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" A z �l. 1146 Route 28, South lt armouth, MA 02664 508-398-223,Lext- :1.260
REcEIV �.� D
APPLICATION FOR CERTIFICATE OF INSPECTION . [ Nov 0 8 202
September 1, 2023 PAYABLE UPON RECEIPT ,_..,..
�'�. C EPARTMENT
(X) Fee Required;, ) M1.0O
( ) 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 telow-named premises located at the following address: //
Street and Number:/5? ‘,4-
1 ��� fr a d-�
Name of Premises: �' ;t L 1 f SC. _ _ (S I Tel: (a 4 ��5 a-4-.
Purpose for which permit is used: E: 7/4 A)7 ,
License(s) or Permit(s)required for thepremises q by other governmental agencies: �r
License or Permit Agency" 0 '71/— 9q 1/—Nci j
Certificate to be issue t kilI - Tel:
Address: /�,-� G Q arms d a f--_ 4,k9
r5 �lp� �a'�
„el1r pirlt
of Record of ilding v ' t ��� -J
Address t '.7-'K 4 Pkf py/-4 Dr e
Present Holder of Certi icate t �' 7S- 1°
ignature •
person to whom - � lllir/�
o Title
Certificate is issued or his agent
(90
Date
Email Address:a/0/4 IL/4, /4na4•4, er 6/91 CC S e V/ e._--&
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# / 17/- 3__/7'/
12/31/2023-12/31/2024
4c�® CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY)
��
00/29/2023
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 NAME: Automatic Data Processing Insurance Agency, Inc.
Automatic Data Processing Insurance Agency, Inc. PHONE 1-800-524-7024 1 FAx
_(AA/C No EM): A/C,No)
E-MAIL 1
1 Adp Boulevard ADDRESS:
Roseland INSURER(S)AFFORDING COVERAGE NAIL#
NJ 07068 INSURER A: Employers Preferred Insurance Company
10346
INSURED
Inaho Japanese House - - -
INSURER B
INSURER C: - - -----
DBA:Inaho Japanese House
INSURER D:
157 Route 6a — - -
--
INSURER E
Yarmouth Port MA 026751713 - - - - -
INSURER F
COVERAGES
CERTIFICATE NUMBER: 2939866 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 I __ _—___. —.—.--_—.—_.. -- rSUBR' _
LTR
INSD T— f IT
TYPE OF INSURANCE POLICY EFF? POLICY EXP WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
COMMERCIAL GENERAL LIABILITY I
CLAIMS-MADE EACH OCCURRENCE $
OCCUR DAMAGE I O HEN I ED
PREMISES(Ea occurrence) $
- - - - MED EXP(Any one person) $
I
PERSONAL&ADV INJURY $
' GEN'L AGGREGATE LIMIT APPLIES PER.
POLICY PE L LOC GENERAL AGGREGATE
I OTHER.
PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY $
COMBINED SINGLE LIMIT $
ANY AUTO Ea accident)
BODILY INJURY $
OWNED SCHEDULED person)
AUTOS ONLY AUTOS
HIRED NON-OWNED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE I $
_(Pr accident)--
EXCESS LIAB $
f UMBRELLA LIAB 1 OCCUR EACH OCCURRENCE $
CLAIMS MADE
DED I LAGGREGATE $
IANYPROP ARETENTION
AND EMPLOYERS'COMPENSATION J_$-------
WORKERS
LITY
A OFFICER/MEMBR EXCLUDED? N N/A N EIG248569606 05/02/2023 PER oTH-
PROPRIETOR/PARTNER/EXECUTIVE
Y/N ELI STATUTE ER
EACH ACCIDENT 1,000,000
I(Mandatory in NH) OS/02/2024 - $
If yes,describe under ' E L DISEASE EA EMPLOYEE $ 1,000,000
I DESCRIPTION OF OPERATIONS belowI--- - - --- i_.
i E.L.DISEASE-POLICY LIMIT. $ 1,000,000
I 1
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)p gwred)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
INSURED COPY
AUTHORIZED REPRESENTATIVE
0-
ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD