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HomeMy WebLinkAboutBCOI-23-1766 2024 2 § c 0 d O \ \ 7/ n m ° / o W \ 2 \ •c 7 d J k § kf a) a Q k S \ N \ ® -c ) § 4 / \ 62 k ¥ / , �a /c off a) c_) § m § .0 _= O � % @ co c [ \ a - - ± E % k k � c , CO 2 2 ƒ \ \ - a ol / � \ � § \ \ d d 2 §4.0 -■ ©■= ihi U C e® % / Et ■ a32a) < � E1i _ o = C 0 F � \ � \ D - f a) . 2 cc @ \ e I & \ £ a% ■ O < o 2 § E ■ % < & \ % Z E § , 2 I I- q f � R 7 o ■ 2 2 0 0 b a f 2 \ 2 _ v o c m / d � k � \ � kb / / k \ CO C. � 2 \ CO , 22 \ / % k5 e • . c E 0. , a c Z 0 o \ \ \ \ E o k = \ \ }\ i co a / 7 � f Pik S k ) / V _ "a q $ a) $ § § § 07 R o E 2c ' : m U. 2 = a) n k7 2 E ¥ / § '� $ = E G / § > \ c 2 � \ § \ z \ 5 2 g $ Cr ) 3 I % c m % E c m e / a F ° m LE 2 ° � � k $ 3 ° a)o 0 O. $ \ \ k \ o -I 2 % 2 $ tf \ 44 » : \ 2 ° kf \ q = « ® § \ ) 7 £ C ) ! v.5y y ,a T W ; 'VA MOUT }� 1 M R t o •^ S[�� . 1146 Route 28, South a ° gout , NIA 02664 508- 9 -2231 ext. 1260 id /;. gill 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 -plocated at the following address: Street and Number: 1\ YivA !r1 S 1►�t t.l Name of Premises: t'(4)71r, 311C Cr 10.l i pr Tel: 7 I ' 7 77 Purpose for which permit is used: ckt\ st..A. -tAi.C .u..i..'t License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency RECEIVED OCT[ jiJ05 BUILDING DEPARTMENT Certificate to be issued to Pi pa(m c` Tel: ,- i 71- 7 7 7 k Address: r-lc C Sji � Owner of Record of Building---0S —FtA b► Address '=5i Present Holder of Certificate l par i / V P ►.� Signature Iris MirrwholS Title Certificate is issued or his agent t3 ,_,/� Date l�'v� • Email Address: ei T 1\� CCW171 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# /. '.p/— a 3_ /7Z.,� 12/31/2023-12/31/2024 11 I Accwri CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �.� 09/28/23 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 (a/cNr o ); 508-771$381 FAX No): 508-771-0663 34 Main Street EMAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance©gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: GUARD INSURED INSURER B: TWIN CITY CALAMARI INC INSURER C 175 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. INSRL TYPE OF INSURANCE ADDLSUBW POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DDMfYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 1 0 RENTED CLAIMS-MADE X OCCUR PREMISES(Ea rvnurence) $ 100,000 MED EXP(Any one person) $ 5,000 B 84 SBA BD 5981 11/27/22 11/27/23 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 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 0TH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTE Y/N IV E.L EACH ACCIDENT $ 560,000 A OFFICER/MEMBER EXCLUDED? N/A CAWC158929 06/01/23 06/01/24 -- -- (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 LIQUOR LIABILITY PER OCCURENCE 1,000,000 B 84 SBA BD 5981 11/27/22 11/27/23 GENL AGGREGATE 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 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 RI#P ESENTAT1VE 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD