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HomeMy WebLinkAboutBCOI-23-1774 2025 : ,/Of 14%4 \ TOWN OF YARMOUTH =_- Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 0 ;y`l 508-398-2231 ext. 1260 Fax 508-398-0836 tr' MAT TAC;E5E- q '' /�c�RpORATE�,bv" APPLICATION FOR CERTIFICATE OF INSPECTION September 23,2024 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: /3 2 7 /)l LGin $z?iee.4 Name of Premises: Crazy Z©S 7 i' Tel: 52 -s9t -SI, Purpose for which permit is used: 2 Y1 S p-e 6 r-c 7 7 ./_�S w -�j &--o License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to CrcY79UJ 2i2 T 1: — 0 Address: /3A 44Gu/1 5 -e'- eet 0--r a 4 Owner of Record of Building %I(Eo?O pO S j4 L.l 5 Address Present Holder of Certificate 4 5iir ./41*- Signature of person to whom Title G�'/ Certificate is issued or his agent /0 ^/6 Date Email Address: V ai/lAda 1 a S3 Get LA CO-W R F c :7, `k.A 'p• OCT 15 2024 E3U 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 CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# ,, l J 12/31/2024-12/31/2025 v/— q'3 —/ 77yi r ", THEOD-6 OP ID: MF '4 CC)R CO- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �' 10/11/2024 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 508-771-3300 NAME CT Martha J Findlay Olde Cape Cod Insurance PHONE 508-771-3300 FAX 508 775-3821 Martha Findlay (A/c,No,Ext): (A/c,No): 300 Winter Street ADDRESS:marthaf@occia.com Hyannis, MA 02601 Martha J Findlay INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:American Automobile Ins Compan INSURED INSURER B:Westchester Specialty Ins Co The Crazy Rooster-TATA Inc Teddy's Three Sons LLC INSURER C: 25 Pine Grove Ave Hyannis, MA 02601 INSURER D: INSURER E: 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYY1 (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR SAG 2005797-24 07/01/2024 07/01/2025 DAMAGE TO RENTED 100 000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE• COMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ i UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED 1 RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Property Section FSF16987955 001 07/01/2024 07/01/2025 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Food Breakfast and Lunch Liquore Liability CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth, MA 02664 mcutiiki3 F i ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD