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HomeMy WebLinkAboutBLDX-25-743 application .0-f•Y it R E D E I Y E D <Office Use Only ` Permit# �� °\ � *► ' � JUN 04 2025 Amount lab0?� 4TTA"11�•f.3 c5 Permit expires 180 days from DEPARTMENT issue date LBUILDING y __._._____ BOX- 075_-74- 3 BUILDING PERMIT APPLICATION Spri ng3 h.et TOWN OF YARMOUTH Yarmouth Building Department reS--jl/aA 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 108 Bray Farm Rd North Yarmouth Port, MA 02675 ASSESSOR'S INFORMATION: 11 Map: 151 I Parcel: 24.1 OWNER: Taylor Bray Farm P.O. Box 66 Yarmouth Port 508-326-5430 NAME PRESENT ADDRESS TEL. # CONTRACTOR: UnderCover Ten 112 Great Western Rd, Uni NAME MAILING ADDRESS TEL.# ❑Residential ['Commercial Est.Cost of Construction$935.00 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor a I have Worker's Compensation Insurance Insurance Company Name: WeSCO Insurance Company Worker's Comp.Policy#WWC3678633 20 X 40 WORK TO BE PERFORMED n Tent Duration 06/13 to 06/16/25 (Fire Retardant Certificate attached?) Wood Stove ( I Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (n)Remove existing*(max.2 layers) Insulation 1 i Old Kings Highway/Historic Dist. (0)Replacing like for like Pool fencing r *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that the statements herein contained are true and orrect to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial evocation o l cense and for rosecution nd .G.L.Ch.268,Section 1. �/ Applicant's Signature: Date: Owners Signature(or attachment) Date: ��� Approved By: Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes No Flood Plain Zone: C Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 11 No ❑ Yes ❑ No In 10, m q rpn v cd incacol-r f- UNDER-1 OR ID: CD ACOR© CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 05/02/2025 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 endorsementis). PRODUCER 617-479-5500 tcstIWE cT Ellen Mitchell DPS Insurance Group, Inc. PHONE 617-479-5500 FAX 617-479-8761 400 Crown Colony Dr.,Ste 103 (A/C,No,Ext): ((A/C,No): Quincy,MA 02169 SS:Emitchell@dpsins.com Daniel P Sullivan INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arch Insurance Company 11150 Us R INSURER B:Wesco Insurance Co 2538 ndercED over Tent&Party Tony Prizzi INSURER C: 112 Great Western Rd Unit 1 South Dennis,MA 02660 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE jsso wvo POLICY NUMBER (MM/DD(YYYY) IMMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I X OCCUR PRPKG0008608 11/21/2024 11/21/2025 PREMI ETORENTED 300,000 PREMISES(Ea omerence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY (Ea aBccidentSINGLE LIMIT $ 1,000,000 ANY AUTO PRAUT0004902 11/21/2024 11/21/2025 BODILYINJURY(Perperson) $ _ OWNED SCHEDULED AUTOSRREE ONLY X AUUTTOSWNEp BODILYO INJURYp (Per accident) $ X AUTOS ONLY X AUTO ONLY (Perr a ent)AGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE ,$ DED RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE ER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WWC3744292 11/21/2024 11/21/2025 E.L.EACH ACCIDENT $ 1,000,000 QpFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 I es,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Equipment Floater PRPKG0008608 11/21/2024111/21/2025 Equipment 600,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Party Goods Rentals-6/14/25 CERTIFICATE HOLDER CANCELLATION TAYLORB SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Taylor Bray Farm THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 108 Bray Farms Road N Yarmouth Port, MA 02675 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents t-a Office of Investigations `� Lafayette City Center �� _ 2 Avenue de Lafayette, Boston, MA 02111-1750 �`' `� wwwmass.gov/dia ~V�= Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:UnderCover Tent and Party, Inc. Address:112 Great Western Rd, Unit 1, South Dennis MA 02660 City/State/Zip:South Dennis, MA 02660 Phone #:508-398-9000 Are you an employer? Check the appropriate box: Business Type(required): 1.I I am a employer with - employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, Tent with no employees. [No workers' comp. insurance req.] 12.Q Other *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:Wesco Insurance Company Insurer's Address:420 Maple Ave City/State/Zip: Yukon, OK 73099 Policy#or Self-ins. Lic. #WWC3744292 Expiration Date:11/21/25 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§ 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 3 / I +—j / S— Phone#: 508-398-9000 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(check one): 1.DBoard of Health 2.0 Building Department 3.❑City/Town Clerk 4.1:Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia 4�a Page: 1 /7ro " ,� Certificate of Flame Resistance F 4.,ter a,Ks El ISSUED BY: REFERENCE REGISTERED MATERIAL VENDOR LISTING Registered Fabric of IN CHART BELOW FOR CORRESPONDING CA Concern Number REGISTRATION NUMBER Date Manufactured (SEE CHART) 4/9/2020 This is to certify that the materials described below are inherently flame retardant. Undercover Tent& Party Invoice Number: 0240382-IN VENDOR TRADE NAME CA REO A Undercover Tent& Party Customer PO: CACOAB.„ING LAN TEA F-041901 31 American Way Customer Number UNDE026 COVINSALES DOUBLE POLISNCLEAR VIE F-072t01 South Dennis,MA 02660 COVINSALES FR TENT LINER F-OBTSOI DAF PRODUCTS OAF DPC F-059501 DAF PRODUCTS OAF REINFORCED TENT F-050302 Certification is hereby made that the articles described below are made from a flame-resistant GLENRAVEN INC FIRESIST F-010101 fabric or material registered and approved by the State Fire Marshal for such use. Reference NERCULITE PROM PAT OS00 F-08830, chart to right for Trade Name of flame resistant fabric or material used and associated SERGE FERRARI PRECONT RAINT 302 F-044001 SERGE FERRARI PRECONTRAINT 702 F-044008 registration number below. SNYDER MFG PRV-GROUP2 F-014001 SERGE FERRARI RIOTS F 101324 THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING Aztec Tents, 2665 Columbia Street,Torrance, CA 90503 Alex Kouzmanoff President Name of Applicator or Production Supenntendent Name Title Additionally the fabric has been tested and passes the following flame retardancy standards: -NFPA 701-2019(Test Method 2) -UK BS7837:1996(2015) -Canadian-CAN/ULC S109-03 -European M2 ITEM CODE ITEM DESCRIPTION UNIT ORDERED PRODUCED CA REG# Z221Z30E1535 '30x15 JT/JT Lite End Top CLR EACH 2 2 F-077101/F-014001 w/SN4P Blockout White Trim w/4 Ratchet Tensioners (With New Clear Trim Details-Effective 4/1/13) Stock 20342a,20342b Z22130CM1035 30x10 Mid JT/JT Lite Top CLR EACH 2 2 F-077101/F-014001 w/SN4P Blockout White Trim w/2 Ratchet Tensioners (With New Clear Trim Details-Effective 4/1/13) Z210DV204002 20x40 1 pc DV Qwiktop Only UW EACH 1 1 F-059302 w/Double Valance Blockout White w/(12)Rope Tensioners Taylor Bray Farm Sheep Festival 40x60 , 20x40 , 20x40 Tents , ..... . . , , . „ , , .. . ... . ., . • ..,.. ,.. • . , ..,. . . ., ... .„ .I .. , ... ,.... . .„ ,,....... . . .... �• �. .... .... ..- .• ., • .... • f • tr.R`A r. .` a' ',. fir : �d� . .....1*41(‘ \.�\ et�� .tom •\\\ »• Newgh li 11. \ • "'�� - Amalgam; K , �� V ' ' u,. _ l. ;, 'I. 4 4, ,:;i:,,,, ,:i 11, ,, U8 Bray Farm moA . r Rd N,Yarmouth 1 ;� aS k