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C? tH BUIL INC EPARY ENT
" 5 S` 1146 Route 28, South 4'arrnouth MA 02664 508-398-2231 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: 51 Ar<l r rV SS L t Y C �r/.4'►o rrt44-1 y`�
Name of Premises:, j" 4:e C Tel:
Purpose for which permit is used: /2 $
License(s) or Permit(s) required for the premises by other governmental agencies:
RECEIVED
License or Permit Agency — --m -�-� - --
uo r NOV 28 2023
NT
ay
Certificate to be issued to j,-� / `0 C%"� f 4 CTel: j(�8—3Co`2-5 0
" l� ® cs,r O Address: 81 t< t wt �' et,� Ytvt t r1--1-1 (V(/1- Z 6'7J �j a7
117
Owner of Record of Building
Address q\l/1
oPresent Holder of C ificate ',
ej-0,_ +-
Sig re of person to whom Title
Certificate is issued or his agent d f 23
Dat6
��
Email Address: 'Z (v';') rr L cA�'►�
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 abcve 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# CO 3-1E0 `-, (1,/,
12/31/2023-12/31/2024 �/
Acc oRci CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DD,YYYY►
11l22/23
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 CUNC7 --
I NAME;TA PAUL SCHLEGEL
Schlegel&Schlegel Ins Brokers,Inc. I(aCNNo,eau; 508.771-8381 1{,a ,No); 508-771-0663
34 Main Street ADDRESS: schlegelinsurance@gmail.com
West Yarmouth,MA 02673
INSURERS)AFFORDING COVERAGE NAIC a
INSURER A: GUARD -
INSURED
I INSURER 8:
IL MONTELBELLO ; INSURER C:
64 KINGS WAY INSURER 0
YARMOUTHPORT,MA 02675
I INSURER E: f
I INSURER F: III
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 SUEPC POLICY£FF POLICY ExP
LTR TYPE OF INSURANCE _ INSD WVD POLICY NUMBER (MMID0 lYYYY) (MM70DfYWY)1 LIMITS
x`COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000
DAMAGETO RENTED —
I CLAIMS-MADE , I OCCUR I ( "PREMISES(Ea occurrence) $ 500,000'
MED EXP(Any one person) $ 5,000
A iLBP72582 12129/22 12129/23 I PERSONAL&ADV INJURY $ 1,000,000
GENTAGGREGATE LIMIT APPLIES PER 4 GENERAL AGGREGATE S 2,000,000
PRO n
POLICY JECT L f LOC 1 PRODUCTS-COMP/OP AGO L$ 2,000,000
OTHER I s
AUTOMOBILE LIABILITY --- COMBINED SINGLE LIM!I- 1$
ANY AUTO i BODILY INJURY(Per person) I S
OWNED 1 SCHEDULED t
x.I AUTOS ONLY AUTOS I BODILY INJURY(Per aden,j{$
HIRED NON-OWNED I PROPERTY DAMAGE !S
AUTOS ONLY _AUTOS ONLY Per arndenl)
I $
UMBRELLA LIA9 OCCUR r
EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE.� AGGREGATE
DED 1 RETENTION$ $
I WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN - I_-._ I S(ATJ,E ER
ANY PROPR'ETOFVPARTNER,'EXECUTIVE
A OFFICEReMEMBER EXCLUDED? N NIA ILWC487598 ( 09/04/23 09/04/24 E.L.EACH ACCIDENT $ 100,000
{Mandatory In NH) , E.L.DISEASE EA EU.PL.OYFF S 10(1,000
If yes,describe under i
DESCRIPTION OF OPERATIONS before I E.L.DISEASE-POLICY LIMIT $ 500,000
I j
A LIQUOR LIABILITY 1LBP938928 12/29/22 12/29/23 I 2,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (AGGRO 101,Additional Remarks Schedule,may be attached If more space Is required)
Coverage may or maynot be in place at time of loss,no certificate holder on file.
r CERTIFICATE HOLDER CAN
CELLATION
ISHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
I TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS.
LICENSING DEPT
I
1146 ROUTE 28 AUTHORIZED RE Nf .it SOUTH YARMOUTH,MA 02664, 1. .'' �- - -d}
`'
I TAT i
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