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HomeMy WebLinkAboutBCOI-23-1741 2026 '4; Y TOWN OF YARMOUTH Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 TTACHEESE OR0ORATED\9 APPLICATION FOR CERTIFICATE OF INSPECTION July 01, 2025 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�thhe below-named premises located at the following address: Street and Number: G% r 1 I 5 C,1 rGU 1 J Yet rmo '0+ A- 0 2 06 Name of Premises: IV1 e e n, 400Se' Tel: 50 g—V b 2 r `-"' I,, Purpose for which permit is used: ill ee�� , ,54 Ci a I( eve,+s Y I t i i e o(,�(�er ust License(s)or Permit(s) required for the pre es by other governmental agencies: License or Permit Agency occv nGy I�►(65 Wa y ?ros+ Certificate to e ssued to i n1.S Lki y � r l)5}' Tel: 5 Og- �2— 353E Address: 6e/' / lil Yafmoc To!'r,iif 0263-55 Owner of Record of-Building 'n a% 7 U t Address 8 16;44s ci IX( Or 60-) O2 75 Present Holder of Ce3'fificate ) y ru51 ogrS n;111,5 r&fi ve 4-55 15 in+ Signature of person to whom Title Certificate is issued or his agent J U 1 y ) ZO Da Email Address: c,c1 m in , k w c, ba r k a a rnarrivp v►e n . CO M 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-23-1741 08/10/2025-08/10/2026 /ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 7/3/2025 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 endorsement(s). PRODUCER CONTACT The Baldwin Group Northeast LLC PHONE FAX 410 University Ave tA/c.No.Ext):800-553-1801 (A/c,No):877-816-2156 Westwood MA 02090 ADDRESS: mail@rogersgray.Com INSURER(S)AFFORDING COVERAGE NAIC# License#:PC-514062 INSURER A:Manufacturers Alliance Insuran 36897 INSURED KINGWAY-02 INSURER B Kings Way Trust CIO Barkan Management INSURER C: 64 Kings Circuit INSURER D: Yarmouth Port MA 02675 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2009116710 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 MAIL HAVE BEEN REDUCED BY PAID CLAIMS. INER ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE I OCCUR PREMISES(Ea occurrence) $ - MED EXP(My one person) $ PERSONAL&ADV INJURY , GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY PRO-JECT LOC PRODUCTS-COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ 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$ $ A WORKERS COMPENSATION 202401-10-06-89-9Y 2/18/2025 2/18/2026 X AND EMPLOYERS'LIABILITY STATUTE ER Y ANYPROPRIETOR/PARTNER/EXECUTIVE N N NIA E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUT ED REPRESENTATIVE Souith Yarmouith MA 02664 - ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD