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Home My WebLink AboutBCOI-23-1785- 2 § 7 � 0 $ ƒ cis k � 0 .1). \ k E c v \ / ca a / _ \ CO ° _a -c \ \ / , ' •CP CP / \ 0CV ka 0 5 \ } \ _ « o 2 l ° \ § c % o n 2 ID u411 / o $ . a = k = I /ibiD . E § � / 2 E2 / ' .0 CO t2 7 = \ � a Q ■ t & ■ = t o @ % f / � � \ d f � f « $ Z / � L < CV § 222 / / 2 // \ In ` % k2o � _0 o _ 2 a) F % I ■ = o It 2 t ■ k & ■ 2 � / u% $ O � k \ / m \ f & k � � _C § 2 Gf T- § � � o - _ \ 2 E § \ \ / \ / \ \ f / 2- E w ■ � 3 § 32 § 2 s o C / Ow \ 00 � k0. \ k .0 3 / 2 '/ o j " j ■ CD oo * 2 = 3 Z & t c = § EE ƒ E C 0 k \ \ }/ // = a - m • J �% ) g k ) / ' ca o 2 $ # k 0 ° m co 0 _o/ 0 R $ k $ eU) § I G / ® . = § e = k \ a � \ \ / m c & _ ® q ° � \0 ili / 0 a / § / \ 2 = k = t 7 \ 2 2 S $ - 0 k 2 0 U O0c 5 3 ° 2 o a 2 9 m § k J 2t / / 7 ,G1- A177..,.:::# § \ 2 _% 2 2 `3 + n - ( / 3 7 £ 2 // TOWN OF YARMOUTH \so, ; ,c, /41 ENT 1146 Route 28, South 'Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION October 23, 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: I- A ' ``CI L° Name of Premises: \--\e,..cvA1,-) r (& Tel: (5a))9`1 -c �- Purpose for which permit is used: L,,qua,,, l�n� License(s) or Permit(s) required for the remises by other governmental agencies: RECEIVED License or Permit Agency OCT 24 2023 BUo t MENT By Certificate to be issued to tics mOi Tel: (flLt) `f , Address: 1\% VIA 5' yahN0v (J L 1 Owner of Record of Building 9-- ` I Address Present Holder of Certificate 16` of person to whom Title Certificate is issued or his agent 1,0/) ( Date Email Address: ) 'c;'r''1 ,,-�i ,fllry,q�'1. C.0 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 # LzL C I_2 3 —/7 -- 12/31/2023-12/31/2024 A ® CERTIFICATE OF LIABILITY INSURANCE /Y DATE(MM/DDYYY) 6/1/2023 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 RogersGray,A Baldwin Risk Partner NAME:CONT r NAME: 410 University Ave PHONE Westwood MA 02090 (A/C.No.Extl:800-553-1801 FAX E-MAIL (A/C,No):877-816-2156 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURED License#:PC-514062 INSURER A:Star Insurance Company 18023 Graham LLC GRAHLLC-01 INSURER B: 358 West Main Street INSURER C: Hyannis MA 02601 INSURER D: INSURER E: COVERAGES INSURER F: CERTIFICATE NUMBER:405045072 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 I INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 1 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE E 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 SUER LTR TYPE OF INSURANCE INS!) VINO POLICY NUMBER POLICY EFF POLICY EXP COMMERCIAL GENERAL LIABILITY (MM/DD/YYYY) (MM/DD/YYYYL LIMITS CLAIMS-MADE EACH OCCURRENCE $ OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $ POLICY JECOT LOC GENERAL AGGREGATE $ OTHER: PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) $ UMBRELLA $ LIAR OCCUR EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $ DED I 1 RETENTION$ AGGREGATE $ A WORKERS COMPENSATION WC0871084 $ AND EMPLOYERS'LIABILITY Y/N 1/29/2023 1/29/2024 X I PERATUTE I 1OTH- ER ANYPROPRIETOR/PARTNER/EXECUTIVE J ST OFFICER/MEMBEREXCLUDED? N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 • I I I j DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) When required by written contract,the following applies: Workers Compensation-Waiver of Subrogation(WC000313 4/84) * location is for Sacred Heart Chapel 32 Summer St Yarmouth Port 02675 JUL 13 2023 1 1 CERTIFICATE HOLDER BUILDING . .. qRI P CANCELLATION °' I SHO THE ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE VTHEREOF, NOTICE WILL CBE CDELIVERED RIN Roman Catholic Bishop of Fall River ACCORDANCE WITH THE POLICY PROVISIONS. Corporation Sole C/O Catholic School Office 423 Highland Ave. AUTtjQ,@(ED REPRESENTATIVE Fall River MA 02720 ACORD 25(2016/03) The ACORD name and logo are registered mar ks1988-2015 of AC OR of CORPORATION. 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