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bUIL ING EPA T.. ENT
$ 1146 cute 28, South Yarmouth, A 02664 508-39 -2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
December 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: y/ ✓G 2 � rl� rya
Name of Premises: / -/ / d Tel:( / 7) 8 —( L
Purpose for which permit is used: l,/t/ClL6 4- SC /r✓ O c c vP/+rC y Csq
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
,49 Gi/ v - t 74/.Ain FN'f" GA, f' u
Certificate to be issued to i.), 1g-- 7 ✓Ji L /2 M Tel: (o/? , 8 2/ / z tl c/
Address: I L/ / 2 8 - 2
Owner of Record of Building /h c%1-t'e- G /.
Addr-
'resent Holder o rtificate 7V-c ,3�r/ c- ,2 eM RE C E i V T D
DEC 06 2023
Signore of person to whom Title --
Certificate is issued or his agent i 2 2? o 1 �� 4 ENT
Date
Email Address: A g_1.4 11/4) ( ik"f./ C. ,Q o 0 c 4 r C''cz-A .00-1
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 CA �� ,,O. T ISSUE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection# �X"O/oa3— 179
12/31/2023-12/31/2024
N UT
1146 Route 28, South Yarmouth, l4'IA 02664 508-3 8-2231)1 Rt.R2CbE IVED
NOV 16 2023
APPLICATION FOR CERTIFICATE OF INSPECTION
BUil DING DE PARTMENT
November 16, 2023 PAYABLE UPON RECEI' —
(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�ell premises located at the following address:
.-7
Street and Number: / d9�9-/,/ '� -61'49 a re Z$ I fjr/��( ,�v� ( c/ZI7_/
Name of Premises: 'i 6 v,f"/C /;> '/'2 Tel:l (;./ 7) 7?-/-/
Purpose for which permit is used: 4' ✓dam. 6:4•4 4,4,N d7,4,14y
License(s) or Permit(s) required for the premises b'other governmental agencies: /
License or Permit Agency
/�° "7
/1\
Certificate to be issued to 4. /(/GE /Wi/' v.✓rel: LL C //
r
Address: ,19/ 444 v,%E `l`. 11v d- u
Owner of Record of Building ik/Cf,/ LL 1
Address r�� SAX 2/2 8 , yAt it, cri J /Y//.d- )Z E c� /
Present..Holder-o€ ,' -z '.rtificate .-
-sfg of person to whom Title
Certificate is issued or his agent // i6/z '
Date
Email Address: 3,r/,rr✓ /7 u`v�/C o on?L,'Q-toe t"
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 # 8C(]/-c23-179(y
12/30/2023 to 12/30/2024 `/f
ACd C CERTIFICATE OF LIABILITY INSURANCE DATE(M,°D"YYY)
klai.so....-- 11/08/2023
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TIE 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 hi lieu of such endorsement(s).
PRODUCER CONTACT
SCHLEGEL&SCHLEGEL INSURANCE PHONEH, y !T,No):
34 Main Street E-MAIL
West Yarmouth, MA 02673 ADDRESS: _—
INSURER(S)*FrORDIN000VERAGE ^I NAICN
INSURER A: NorGUARO Insurance Company 31470
INSURED --- INSURER B: ---
ALPHA ENTERTAINMENT GROUP LLC
541 Main Street Route 28 unmet C:
West Yarmouth, MA 02673 INSURER 0: -INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
. THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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.
' POUCY EXP
LYR TYPE OF INSURANCE MD Reno �t POLICY (MNNDOIYYYYYY1 IIYRMIDO/YYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 0
DAMAGE TO RENTED $ 0
CLAIMS-MADE OCCUR PREMISES(Ea occurrence)
MED EXP(Any one person) S 0
PERSONAL&ADV INJURY S 0
GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 0
POLICY r-{
PRODUCTS-COMP/OP AGG S 0
�JEC'T LOC OTHER: S
AUTOMIOaLELMINLTTY (Ea accide )
COMBINED SINGLE LIMIT $
ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED BODILY INJURY(Per accident) S
HIRED ONLY _ AUTOS
HIRED
NONAWNED PR DAMAGE S
AUTOS ONLY AUTOS (
S
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS _CLAIMS-MADE AGGREGATE S
DED RETENTIONS -',. S
WORKERS COMPENSATION /7 _X.ten/ � D �. #1/41/"IS X CSTEATUTE �R.
AND EMPLOYERS'LLIABILITYYIN r9_
A ANYPROPRIETOR/PARTNER/EXEC Y NJA ALWC30483$ 11/21/2022 11/21/2023 EL EACH ACCIDENT $500,000
( ry In NH) E L DISEASE-EA EMPLOYEE S 500,000
If yes desane under
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $500,000
_ 1
DESCRIPTION OF OPERATIONS I LOCATIONSI VEHICLES(ACORD 101.Additional Remarks Schedule.may be attached I more space Is required)
Employees: Full lime: 2; Part Time: 8 Governing Class Description: RESTAURANT NOC
Exclusions:
BRIAN SERPONE, MEMBER;
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Alpha Entertainment Group LLC ACCORDANCE WITH THE POLICY PROVISIONS.
541 Main St Rt 28
West Yarmouth, MA 02673 AUTHORIZED REPRESENTATIVE
7g#47-e'11-4--. -..a.....z.'
01988-2015 ACORD CORPORATION. All rights reserved.
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