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HomeMy WebLinkAboutBLDX-25-1282 - Seaside Fest 3d Office Use Only r� J1 CA ^ 4 it# C _- Amount l'e°RPOR►TEO/ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 1175 Route 28 Joshua Sears Field OWNER: Town of Yarmouth Yarmouth Seaside Festival NAME PRESENT ADDRESS TEL. # CONTRACTOR: N/A PO Box 489 South Yarmouth 508-364-5319 NAME MAILING ADDRESS TEL.# EMAIL: rhonda@yarmouthseasidefestival.com ❑Residential 0 Commercial I 1 Est.Cost of Construction S Homeowner is Applicant? Yes X No Home Improvement Contractor Lic.#20 x 40 & 20 x 20 Construction Supervisor Lic.# WORK TO BE PERFORMED r Tent 2 Duration 3 days (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only *Demolition Raze Structure Solar System ESS System Chimney Fence *Please submit utility disconnect letters for electric&gas—structures over 75 years old require historical review *The debris will be disposed of at: NSA Location of Facility I declare under penalties of.--..N at statem herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial. - oca n i ense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: t. 4 Date: 6/9/25 Owners Signature(or attachment) Date: 0 C'/,3 C/�� Approved By: Building Official(or designee) R E C E I y+' E Rev 6/24 JUL 01 2025 t a BUILDING DEPARTMENT _By The Commonwealth of Massachusetts Department of Industrial Accidents tie 9 Office of Investigations Lafayette City Center t� 2 Avenue de Lafayette, Boston, MA 02111-1750 , www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Yarmouth Seaside Festival Address:1175 Rooute 28 City/State/Zip:South Yarmouth MA Phone#:508-364-5319 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P h' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its , 10.0 Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no tents employees. [No workers' 13.© Other comp. insurance required.] *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:To be Determined Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: 1175 Route 28 City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 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: 6/9/25 Phone#: 508-364-5319 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): 11:1Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 51alumbing Inspector 6.0Other Contact Person: Phone#: CIIenlik 18325 YARMOSEA ACORO,. CERTIFICATE OF LIABILITY INSURANCE DATE"WOOMCI" 09/192025 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:Ifthe certificate holder Is an ADDTIONAL INSURED,the policy(es)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate don not(order any rights to the certificate holder In lieu of such endoreement(s). PRODUCER Mgr Serena Hurtt,AIMS,AU Haas&Wilkerson Insurance FAX 4300 Shawnee Mission Parkway �'me`913 43 urt @ I FA. Fairway,KS 66205 ADOaps:serem•hurtt�tlWMs.lwm Fairway, INRRERS)AFFORDeIOCOVERAGE Noc913 e INSURER A:ACE American Insurance Company(CHUBS) 22557 INSURED HevHER a:ACE Property a Casualty Ins Co.(CHUBB) 20699 Yarmouth Seaside Festival - 56 Longfellow Drive NSORERC: Yarmouth Port,MA 02675 SI9unERD: REIMER 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 CONDrrION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS, RN1SSEXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CI AIMS. LliiR TIER OF INSURANCE WAR POLICY NUMBER ADM(PorIIOerYYY I Mafia A X CONNERCML°RlRALLIABII Y SYYYYUD G71700501 09/25/2025 08/15/2026 EACH OCCURRENCE 11,000,000 ICLASASAMDE OCCUR e(FagoBnnrA) 8500,000 MED sap(Any one moon) i Excluded FetBCNAL&ADvINJURY S1,000,000 GENL AGGREGATE UNITSEPUES PER earfal LAGGREGATE s5,000,000 POLICY❑JPrrTULOC PROOUCTS-OOAPMPEGG f5,000,000 OTHER: i B NRONOB..LMAIOr 112513530/ 09252025 ou15292a, O81Ne'Eut" i1,000,000 _ANY AUTO BODILY INJURY IW,person) S Mimi, SCHEDULED AIIf 90OILY INJURY e'er a N.nt I X HIRED X NORCERNE PROPERTY AUTOS ONLY A ONLY I _UMBRELLA LIAR _OCCUR EACH OCCURRENCE EXCESS LIAR CLARwmEE AGGREGATE f DYE I I RETENTIONS WEIOERS CONPERSATIOM PER 0Tµ AND EMPLOYERS.LIABILITY YIN STATUTE I I6t ANYPROPRI TBERAMTNERIEXECUnVE EL EACH AMIDE-NT f OFFlDERa1EMBER EXCLDDEDI ❑NIA (Merddd.y aI Nis El DISEASE-EA EMPLOYEE S IIyw i41RTI0N dWTIO OFOPERATIONS ONow EL DISEASE-POLICY LIMIT f DESCRIPTION OF OPERATIONS I LOCATIONS I YENCLRS(ACORD 101,AddISonal Rrrerls aelwdoM,mW er Reeelyd N room epee I.required) The certificate holder is named as Additional Insured on the General Liability policy but only with respect to the liability arising out of the Named Insureds operations or premises owned by or rented to the Named Insured per form CG2026 CERTIFICATE HOLDER CANCELLATION Bridgewater State University SHOULD ART OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 131 Summer Street ACCORDANCE WITH THE POLICY PROVISIONS. Bridgewater,MA 02325 AUTHOR®REPRESENTATIVE .Q/y(JNee LE-- 611988-2815 ACORD CORPORATOR.AN rights reserved. ACORD 25(2016/09) 1 of I The ACORD name and logo are registered marks of ACORD #8891258/M891257 HURTS Client/1:16325 YARMOSEA ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(IIMIDDAYYYY) 09/19/2025 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 pallcy(Iss)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms end conditions of the policy,certain policies may require an endorsement A statement on Ibis certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRooucNet Serena Hurtt,AINS,AU Hass&Wilkerson Insurance p FAX L"t�o,ela 913 43 urttl (NC.No):Shawnee Mission Parkway ( „D4 . serena.hrttighwins.com Fairway,KS 66205 INSURER(S)AEG COVERAGE NAIL C 913 432-4400 MSURER A;ACE American Insurance Company(CHUBB) 22667 INSURED Yarmouth Seaside Festival mums n:ACE Property&Casualty Ins Co.(CHUBS) 20699 56 Longfellow Drive INSURER c Yarmouth Port,MA 02675 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. ADOLSUBRPOLICY Ea. ESP TYPE OF INSURANCE INSR WYD _ POLICY NUMBER 'IMMIDDlTWO DIYYYY) UNITS A X COMMERCIAL GENERAL LIABILITY G71700501 09/25/2025 08115J2026 EACH OCCURRENCE s 1,000,000 �B(CLAIMS-MADE [=1 OCCUR pEli oocunbm ooj s500,000 MED EXP(Any one parson) SExcluded PERSONAL 3 ADV INJURY $1,000,000 GEM AGGREGATE LIMIT APPLIES PER! GENERAL AGGREGATE *5,000,000 X�POUCY JECT Loc PRODUCTS-COMP/OP AGO $4,000,000 OTHER S B AUTOMOBILELVBNITY H25135301 09/25/2025 08/15/2026 firINEDSINGLE Lima ;1,000,000 ANY AUTO BODILY INJURY(Par person) S SN ONLY A EDULED BODILY INJURY(Per accident) S HIRED NONOWNED PROPERTY DAMAGE AUTOS ONLY x AUTOS ONLY (Per=Henri S $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE S Den RETENTIONS _ _ $ _ WORKERS COMPENSATION PER OTH. AND EMPLOYERS UABRIVY STATUTE ER ANY PROPRIEMICI PART DRERECUTIYE.Y!N E.L.EACH ACCIDENT S T K:E ERf'WJ.UDED? N!A (Mandatory In NH) El.DISEASE-EA EMPLOYEE S Ryes desalt*under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS!VEIICIEs(ACORD 101,AddlUoml Remarks Schedule,may W attached N more spew le rpulnd) The certificate holder Is named as Additional insured on the General Liability policy but only with respect to the liability arising out of the Named Insureds operations or premises owned by or rented to the Named Insured per form CG2026 CERTIFICATE HOLDER CANCELLATION Cape Cad Collaborative THE ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1175 Route 28 ACCORDANCE was THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 01988-201S ACORD CORPORATION.All rights reserved. ACORD 25(2016I413) 1 of 1 The ACORD name and logo are registered marks of ACORD 536912591111691257 HURTS im...im.ma..iair _. _ ,. . , . ,i.h; 40 skie„ 4 4, issciff ISSUED BY: 4 Qt. EUREKA! TENTS / a dtv. of Johnson Outdoors Gear LLC .,t1 fiel BINGHAMTON, NEW YORK 13902 c, Manufacturers of the Finest (0--c-g.---Q7,--,-, 0 cwy Tent Products Described Herein � 44)1'4- -11,,,., �'+`4 ( . 0.7 DEALER NAME: CAPE RENTAL WORLD ADDRESS: 8C COMMERCE DR CITY: ORLEANS STATE/ZIP: MA 02653 4 ♦ 40 This is to certify that the products herein haw been manufactured from material iiherendy flame retardant as here after specified by the material supplier. Certification is hereby made flat: The articles described on this certificate have been manufactured with an approved flame retardant chemical that was tested and passed the folovng codes: Cal#orria State Fire Marshal Code, NFPA-701, Underwriters Laboratory of Canada (ULC-S109-M87) and (ULC-S109-2003). Desc ion of item cemr d: ' Traditional Party Canopy WBO 20x40 Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric TENT DEPARTMENT,TOI*JSON S GEAR tic y -w a .,•�•