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HomeMy WebLinkAboutBCOI-23-1767 2024 1146 Route 28, South If armouch, MA 02664 508-398-2231 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: 33" fnCL Name of Premises: l:11GiCit S d kx. c-4,11\ Tel: '5(.i '' r77/-51 S71 Purpose for which permit is used: M,i 1 ‘ .C 1 R.yti.ae-Ajt License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency RECEIVED Tel: i -»I— OCT 05 2023 Certificate to be issued to �U1r n1kwfin 1�e-��� � SI S Address: �� V�D 1n ZjP(.„2t BUILDING DEPARTMENT Owner of Record of Building) (% —Tr NA-A.A. By. Address Y1 Present Holder of Certificate Lja( Y‘ V Qtti;,yQ��-�- Signature of p o whom Title Certificate is issued or his agent 9'A/O3 Date Email Address: C.,L1 \1 �� C 0)(1.J' . CC.%^t`rl 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# 7., /0(07 12/31/2023-12/31/2024 Awn CERTIFICATE OF LIABILITY INSURANCE DATE( YYYY) ��- 09/28/228/23 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: WORLD INSURANCE ASSOCIATES LLC (P,gHON Exti. 508-771-8381 FAX No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAM# INSURER A: AIM MUTUAL INSURED INSURER B: CAP SPECIALTY KOUNADIS ENTERPRISES D/B/A THE YARMOUTH HOUSE INSURER C: 335 MAIN ST INSURER D: WEST YARMOUTH,MA 02673 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 ADDLEUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL UABILJTY EACH OCCURRENCE $ 1,000,000 DAMARENTED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 B CSI800192502 04/10/23 04/10/24 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABIUTY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EL EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? N I A WCC5005022314 06/08/23 06108/24 (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 PER OCCURENCE 1,000,000 LIQUOR LIABILITY B BR20220502 04/01/23 04/01/24 GENERAL AGGREGF 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) OUTSIDE DINING IS ALLOWED PER GL POLICY 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. SOUTH YARMOUTH MA 02664 AUTHORIZED ROP Ey NTAT1VE l 1 ./©1988-2015 ACORD CORPORATION. All rights reserved. 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