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1146 Route 28, South A arnnouth MA 02664 508-398-2231 ext. 1260
A V'ts� IFICATE OF INSPECTION
September 1, 2023 PAYABLE UPON RECEIPT
SEP 25 2023
(X) Fee Requir d $150.00
BUILDING DEPARTMENT ( ) No Fee Require
In accordance with the provision a assac usetts 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: 1 k)Pk 0--C
Name of Premises: Sk, I 15 Tel: JU A
Purpose for which permit is used: r ra}`.i v(t of"
License(s) or Permit(s)required for the premises by other governmental agencies: 90 �- Z.
License or Permit m
Agency y;
1019-
10 '
Certificate to be issued to f - rn, L L C Tel: ,52)&13 q -f --
Address: PO 6-y 3'16 S (1 V 1'�CL-efi
Owner of Record of Building0 h 6�/ 1 ,
$U Vv� CI hQV-t'
Address I Ni 10t-tv�Z° Li ri � ` e
Present Holder of Certificate S IC(9 L ���
r
Signature of person to whom
Certificate is issued or his agent Title
Date
Email Address: S eC_,Shu Co c o It [ (iv)
Instructions: Make check payable to: Town of Yarmouth
1146 Route 28, South Yarmouth, MA 02664
Return this application to:
Building Inspectors 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 be`ore 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# PAL)
12/31/2023-12/31/2024
i CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY)
05/01/2023
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 SUBROGATIONIS 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
THE OCEANSIDE INSURANCE GROUP CONTACT NAME:
08084400 PHONE (508)771-1660 FAX
PO BOX 38 (A/C,No,Ext): j(A/C,No):
WEST DENNIS MA 02670 E-MAIL ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A: Hartford Accident and Indemnity Company 22357
INSURED
INSURER B:
SKP1M,LLC.,731 MAIN STREET LLC,277 S.SHORE INSURER C:
DRIVE LLC DBA SKIPPY'S PIER 1
PO BOX 370 INSURER D:
SOUTH YARMOUTH MA 02664-0370 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 ADDL SUER
LTR W POLICY EFF POLICY EXP
TYPE OF INSURANCE POLICY NUMBER
INSR VD (MMIDD/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:
POLICY PRO- I ILOC GENERAL AGGREGATE
JECT PRODUCTS-COMP/OP AGG
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident)
ALL OWNED SCHEDULED BODILY INJURY(Per person)
HIREDS AUTOS BODILY INJURY(Per accident)
AUTO
NON-OWNED
AUTOS AUTOS PROPERTY DAMAGE
(Per accident)
_ OCCUR
UMBRELLA LIAB
EXCESS LIAB CLAIMS- EACH OCCURRENCE
MADE AGGREGATE
DEDI (RETENTION$
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY X (SPER
TATUTE I I ORTH-
ANY Y/N
A PROPRIETOR/PARTNER/EXECUTIVE — E.L.EACH ACCIDENT $1,000,000
W
OFFICER/MEMBER EXCLUDED? A 08 WEC AD1A4A 05/30/2023 05/30/2024
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Those usual to the Insured's Operations.
CERTIFICATE HOLDER
Town of Yarmouth CANCELLATION
1146 ROUTE 28 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
S YARMOUTH MA 02664 IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
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ACORD 25(2016/03) The ACORD name and logo are registered marks15 ACORD CORPORATION.All rights reserved.
of ACORD