 '',1 EACH OCCURRENCE I$1,000_000 ..._ —I CLAIMS-MADE I X OCCUR DAMAGE TO RENTED I PREMISES(Ea occurrence) $100.000 I i MED EXP An o ' (Any one person) f 5.000 PERSONAL&Any INJURY I$1,000,0041 GENL AGGREGATE LIMIT APPLIES PER: � t GENERAL AGGREGATE '$2,000,000 POLICY 7 2CT ' !LOC 7 PRODUCTS.COUP/OP AGO $2,000,000 {OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ I (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED ' 'l SCHEDULED I AUTOS _AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS (Per accident $ $ UMBRELLA U1B /OCCUR OCCURRENCE $ i� ; EXCESS LIAe EACH _ ... CLAIMS-MADE I DED RETENTIONS $ AGGREGATE ...... $ A WORKERS COMPENSATION AWC0016135-01 PER OTH- 2?2023 2/72024 AND EMPLOYERS'LIABILITY Y 1 N STATUTE ER ANY PROPRETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT 5 100,000 OFFICER/MEMBER EXCLUDED? I I N I A .__ (Mandatory In NH) I E.L.DISEASE-EA EMPLOYEE S 190,000 H yes,descrNla under I DESCRIPTION OF OPERATIONS below i E.L.DISEASE-POLICY LIMIT $500,000 B `Properly i NPP1597755C 9/7/2023 9/7/2024 Building 750,000 C Liquor j CPP2002911 9//2023 9/72024 BPP 100,000 Per Ocwrence 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Property Location-627 and 633 MA Route 28 West Yarmouth MA 02673 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth MA 02664 AUTHORIZED REPRESENTATIVE I 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD