HomeMy WebLinkAboutBCOI-23-1768 2024 a
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:.L 9 1.:14 o to 28, South a m �outh, � 12664 508-398-2231 ext. :1261
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: ±K mak n Wet-i
Name of Premises: Rk- % gkte...k-ck S Lt bk`Decilky's_t r s h Tel: h(r�- 9 7 l- S c---
1Pr1M hAn -
Purpose for which permit is used: RA.i 15-z;-vi LQ ft e5..jta.,,r -t
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency RECEIVED
OCT 05 2023
BBANOretrbs,
Certificate to be issued to &A11.i, j,, ,,v, IRic. l-kk4,2_ Tel:
Address:5b;c raw, S- ,
Owner of Record of Building t,,,iky rri . }RR a 4-c- - t.(S-C
Address i 3 S.- \ .r1 Sk ,,Lt.. LA,SA MvtAZ1, rn A Ca-LP ]-3
Present Holder of Certificate 5tc-Llty+S ,.,s h pilt 1-4evt,<L)
Signature of person to whom Title
Certificate is issued or his agent
Date
Email Address: C_K'11"1rt C yl 1, Cb:[Y\
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 CANN T ISSUE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection# br&3--/-7to'
12/31/2023-12/31/2024 b
AC /iC�Cr
�.-- CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/OD/YYYY)
3
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
CON IACI
NAME:
World Insurance Associates LLC
34 Main Street PHONE
E-MAIL
o, ): 508-771-8381 I rt,No): 508-771-0663
West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@
gmail.com
INSURER(S)AFFORDING COVERAGE
NAIC#
INSURED INSURER A: Indian Harbor
RED FACE JACK'S INC D/B/A/SCALLY'S IRISH ALE INSURERC: GUARD
INSURER 585 ROUTE 28
WEST YARMOUTH,MA 02673 INSURER D
INSURER E:
COVERAGES INSURER F:
CERTIFICATE NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED BOVOEnFORMBER: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 .(ASH
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POUCY EFF POUCY EXP
(M
X COMMERCIAL GENERAL UABIUTY MlDDn YYY) (MM/DDIYYYY) LIMITS
I CLAIMS MADE I XI OCCUR DAMAEACH OCURRECE CU RRNNEU $ 1,000,000
PREMISES(Fa occurrence) $ 100,000
A ESG0064047 MED EXP(Any one person) $ 5,000
GEN'L AGGREGATE LIMIT APPLIES PER: 08/12/23 08/12/24 PERSONAL 8 ADV INJURY $ 1,000,000
POLICY n JECOT I I LOC GENERAL AGGREGATE $ 2,000,000
OTHER. PRODUCTS-COMP/OP AGG $ 2,000,000
AUTOMOBILE UABIUTY $
ANY AUTO COMBINED SINGLE LIMIT $
(Ea accident)
OWNED SCHEDULED BODILY INJURY(Per person) $
AUTOS ONLY AUTOS
■ HIRED NON-OWNED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE
Per accident $
UMBRELLA UAB $
OCCUR
EXCESS UAB CLAIMS-MADE EACH OCCURRENCE $
DED RETENTION$ AGGREGATE $
WORKERS COMPENSATION
PR OTH-
AND EMPLOYERS'UABIUTY
Y/N S $
ANYPROPRIETOR/PARTNER/EXECUTIVETATUTE ER
5 OFFICER/MEMBER EXCLUDED? I I n i q
(Mandatory in NH) REWG 159386 06/19/23 06/19/24 E.L.EACH ACCIDENT S 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below
(MandyEL DISEASE-EA EMPLOYE: $ 100,000
E.L DISEASE-POLICY LIMIT $ 5,000,000
I III
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
OUTSIDE DINING IS ALLOWED UNDER THE GL
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 RTE 28
SOUTH YARMOUTH MA 02664
AUTHORIZED R=p- -
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
ACORD CORPORATION. All rights reserved.