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' 1146 Route 28. South \ o mouth, MA 02664 508- 98- 23 ext 1260
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APP E:01110IREI ICATE OF INSPECTION
September 1, 2023 PAYABLE UPON RECEIPT
OCT 25 2023 (X) Fee Required$100.00
( ) No Fee Required
BUILDING DEPARTMENT
By _.
In accordance with the provisions o e assac usetts a e Building Code, Section 110.7, I hereby apply for a
Certificate of Inspection for the below-named premises located at the following address: t#5
Street and Number: S`t R 1 G
Name of Premises: Y4 bu U 64 PCZZ4 f EO4AJ Tel: SO8 -3Ga
Purpose for which permit is used: FOCA) .5z.t&titC.L.
License(s) or Permit(s) required for the premises by other governmental agencies:
J
(41
License or Permit Agency
Bo if
6L.GoU6LtC 13£t/,
.70Cr4
Certificate to be issued to j/q P.NtbuTh1 pizza %Sy &V R N Tel: 5 4 S * Ga -
Address: S59 der 6,4-
Owner of Record of Building C t4 y-�—�-.
Address 5 5 g gr- GA
Present Holder of Certificate .TIGAr LLC. 013/4 YAeAtour PO , QY 1 t/AN
_ G . /146 l2
Sign person t wh Title
Certificate is issued o f agent �/i 157 3
Date
Email Address: 4--ZiANo f catilc.a S '- tiE 1
Instructions: Make check payable to: Town of Yarmouth
1146 Route 28, South Yarmouth, MA 02664
a
Building Inspector's Office
Return this application to: p
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 bezore 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 CANN_Olf/ISSUE YOUR CEFTIFICATE OF INSPECTION.
Certificate of Inspection# 13 c.. -G7 3-1777
12/31/2023-12/31/2024 ���
A t/ Worker's Compensation and Employer's Liability Policy
7 Berkshire Hathaway NorGUARD Insurance Company - A Stgck Co
( y Policy Number 30WC; 75217
Renewal of 30WC216993
lA 0!..0 �D Insurance Companies NCCI No. [25844]
Policy Information Page
1[1]Named Insured and Mailing Address Agency
IJOCA, LLC DOWLING &O'NEIL INSURANCE AGENCY
DBA/TA Pizzas by Evan 973 Iyannough Road
450 Station Ave P.O. Box 1990
C/O Botsini Corp Hyannis, MA 02601
South Yarmouth, MA 02664 Agency Code: MADOWL10
r
Federal Employer's ID XX-XXX1292 Insured is Limited Liability Co. (LLC)
Additional Names of Insured
(N2) Pizzas by Evan
Locations on Policy
(L2) 559 Route 6A , Yarmouth Port, MA 02675-1915
(12/30/2022 - 12/30/2023)
[2] Policy Period
From December 30, 2022 to December 30, 2023, 12:01 AM, standard time at the insured's mailing
address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $500,000
Bodily Injury by Disease - each employee $500,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
[ ___ _ ___
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 5,637
Total Surcharges/Assessments $ $215.00
Total Estimated Cost $ $5,852.00
INTERNAL USE XX Page - 1 - Information Page
MGA :J0WC375217 WC 000001A
Date : 11/25/2022
MANOTE
Issuing Office: P.O. Box AM,39 Public Square,Wilkes-Barre, PA 18703-0020 • www.guard.cont
%Y rkers Ctunnensation And Employers Liab4n) Insurance rlit:s, WiF:.00 00 01 A
Cover 1*PrestitaxiPokey' Number
h
,ij Liberty U Secunty Insurance Corrpanv X' (241114 77 npj
Mutual. Prmom Polley Nu
detteltANCI
ItMtti ...: ?7 n
NCCf Co No. tiaeat_
Workers Compensation and
Employers Liability Insurance Policy
Information Page
ITEM 1:The Insined&Mailing Adokorss Aged Mail*Milken I Phone No.
40S BISTRO, INC. {tr17)64S-5 I00
I FILLMORE RD INTERCONTINENTAL INSURANCE
WEST YARMOUTH, MA 02673 BROKERS. LLC
70 FEDERAL ST STE 3irA.
BOST()N,. MA 02110-1974
MdMdusl Partnership
Corporation et FEIM:A.XXXX24f►tt 1111M2251 I
Other workplaces net shown matte:'
ITEM 2 The policy pelted Is nom 05117/2023 to 05/17/2024 12:01 am StandardTimrat the insureBsinailingarikess,.
ITEM 3 A.Winters Compeesaties htsersoce:Part One of the policy applies to the workers Compensation Law
of the states lasted here: MA
B.Employers thiddlity nee: Part Two of the policy applies to work in each slate lamed in Item 3 A.
The Smits of our liability under Part Two are. Bodily Injury by Accident Sit coo each accident
Bodily Irsury by Disease S500 000 policy lend
Bodily Fury," by Disease S500 000 each employee
C.Other States Insurance: Pan Three of the policy applies to the states, If my,listed here, See
Extension of Information Page
D.This policy Includes these endorsements and schedules: See Policy Forms and Endorsements Summary
ITEM 4 The premium for this policy will be determined by our Manuals of Riles. t las s. Rates and Rating
Plans, Alt information required below is subject to verification and charms by audit
Ica lions Cede MINIMS Total Rate per Estimated
lie. Estimated Annual $100 of Annual
Remuneration Remuneration Premium
See Extension of Information Papist
S
Total Estimated Annual Premium $2.049;00
Total Surcharges and Assessments $70 00
MinimumPreen $259 00 MA Total Estimated Cost $2,114,00
It indicated below intennt adjustments of premiumspremaims ettall be made
Deposit Premium $2,119.00
Countersgnedby:
Issue Date
To report a abaft pia your Agent or 1-844-325-2 7
We UO ile ei A(WC 30I0 )
1917 National Council on Compensation insurance, Inc.
6477EXt3 POI.SvCS 45C INSURED COPY MISR, PAGE IS OF el