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HomeMy WebLinkAboutBCOI-24-18 p..- es\, TOWN OF YARMOUTH (7"'- '.- � � Office of the Building Commissioner 111, a;fir 1146 Route 28, South Yarmouth, MA 02664 f - -,, 508-398-2231 ext. 1260 Fax 508-398-0836 4,N �,� ,�►� ;iiakit /kc�RP0RAIE: z� RTIFICATE OF INSPECTION January 1, 2026 PAYABLE UPON RECEIPT 12 2026 i ( X) Fee Required$181.00 ( ) No Fee Required BUILDING DEPARTMENT In accordance with the prov 8 State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: a i I SU`'i Ch0 re 0( ‘ Name of Premises: 5 JI14-SGwO kra it I Tel: 568=3q 37O6 Purpose for which permit is used: 1Y10 k-Z i License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to d9/77 Shot a) via,L L C Tel: 53glig37o6 Address: Owner of Record of Building SC.v 't Q S abev-r Address PO tg6y 376 5 . 1 YYtcsu l Y`'\,4 �--(., C y Present Holder of Certificate 9 11 a u h � pr , L L C . r ()Tar,"t'r Signature of person to whom Titl Certificate is issued or his agent / ,) Co Date Email Address: 5 P Q S Y1 LW)1 GL 0 1 , L 6►"1 Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth, MA 02664 Return this application to: Building Inspector's Office Please note: Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified. Application must be received before the certificate will be issued. The building official shall be notified within ten(10)days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# BCOI-24-18__ 02/17/2026-02/17/2027 .... • . ' •'. . -,•,-.','''' ' - ',' . ----". .' A-.•-•-•'I.; -1 i :.t.,.,.,...e.•;_. .. , asos I: mAL ' ! .._._„.., ._.....2. .-, _- f ,. - ,,.,,,, ,,,...11,..,,,E,..,4,$,,,,„,.,_- - -____-_- ' - , .1' ...•it 41.1 i,,,Z.Alz:-.,". ::,..:^14,4,,,3:V.t,,.; - -- _,-- - . . , • . . - !... -�� DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/01/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY 'DR 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 be endorsed. If SUBROGATIONIS 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:: THE OCEANSIDE INSURANCE GROUP 08084400 PHONE (508) 771-1660 FAX No : (508) 775-1135 (A/C, No, Ext): (A/C, ) PO BOX 38 E-MAIL ADDRESS: WEST DENNIS MA 02670 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A : I-Dartford Fire Insurance Company 19682 INSURED INSURER B : SKP1 M, LLC., 731 MAIN STREET LLC. 277 S. SHORE INSURER C : DRIVE LLC DBA SKIPPY'S PIER 1 - INSURER D : PO BOX 370 SOUTH YARMOUTH MA 02664-0370 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MM/DD/Y YYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person) PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY PRO- LOC PRODUCTS - COMP/OP AGG JEOT OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED BODILY INJURY (Per accident) AUTOS _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) UMBRELLA LIA3 OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS- AGGREGATE MADE DED RETENTION $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS' LIABILITY STATUTE ER ANY Y/N E.L. EACH ACCIDENT $1 ,000,000 A PROPRIETOR/PARTNER/EXECUTIVE N/A 08 WEC AD'A4A 05/30/2025 05/30/2026 OFFICER/MEMBER EXCLUDED? E.L. DISEASE -EA EMPLOYEE $1 .000.000 (Mandatory in NH) If yes: describe under E.L. DISEASE - POLICY LIMIT $1 ,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the In sured's Operations. CERTIFICATE HOL.DER CANCELLATION 277 South Shore Drive, LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Surf and Sand Motel BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED Sandra M DiGiovanni IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 370 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD