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HomeMy WebLinkAboutBCOI-23-1755- a a) O c') O a) N 10 ' In as O a) •0 O to N (n 2 r- k N Q O i C U U) N y a) cd 0. ,E. p E c a) 0 V: a) a) .p L_ V m a) N c C) L L 0 `O '00_ 0 -4: CO 7 4= U 0 C 0 CD CO U• 0 N c 7 O O O U_ O p Z _0 ) L Q U O 2 _C as c Cl) U U U o ° U c r • a) cz „i C co 2 2 L •c y 0 3 C U c a) 0 O c` 2 O_ N C \ 7 d CU ,i9 0 O .� 0 O y u) . °a..a C v 0CeC_ C �_ omit) i 4 N a) .0 V 0c., NE a) � a) -A 411 .0 N GM 0- ra- = O ch Q .7) Q '� -, ,w 0 C a1 U) a N. U C O CO E co ` IN O y 7- = co N w cd E-° ` ' _ _ cy- OM co wa'a w � ~ � � 1O C.) v. c6 O � O � u)3 � O � � O � g .c d aD w 36, dO z � } r2 • � '' a 3 I'U) Z ; a� � � '6 m � z O c c c � v >W = aic_ c�a _ E a1 O C > U L .. m a a1 0 'in ,- v rn o O O a _5 E ix r 00 7) 0 O 'C c 0 0 U 0 C 0 L c C C 0 C 03 O O N cB O M•vi ti 'C d O OOv aa)) E @E ~ Z ai c _ E E .cE U 4 a c L ZU tnU p Ca) U) - L. L u) C L CO L U C m a) c 0 't O CI) 8 cc_ LL .0.0 a) U 4 O a) U) O U U ▪ ~ (U) L a) LL O O L N J+ L Cl) u) -aQ c .- a) .c .O c c6 � O = - v0- c *- co w J N a) w Q a- a) E. �_ • co R L z `0 a) 7- _c aN O Oa) s m - a) a) co V .,— p U .V O c.) as a) cq O a Oa) w 0 •n 3 � — J 7 • a) '� 4 Ilit) c6 O` cc U 0 O M 0 N N E O • _ coOO 45 o Q ~ aci co co CD c4 CE c z tnC �`� . \t, r 44t--.),5.3) a $cz\�, ��, ,,,,:. iV !� D 1146 Route 2S € th ' 'a t-mouth, MA 026 4 ( - IS-22 .. r t SEP 2 2 2123 APPLICATION FOR CERTIFICATE OF INSPECTION BUILDING DEPARTMENT By: September 1, 2023 PAYABLE UPON REC (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: ---r4Street and Number: ‘ 6 ? ,e-` .2 1 /�4" i i f. k e S t ,4 le 0 d J Name of Premises: Cfl�7Ya ek (f4 'l 6'fr �5 ( u Tel: S ` -16 i - 17 6)Ci Purpose for which permit is used: 14 h.1 V h L 6P4N ,7 o f.,x 2 1" Ce i S k' k‘i License(s) or Permit(s) required for the premises by other governmental agencies: \P (111 License or Permit Agency ID. )-5 Certificate to be issued to V rie 41 c1 iq114 I r Tel: S 6 -3 6 q- 7° C� c)-\ Address: (?/ r�� r-I c--e< fie�e . so, ti eqe �,/, f 6'-/4 0,96 G e c/5)/ Owner of Record off Building Gc ,I tr(04 ry„,„ Address Present Holder of Certificate Signature of person to • Tit Certificate is issued or his ..ge q - .a - 07 3 Date Email Address: e�¢ f F h n i ' CO n, C!g S J" * () el— 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# e C 0/ 3--J�.Ss 12/31/2023-12/31/2024 0 A CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/22/2023 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 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). CONT PRODUCER NAMEACT Joseph Dupuis McShea Insurance Agency, Inc PHONE FAX (A/C.No.ExU; (508)420-9011 (A/c,No):(508)420-9010 1645 Falmouth Road, Rt 28 BLDG D ADDRESS: joe@mcsheainsurance.com Centerville, MA 02632 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: The Hartford Insurance Company 11000 INSURED INSURER B: NATIONAL GRANGE MUTUAL 14788 _ Captain Parkers Pub, Inc. INSURER C: The Hartford Insurance Company 22357 688 Route 28 INSURER D: West Yarmouth, MA 02673 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000413-0 REVISION NUMBER: 1 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 08SBANX5037 04/05/2023 04/05/2024 EACH OCCURRENCE $ 2,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY JEt° LOC - PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER. $ B AUTOMOBILE LIABILITY M1 T2388U 08/07/2023 08/07/2024 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) 1,000,000 _ BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) A X UMBRELLA LIAB X OCCUR 08SBANX5037 04/05/2023 04/05/2024 EACH OCCURRENCE $ 4,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 DED RETENTION S $ WORKERS COMPENSATION C' AND EMPLOYERS'LIABILITY YIN 08WECCM3443 04/01/2023 04/01/2024 X STATUTE OERH_ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A — (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICYLIMIT $ 1,000,000 A Liquor Liability 08SBANX5037 04/05/2023 04/05/2024 Per Occurrence 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Liquor Liability is included as part of the Commercial Package policy with The Hartford limit is$1,000,000 per occurrence/ $2,000,000 Aggregate Location Address: 688 Route 28 Yarmouth, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Buildung Department, Board of Health, Liquor ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth, MA 02664 ----- (JFD) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are re ' ered marks of ACORD Printed by JFD on 09/22/2023 at 02:45PM