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-�, 1146 Route 28, South Yarmouth, �M: 02664 508-39 -22 ) 6E E V F D
APPLICATION FOR CERTIFICATE OF INSPECTION NOV 1023
BUILDING DEPARTMENT
September 1, 2023
PAYABLE UPON RECE --
(X) Fee Required$100.00
( ) 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: qO 1 I f Zg
Name of Premises: erairdis Tel: 6o — ,gg J`"
Purpose for which permit is used:
License(s) or Permit(s)required for the premises by other governmental agencies:
i n.S-(2
License or Permit Agency lA
(P
( erd i $ a4e
Certificate to be issued to G Tel: 50g 771 0/2, 0-i \A\��
NPAddress:
Owner of Record of Build' g �� ��
Address 8 q 1' d- ir ri._ dZl103/ (,�Q�
Present Holder of Certificate �,e f cas rar- "J
lip-
CU
airrr-e of pers. to ho Title
Ce icate is ':'ued or ','s agent I 111123
Date1 II CCJ1
Email Address: ,,j 9P KUV 9 c� b I' tC )
Instructions: Make check payable to: Town of Yarmouth
1146 Ror;te 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 abc've 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# ea)/- --/7s-e---
12/31/2023-12/31/2024
• GERACAF-01 PAN
4114....... — CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
10/30/2023
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).
PRODUCER
( CONTACT
Kaplansky Insurance NAME:
PO Box 2743 I PHONE FAX
(A/C,No,Ext):(508)255-7880
8 Main Stac,No):(508)240-2908
Orleans,MA 02663 E-MAILa SS:info@kaplansky.com
INSURER(S)AFFORDING COVERAGE I NAIL B
INSURER A:The Hartford 111000
INSURED I INSURER B:Markel Insurance Companies Gerardi's Cafe Inc dba Gerardi s Café &Diego&Sasha I 38970
Gerardi I INSURER C:
902 Rte 28 I INSURER D:
South Yarmouth,MA 02664 ! INSURER E
I 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 IADDLISUBR'
LTR TYPE OF INSURANCE INSD i WVD I POLICY NUMBER POLICY EFF POLICY EXP
A ,(MM/DD/YYYYI (MM/DO/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE X OCCUR EACH OCCURRENCE $ 1,000,000
I
08SBAAS6K9F 6/19/2023 6/19/2024 DRAMA SESO( REoNT D nce) I$ 2,000,000
I
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY I$ 1,000,000
GENT AGGREGATE LIMIT APPLIES PER: 2,000 000
X POLICY JPE CT LOC GENERAL AGGREGATE $ e
PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER:
AUTOMOBILE LIABILITY $
COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
OWNED I SCHEDULED BODILY INJURY(Per person) $
AUTOS ONLY I AUTOS
HIRED NON-OWNED BODILY INJURY(Per accident) $
AUTOS ONLY 1. ___ AUTOS ONLY PROPERTY DAMAGE
(Per accident) $
UMBRELLA LIAR OCCUR $
EXCESS LIAB EACH OCCURRENCE $
CLAIMS-AADE
DED I RETENTION$ AGGREGATE $
B WORKERS COMPENSATION I $
AND EMPLOYERSLIABILITYX STATUTEI ERH ANY PROPRIETOR/PARTNER/EXECUTIVE IY!N MWCO213340-01 6/19/2023 6/19/2024
(MandaOFFICEtory
in ER EXCLUDED? I N N/A E.L.EACH ACCIDENT $ 500,000
(Mandatory in NH)
tf yes,describe under E.L DISEASE-EA EMPLOYEE $ 500,000
DESCRIPTION OF OPERATIONS below
A LIQUOR LIABILITY 08SBAAS6K9F 6/19/2023 E.L.DISEASE-POLICY LIMIT I$ 500,000
: 6/19/2024 Each Common Cause 1,000,000
A LIQUOR LIABILITY 08SBAAS6K9F 16/19/2023 6/19/2024 Ag
gregate 2,000,000
I II
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if mores space is I
Hired auto and non-owned auto is included per form SL 3026 1018. Pa required)
LOC 1,BLDG 1 902 ROUTE 28 SOUTH YARMOUTH,MA 02664
Business Personal Property limit:$82,500
Building limit:$730,400
Property Deductible:$1,000 All Other Perils Deductible with 2%Deductible for Windstorm or Hail
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
Yarmouth Town Hall-Liquor Licensing Dept. ACCORDANCE WITH THE POLICY PROVISIONS.
1146 Massachusetts 28
South Yarmouth,MA 02664
AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03)
A
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