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HomeMy WebLinkAboutBCOI-23-1800 ,,%g 'YAK TOWN OF YARMOUTH /4 ' ''-1 _F =T Office of the BuildingCommissioner 1146 Route 28, South Yarmouth, MA 02664 te �- 47,'i 508-398-2231 ext. 1260 Fax 508-398-0836 MATTACHEESE /'"91°'0RATE0\,., , APPLICATION FOR CERTIFICATE OF INSPECTION November 1,2025 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: ? (10 /44 i 1J 37E_ P 6)MI JI Name of Premises: Tel: 3��J I y� Purpose for which permit is used: ((mu(*) License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency ?DilQ1,04l1 &Q XU 6a>4 cc 6' Certificate to be issued to Aki (A 4ult ife_6a at, Tel: 7 / 75-00 Address: (COO (!ev-d w 1,1 160.4-, 1 r m 1 fl"7G O20,7 Owner of Record of Building 46 ,-,(-- 1) Address /0 3 Tjt2Ag,ii 3TP i C-f, L icTIJ V4PJ-td(1 i'/ AY124 Oa,6 6,`f Present Holder of,Certificate rjd f4 (,/j/ rct �� ��i � Si ture o person to whom Title Certificate is issued or his agent Ii- 06-d Date - - Email Address: (__,-/Wr---el el 616 4)(\-11 CO NOV 17 2025 l l N 3 :Ir- 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-23-1800 3S°I 12/31/2025-12/31/2026 LI Wiz.. . _ X `S: `: ;"fit ,. .jam.:: .. .. .. - The Commonwealth of Massachusetts I =9iIA - l Department oflndustrialAccidents ieo1_ 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: New England Authentic A uthentic Eats LLC DBA Papa Gino's Address: ( T�sr1 �/q)N city/state/Zipsd giell L/ V1 i da(6Y Phone#:3.0 t?- 3 7,?-1/y6 Are you an employer?Check the appropriate box: Business Type(required): 1.El I am a employer with 20 employees(full and/ 5. 0 Retail or part-time).* 6. ❑✓Restaurant/Bar/Eating Establishment 2.❑ 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. 0 Entertainment their right of exemption per c.152,§I(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]** 1 I.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#I 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#I. I amen employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:Bankers Standard Insurance Company Insurer's Address: 436 Walnut Street City/State/Zip: Philadelphia,PA 19106 Policy#or Self-ins.Lic.#71838009 Expiration Date:02/11/2026 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 perjuiy that the information provided above is true and correct Signature: 2&) �1�" Date: Phone#: 781-467-1647 I„ lllJJl Official use only.Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia EATSLLNE01 ACHARLES coRc) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `.� 2/6/2025 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 lieu of such endorsement(s). PRODUCER License # 1780862 CONTACT Adrienne Charles NAME: HUB International New England PHONE I FAX 300 Ballardvale Street (A/c,No,Ext): (NC,No): Wilmington, MA 01887 A DRIESS: adrienne.charles@hubinternational.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Federal Insurance Company 20281 INSURED INSURER B :Bankers Standard Insurance Company 18279 New England Authentic Eats LLC INSURER C :Safety Insurance Company 39454 600 Providence Highway INSURER D : Dedham, MA 02026 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 SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRINSD WVD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 $ CLAIMS-MADE X OCCUR 36090727 2/11/2025 2/11/2026 DAMAGE TO RENTED 1,000,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 15,000,000 POLICY PRO- X LOC J_CT PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO 73648658 2/11/2025 2/11/2026 BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ A UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE 56726587 2/11/2025 2/11/2026 AGGREGATE $ 5,000,000 DED RETENTION$ $ B WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY Y/N X STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE 71838009 2/11/2025 2/11/2026 E.L. EACH ACCIDENT S 1,000,000 OFFICER/MEMBERt n N EXCLUDED? N N/A 1,000,000 E.L. DISEASE-EA EMPLOYEE $ If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS below _ E.L. DISEASE-POLICY LIMIT $ C Assigned Risk Cornmer COM5928781 2/11/2025 2/11/2026 'Each Occurrence 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) NAMED INSURED SCHEDULE: WC PG Franchising LLC ( Papa Gino's Franchising Corp.) WC DA Franchising LLC (D'Angelo Franchising Corp.) D'Angelo Sandwich Shops Advertising Fund Inc. NEAE Card Services LLC New England Authentic Eats LLC Evidence of Coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE New England Authentic Eats LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Coverage 600 Providence Highway Dedham, MA 02026 AUTHORIZED REPRESENTATIVE 44,&,4,„1. 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