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HomeMy WebLinkAboutBCOI-23-1800 2024 2 o / / \ 0 �_ 10 _ / a U ° @ ' = a 3 ca \ E / _o J @ C / § _ _ � • - a) § 5 0)c. 0.Ls • ci.la ( j \ » o b3 \ \ / \ / ] / % _ , 00 a / ± S \ r / MI P. § 2 � — 5 hll ; o k %!° / I 0EK 0 # o E CO © � 92 ° ° .0 w t � � < 5 \/ / e 2 ■ m ® o / / f � _to \ � E $ © ao3a) � £ / % ' % 2 E o ■ u 3i. / § \ a — c0D 03z rTaaos . o [ a % e o e q \ m § k 2 / 7 £ % 12 ■ 0 U © m2 k < k - > E $ m 7 A * ' £ $ \ _ \ § — Qg2 % / � § 2 \ = 5 O '- _ _ % _ 2 % cm - 2 / / k / / ) c, E 2 \ ® 3 § . / o 5 ) 2 / 0 \ 00 / § \ § E 2 P c \ 0 » . , 3 k \ k ( ( /( o « ofU zoro E > a) 5 _ co _ g co as 2 / ' \ - k \ d j -0ƒ z � ) « E ® / $ ` G / § _> \ U 0 \ / 2 = (a » ® q f o 0 m I % C ƒk ( \ \ \ k it % 2 % 2 0 ± — / k 2 S Q 0 § 2 \ j ) g 2 % \ ] < a w f ° e a ® D a _ \ \/\ § � § * coM � — a) E /} c 2 eo .Ro; TOWN OF YARMOUTH BUILDINGDEPARTM RECEIVED :° ENT _.. • M�°APoPoit`3 .� ': 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ex . 1 V 2 7 Z023 BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF INSPECTION BY November 1, 2023 PAYABLE UPON RECEIPT (X) Fee Required $100.00 ( ) 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: ?L/0 r14/V 3-7-P_E E 1 Name of Premises: 61 (,i a/JO 1-2 Tel: sdM8 'l((, Purpose for which permit is used: Velv,/111 License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency k *— 01 FODI L, o I.0 'Pi' '. Certificate to be issued to /4,W � R Au i/07)'� Ca) Tel: 2 /" /0~/t-G/7 Address: (ea) ei°Mm� t6t{(�od-/ beik�1m,)'n1 Ocao?,b Owner of Record of Building 6 eJ�33 E A Z-1- �p Address - 6 S-3 0 3 e(E,1 eMY? ire , 3Dur inw; �MM C2 ,y -� � Present Holder of Certificate 60PA 67'jm/j ., f . In (VOL Yiega00/34/i/L nature of person to whom Title Certificate is issued or his agent /rdg-d3 /n Date Email Address: L-/C1'MS O�, l ril &/,(As.c ���,4 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 NOT ISSUE YOU CERTIFICATE OF INSPECTION. Certificate of Inspection# /---2.3/ ( 12/31/2023-12/31/2024 EATSLLNE01 ACHARLES '4� � CERTIFICATE OF LIABILITY INSURANCE DATE 023YY) 2/21/2023 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 License#1780862 CONTACT Adrienne Charles HUB International New England PHONE FAX 300 Ballardvale Street (A/C,No,Ext): I(A/C,No): Wilmington,MA 01887 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:United States Fire Insurance Company 21113 INSURED INSURER B:North River Insurance Company 21105 New England Authentic Eats LLC INSURER C:Crum&Forster Indemnity 31348 600 Providence Highway INSURER D:Safety Insurance Company 39454 Dedham,MA 02026 INSURER E:Sutton Specialty Insurance Company 16848 INSURER F: 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. ILTR TYPE OF INSURANCE INSD DDLISWVD I POLICY NUMBER IPOLICY/YYWI IMMIDCMYYYYI I LIMITS A X i COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I X OCCUR 543-232571-4 2/11/2023 12/11/2024 PREMISES LEa o E ence) $ 1,000,000 MED EXP(Any one person) $ Excluded i PERSONAL&ADV INJURY I$ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 1 nnn nnn POLICY JECT LOC PRODUCTS-COfOPAGG $ OTHER: I $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 1Ea accident) $ ANY AUTO 133-754107-5 2/11/2023 2/11/2024 BODILY INJURY(Per person) $ OWNED x AUTOS SCHEDULED AUTOS ONLY BODILY INJURY(Per accident) $ AUTOS ONLY AUUTNOSS ONLY (Pe ccIdent) � $ B _ UMBRELLA LIAB X OCCUR EACH OCCURRENCE I$ 5,000,000 X EXCESS LIAB CLAIMS-MADE 5821207461 2/11/2023 2/11/2024 AGGREGATE $ 5,000,000 DED I I RETENTIONS I$ C WORKERS COMPENSATION X PER I STATUTE I OTH- I ER AND EMPLOYERS'LIABILITY Y IN 408-744662-4 2/11/2023 2/11/2024 E.L EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A 1,000,000 FFICERInng7 EXCLUDED? andatory in NH) E.L.DISEASE-EA EMPLOYEE!$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT I S 1,000,000 D Non Owned(MA) COM5928781 2/11/2023 2/11/2024 Each Occurrence 1,000,000 E Non Owned(CT NH RI) JCAP0357-01 2/11/2023 2/11/2024 Each Occurrence 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) NAMED INSURED SCHEDULE: WC PG Franchising LLC(Papa Gino's Franchising Corp.) WC DA Franchising LLC(D'Angelo Franchising Corp.) D'Angelo Sandwich Shops Advertising Fund Inc. NEAE Card Services LLC New England Authentic Eats LLC CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 9:9, 9,4p.---ry ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD