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HomeMy WebLinkAboutBCOI-24-39 Arcade %og 'YA TOWN OF YARMOUTH Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 / 508-398-2231 ext. 1260 Fax 508-398-0836 MATTACHEESE q APPLICATION FOR CERTIFICATE OF INSPECTION March 04, 2025 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 5/0 £1274Te �C Name of Premises: l/'iciod u49- e2 /. }Q /,cEc, ck Tel: .9/Z-375- .51/0.? / RcAde Purpose for which permit is used: WA Me Ma 5e4sonaC 3v5;)163 License(s) or Permit(s)required for the pre ices by other governmental agencies: License or Permit Agency I I v MAR 27 2025 Certificate to be issued toNa a2��T/.YL'd6Q /C/(0l�(rli�(S Tel: 9 8-.375-SyD.Z _,, Address: 5/� R oZ$ 04,51 YRR/Uou ,(M 0w6'93 �� - Owner of Record of Building 5tii/dea42 Al - Address 51-2 Loure ceg , rest, fre,uou-to/ od673 Pres t Holder of C rtificate ~64 2, Si ature of person to whom Title�jj Certificate is issued or his agent 3/0?-/o25 Date Email Address: Joe. fron-t/ CO 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-24-39 04/15/2 02 5-04/15/2 02 6 e.• Ac DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/25/25 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 1 HE 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 provisio is 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 CONIACf NAME: Brian Allain Choice Insurance Agency (A//�No,Ext): 978-343-4853 (A//C, lob 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 INSURER D: West Yarmouth,MA 02673 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 PCLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT Ts 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 ADDLSUBR- POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INS() WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) L MITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PREMISESO(Ea occurrence' $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AC G $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per perso)) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accide nt) $ HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY ^ AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ S WORKERS COMPENSATION X PER OTF— AND EMPLOYERS'LIABILITY Y/NANY STATUTE ER C OFFICER/MEMBER ER EXCLUDED?ECUTIVE N/A 6S62UB1W17748324 10/01/24 10/01/25 EL.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLO'EE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMT $ 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 BE 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 ©1988-2015 ACORD CORPORATIO J. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD