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HomeMy WebLinkAboutBCOI-23-1799 2024 \ / a) ° $ 0 / U 0 � CI 0 /k - a C. g / , « N. jCa / CD 0 % f k � -5 _ \ ) N- Sj2 § S / a a-6 � § � 2q ƒ » a) o o . § / � a % \ ) § , o c k E g 1 B o0 • m m § ƒ ( cZ ° \ £ • 2 CD ¥ = Q CO ! CA C hi Jfl EI 0 to ■ ° co § E 2 I. 0UIJ UI � E k \ ki 0 ur 0 UJ / / \ / � L. .c o a / ■ O 0 / § \ ° ¥ • \ £ \ $ O kd � � � \ oi 'i rc ts d § 2 t 2 a % § \ f 2 o ' © k + E0 bE \ 7E e e E i \ 2E2k 8t- ° $ f - f ca In oz a = o o 1 / f2 ® - _ # f � \ � 0 C o $ c I E 2 / § @ @ / k \ j (\ ■ CO c 2 $ o E I e o a j / 'CB k\ �\ c �/ % as c & _ / 0) 5 k o � 7) o a) 2 $ m c 2 0 c \ ti ƒ �ƒ a) cut = a ) § \ £ @ o = > o ® _ < ! \ "as / / / ) 3 \ 2 as o k E $ e © / / g 5 $ T. \ ,,,.,/,4 ., .-,.., 2 2 ■ § S $ = o = _c % 2 0 U 0 S 2 \ E o 0 = 2 \ / \ ] & o ■ Ec ] % 2 ■ � 2 e E $ / E ] ,* S 2 \ } ƒ\ c ENT } ING EPA r . .. 1146 Route 28, South 'arnouth, MA 02664 50 -39 -2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION September 1, 2023 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: H Q( NkAV livNIZAku M 1 . cjcJ 3 Name of Premises:a MCkfr ittC r' i I°nn`tktccnn 'Fo"111 n K siGekG -Tel: 5Q' - 9" E C .,. 1 V D Purpose for which permit is used: r30I (nc11 LIO)(}0 C ICRoSt NOV 27 2023 License(s) or Permit(s) required for the prem3'ses by other governmental agencies: �:' E BOIL E�' t.115NT License or Permit l Agency By: (3 L - t} -a°S3 IOl>s�1 til_r eN I� Certificate to be issued to -G1 r Tel: 54�` $a4-i1�-� � i�qC ► �'tic. Si Address: H(b 12o4 . lortylotM l MA 02() 3 Owner of Record of Building 1.)0.v, (3`cvp4oito+ `r Address 41 kverwf. SucliNil1 Mk , U 1 a-}to Present Holder of Certificate 4 MChne,14, Signature of person to whom Title Li Certificate is issued or his agent — Date Email Address: 2 1106tav'coll W cow-, 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# 12/3 2023-12/31/2024 1 AC ) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �" 11/21/2023 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 Debbie Kleponis NAME: Brown&Brown of Massachusetts,LLC PHONE (781)455-6664 FAX (A/C,No,Ext): (A/C,No): 980 Washington Street E-MAILDSS: Deborah.Kleponis@bbrown.com Suite 325 INSURER(S)AFFORDING COVERAGE NAIC# Dedham MA 02026 INSURER A: Twin City Fire Insurance Company 29459 INSURED INSURER B: Wesco Insurance Company 25011 La Playa Inc;Nogales Inc,DBA:El Mariachi INSURER C: 416 Main Street Route 28 INSURER D: INSURER E: West Yarmouth MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: CL23112122436 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) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A X Liquor Liability 08SBMAD4757 06/18/2023 06/18/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER. Employment Pratices $ 10,000 AUTOMOBILE LIABILITY GOMBINED SINGLE LIMIT 5 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) S _ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION $ _ 5 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? Y NIA WWC3603102 08/15/2023 08/15/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500'000 If yes.describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of West Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE West Yarmouth MA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD