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Home My WebLink AboutBCOI-23-1773 2025 t ig YA TOWN OF YARMOUTH 7, 'yic- Office of the Building Commissioner '� 1146 Route 28, South Yarmouth, MA 02664 � 508-398-2231 ext. 1260 Fax 508-398-0836 `� c_MATTACHEESE- 4f,. ARP p R AT EO,.;y" �``` APPLICATION FOR CERTIFICATE OF INSPECTION September 23, 2024 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: // /72a/n /1(k c",2 g Name of Premises: //7e. l ient Di.//1y Tel: . Zg. 39 — ? /3 Purpose for which permit is used: License(s) or Permit(s) required for the premises by other governmental agencies: E C E I V ly License or Permit Agency = OCT 15 2024 BUIL 40 T Certificate to be issued to C___00c,.\ S- 11055 . ',rN1- Tel: Address: Owner of Recol4 of Building PS 4 S r ,ve, L 1—C Address 1 b Cxr c„1:04 c u,-N mow. V n,1- 3 s.t,.,.•c1 1 t^ M A (;-G3 Present r of Certificate Signature of person to whom Title Certificate is issued or his agent J a l I 1)a(1 Date Email Address: it.-`(= Cid zn.&Qt.eSel'e A nct S. wl Qs d'i ha /cese+-c. '1 e f" 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# lez/ R3 /2 7, 12/31/2024-12/31/2025 U� ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/26/2024 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 00935-005 CONTACT 935 935/5 Brown&Brown Insurance Services LLC PHONE FAX Ent): (617)471 1220 IAJC.No: (617)979-5147 500 Victory Road,Marina Bay EMAREss: jennifer.wronski@bbrown.com North Quincy,MA 02171 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: A.I.M.Mutual Insurance Company 33758 INSURED INSURER B DC Porcellis Pizzeria & More LLC INSURER C: C/O Candace Cook 130 Cottonwood Rd INSURER D: Harwich, MA 02695 INSURER E: INSURFR 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 INSR SUBR POLICY NUMBER (MMIDDNYYY) (MMLDDY�) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per acddent) $ AUTOS AUTOS _ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) _ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS MADE AGGREGATE $ DED 1 I RETENTION WORKERS COMPENSATION A TORY IMITS OER A D EMPLOYERS'LIABILITY - - - — A AOtJ IPR�P,(jI��F/PpatiER/EXECUTIVE Y/N E.L.EACH ACCIDENT S 100 000.00 F CE me cn�`vDEO� Y N/A AWC-400-7041052-2024A 5/4/2024 5/4/2025 (Mandatory inNH) e E.L.DISEASE-EA EMPLOYEE $ 100,000.00 DE sCRIPTI OnF O! PERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attaced if more space is required) No Member is covered by the workers compensation policy. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth 1146 Route 28 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE South Yarmouth,MA 02664 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD