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HomeMy WebLinkAboutBCOI-24-77 2027 og 1?— TOWN OF YARMOUTH RECEIVED - f � 0;: Office of the Building Commission: r I t 1146 Route 28, South Yarmouth, MA 0 64IAN 15 20161 ',0.------7 y' ' G DEPARTMENT E . _ �i 508-398-2231 ext. 1260 Fax 508-398-0 . MATTAGME[SC / By %oRPORATE i9/ y APPLICATION FOR CERTIFICATE OF INSPECTION January 1, 2026 PAYABLE UPON RECEIPT (X) Fee Required$100.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: f b / go(j7 _ I A'. Name of Premises: gA-Ck S 0 SuT O G k . 1.N c.. Tel: 50e 3 G-66 g 0 Purpose for which permit is used: P--QS rA-v GL-i zov-r (.. LL . 4 1-Z/ 2 ‘g /8 0 0 License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to 44 ck 0✓ rbo-c,k Tel: So e 3 6 2 6 6 9 0 Address: / / 42..acd7-e 4 A• (3 L# . Owner of Record of Building = . eAz L i. Address S$ O ¢o 4L57 . So TI, V A a-7r+n, f k f'r A , 02,6Z y Present Holder of Certificate y�,4.G K.S a v 7"1 a•c A O Signature of person to whom Title Certificate is issued or his agent al- /S -2> 2 6 Date Email Address: 41.I'S-144/4.1x.L-t,#1 07.m."-?L . GO,,r+ 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-24-77 02/01/2026-02/01/2027 `a. 3; ---Ji"1 JACKOUT-01 JSCHILDGE ACCPRIC3 DATE(MM/DD/YYYY) �,� CERTIFICATE OF LIABILITY INSURANCE 1114/2026 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). CONTACT PRODUCER 'NAME: __- , World Insurance Associates,LLC PHONE FAX 34 Main St. (A/c,No,Ext):(508)771-8381 I(A/C,No):(508)771-0663 West Yarmouth,MA 02673 E-MAIL INSURER(AFFORDING COVERAGE I NAIC# INSURER A:NorGUARD Insurance Company 131470 INSURED INSURER B: Jack's Outback,Inc. INSURER C: 161 Route 6A Rear INSURER D: Yarmouth Port,MA 02675-1713 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 ADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE I INSD I WVO 1 POLICY NUMBER !(MM/DD/YYYY)1 IMM/DD/YYYY1 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ - CLAIMS-MADE I. OCCUR DAMAGE TO RENTED _MEMJSES(Ea ocoormacel $ MED EXI Anemone person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY i JEC- i LOC PRODUCTS-COMP/OP AGG $ t__ OTHER $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) I $ ANY AUTO BODILY INJURY(Ir person) i $ I OWNED - SCHEDULED • AUTOS ONLY AUTOS BODILY INJURYier accident$ N_o PROPERTY DAMAGE ; i AUTOS ONLY __ AUTOS ONLYY Jer accidents 7$ I 1 UMBRELLA LIAB i OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE _ $ DED RETENTION$ $ A WORKERS COMPENSATION YI PERTUTE 1 I OT ERH AND EMPLOYERS'LIABILITY JAWC791808 2/1/2026 2/1/2027 1,000,000 !ANY PROPRIETOR/PARTNER/EXECUTIVE N N E L EACH ACCIDENT 4$ (MFandatory n NHS EXCLUDED N I A E L DISEASE-EA EMPLOYEE] $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached ifruired more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRES(iE.NNT.AATIVE � ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Y( ,' lr y r♦ a h f` .