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L LAG lE A ' T ENT 1146 -Route 28, South Yarmouth, MA 02664 08a398-22 1 Exc 1E6 V E D APPLICATION FOR CERTIFICATE OF INSPECTION SEP 13 2023 September 1, 2023 1"'"'�G DEPARTMENT 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: I(x(�,� RIX..k 3 _ Ye.1� f< Name of Premises: k�, ct,A .,nR� 1.-A AtAu S.12,0,\.,ke-Ari'el: Purpose for which permit is used: ._ v-D�' 'K o. ,s-k ,A 4- - License(s) or Permit(s) required for the premes by other governmental agencies: License or Permit Agency v\ Certificate to be issued to R" C\v\ ' w,, {- „ vvVeN-hel: CbS 7L( S(,L(� Address: I0L...> ,12-t� k--a-- C 5. \Aa',en,t, ` �, Owner of Record of Building &,,.,I ,,kA V Address (Ito W a. 4-i ., porn-t- 1 IM A--- 0 3- Sri 2 Present Holder of Certificate esA-cd� C 1,� , cbI; 9,2C 1 ty 0 PAIOAA*1)64, Signature of person to whom Title Certificate is issued or his agent (1 C 1 Z.12' Date Email Address: Pek r�ra,,.+ Cam., `,,°�/ N IRS-LID 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# /,Oi_d3-/ 2 / C 12/31/2023-12/31/2024 T Q- AC CERTIFICATE OF LIABILITY INSURANCE J12/ 00 03/2022 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 NAME:CT Paychex Insurance Agency, Inc. PAYCHEX INSURANCE AGENCY,INC. PHONE 877-266-6850 FAX 225 KENNETH DRIVE (A/C.No.Ext): (A/C,No): EMAIL FlexCerts @paychex.com NY 14623 ADDREss: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:AmGUARD Insurance Company 42390 INSURED INSURER B: RYAN FAMILY AMUSEMENTS INC 116 WATERHOUSE ROAD INSURER C: BOURNE, MA 02532 INSURER D: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMlDDfYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER A OFFICER/MEMBER EXCLUDED?ECUTIVE FFICRMEMBEREXCLUDED?ECUTIVE N NA N RYWC343183 12/31/2022 12/31/2023 E.L.EACH ACCIDENT $ 500000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Town Of Yarmouth 1146 Route 28 Town Hall SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Yarmouth,MA 02664 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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