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HomeMy WebLinkAboutBCOI-24-39 2026 0V.YA TOWN OF YARMOUTH r 0 Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 44 = 508-398-2231 ext. 1260 Fax 508-398-0836 t„ MATTACHEESE / A „f!PORATEC)' . APPLICATION FOR CERTIFICATE OF INSPECTION March 04, 2025 PAYABLE UPON RECEIPT (X) Fee Required$334.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 5/2 awe J7 Name of Premises: aie60/69/%1 ietSatt Tel: ,g —3?,5--,5L/O.Z Purpose for which permit is used: 5e/45Ofr% L //OTet /4 o7PL License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit AgencyL MAR 2 7 2025 Certificate to be issued to iifyd1pagAl/6 Welt ' IA,Iu Kam'"Tel: 977-. ?..5z5'/O Z Address: .572 /�,0oe di, a4,51 Y/1414 eu, 1f4 043, B u I I Owner of Record of Building Nd6a e,iier Address .J/d.l a e d$, '/ t MOZC /, 11,4 0d633 Present older of Cert. cate Sig Gee,ve Signa re of person to whom Title Certificate is issued or his agent 342.7125 Date Email Address: 7OP. i{/j,Q,C/,'/J#9 a Erna • Co/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 CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection#BCOI-24- 04/15/2025-04/15/2026 3`j , 1 TT /Q DATE(MM/DD/YYYY) /RR� CERTIFICATE OF LIABILITY INSURANCE 03/25/25 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT: HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY HE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), •UTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisi s or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsemen A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONIACI NAME: Brian Allain Choice Insurance Agency (A//cC,No,Ext): 978-343-4853 FAX e); 978-345-1007 376 Summer Street E-MAIL Fitchburg,MA 01420 ADDRESS: ballain@choice-insurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Scottsdale Insurance Company INSURED INSURER B: Ace American Insurance Company Sandbar Management Inc INSURER C: P.O.Box 481 West Yarmouth,MA 02673 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 P• ICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TI WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL T E TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDDIYYYY) ITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE RENTED $ CLAIMS-MADE OCCUR PREMISESO(Ea occurrence $ MED EXP(Any one person $ PERSONAL&ADV INJUR $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY n PRO„IBM' LOC PRODUCTS-COMP/OP A.G $ OTHER: $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per pers. ) $ OWNED SCHEDULED BODILY INJURY(Per accid nt) $ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION v PER OT AND EMPLOYERS'UABILITY Y/NANY I� STATUTE ER C OFFICER/MEMBER XCLUDED?ECUTIVE N/A 6S62UB1W17748324 10/01/24 10/01/25 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLO EE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LI T $ 1,000,000 Liquor Liability Aggregate 2,000,000 A CPS7362638 06/26/24 06/26/25 Each Occurrence 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Operations of Insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES B: CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DE IVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I � 1 t ©1988-2015 ACORD CORPORATIO . All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD