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HomeMy WebLinkAboutBCOI-23-1773 2026 og YA��. \ TOWN OF YARMOUTH (,� ' _ �; �, Office of the Building Commissioner 4 _ :/1404-4„: 1146 Route 28 South Yarmouth MA 02664 } y 508-398-2231 ext. 1260 Fax 508-398-0836 MATTACHEESE F /�cpRPpRATED�b39 APPLICATION FOR CERTIFICATE OF INSPECTION August 15, 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 the below-named premises located at the following address: Street and Number: 1 f 0 ei4-e a 0 6 Name of Premises: Tke R c.c 4c/tt[( Tel: 5&S'' 3 9 1/'fv(� Purpose for which permit is used: 1—i uo r— 1.«^c License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency C'riha i r'Sh c- LoLSfcr is Certificate to be issued to 7& DOA Picc.ad i(( Tel: Address: IcN.101' 2.aa4.c al Solo-G, veilreyow� Owner of Record of Building ( I b r)(Air‘ LLL Address (o C t,.n 3t,IN..,r�)r-C IN' (j1111-3 Sc orrilArvVI-, M/` 01S-C i Present Holder of Certificate* 52 st N off ro /rlu c r- gnature of person to whom 'Vitle Certificate is issued or his agent T'/(/aoa 5 Email Address: �N1QC(aw1Dakemk k.e 1- Date 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-23-1773_ 12/1/2025-12/31/2026 A C` ® DATE(MM/DD/YYYY) Ate, CERTIFICATE OF LIABILITY INSURANCE 9/5/2025 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 NAME: Deland, Gibson Insurance Associates, Inc. PHONE FAX 781-237-1515 36 Washington Street (A/C.No.Ext): , (A/C,No):781-237-1805 _ Suite 40 ADDRESS: info©delandgibson.com Wellesley Hills MA 02481 INSURER(S)AFFORDING COVERAGE NAIC# License#:1780348 INSURER A: Mass Retail Merchants Workers INSURED CANAFIS-01 INSURER B:Acadia Insurance Company 31 325 Canal Fish & Lobster, Inc. INSURER c DBA Anchor Tent&Table; Clambakes Etc 10 Jan Sebastian Drive, Unit 3 INSURERD: Sandwich MA 02563 INSURER E: INSURER F: — I t COVERAGES CERTIFICATE NUMBER:1493982078 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 l 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. tINSR ADDL SUBR POLICY EFF 1 POLICY EXP ,LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS t B X COMMERCIAL GENERAL LIABILITY Y CPA 5620998-10 1/12/2025 1/1/2026 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADVINJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY PE� X LOC PRODUCTS-COMP/OP AGG $3,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y Y MMA5625161 1/12/2025 1/12/2026 COMBINED SINGLE LIMIT i $1,000,000 (Ea accident) + ANY AUTO BODILY INJURY(Per person) I $ li r-1 OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X X HIRED —X NON-OWNED PROPERTY DAMAGE $ -- i AUTOS ONLY AUTOS ONLY (Per accident) _B X UMBRELLA LIAB X OCCUR Y CUA5625162 1/12/2025 1/12/2026 EACH OCCURRENCE $1,000,000 _� EXCESS LIAB , CLAIMS-MADE AGGREGATE $ �l DED 1 RETENTION$ $ I A WORKERSCOMPENSATION 014005034175125 1/1/2025 1/1/2026 X MUTE EMPLOYERS'LIABILITY STATUTE ER -_{ Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A -- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) General Liability-Additional Insured(CL CG 04 92 10 18), Primary Non-Contributory(CL CG 01 14 09 16),Waiver of Subrogation(CL CG 04 92 10 18) Auto Liability-Additional Insured,Waiver of Subrogation(Al CA 59 12 22) Umbrella Liability-Additional Insured Follow Form(CU 00 01 04 13) 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 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 1 I I i i i ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL AUTO Al CAMI1222 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL AUTOMOBILE EXPANSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement,the provisions of the Coverage Form apply unless modified by endorsement. SUMMARY OF COVERAGE EXTENSIONS Provision Name of Extension Limit or No. Included A. Broadened Named Insured Included B. Additional Insured by Contract or Agreement Including Primary and Included Noncontributory Other Insurance Condition C. Additional Insured-Employees Included D. Extended Coverage-Bail Bonds $5,000 E. Extended Coverage-Loss of Earnings(Per Day) $1,000 F. Fellow Employee Coverage Included G. Transportation Expense Due to Theft of a Covered Auto(Per Day/Maximum) $75/$2,500 H. Extended Coverage-Air Bags Included Auto Loan/Lease Gap Coverage Included J. Glass Deductible Included K. Extended Coverage-Electronic Equipment Included L. Extended Coverage-Personal Effects $500 M. Towing And Labor(Gross Vehicle Weight of 20,000 lbs.or less) $100 N. Physical Damage Coverage-Hired"Autos" $125,000 1. Loss of use(Per Day/Maximum) $500/$3,500 O. Rental Reimbursement Coverage $2,500 P. Drive Other Car Coverage Included Q. Knowledge of Occurrence Included R. Waiver of Subrogation By Contract or Agreement Included S. Unintentional Omissions Included T. Bodily Injury Re-defined Included U. Employee Hired Auto Included The above is a summary only. Please consult the specific provisions that follow for complete information on the extensions provided. If there is a conflict between this summary and the endorsement provisions that follow,the endorsement provisions shall prevail. Al CA 59 12 22 Includes copyrighted material of Insurance Services Office,Inc., Page 1 of 6 with its permission.