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HomeMy WebLinkAboutBCOI-24-13 2027 r� F Y4 N TOWN OF YARMOUTH 0 Office of the Building Commissioner L 1146 Route 28, South Yarmouth, MA 02664 o _.. `,- y' 508-398-2231 ext. 1260 Fax 508-398-0836 `�/ MATTACHEESE q J \tiC � .N-C)RP 0 R ALE,/ 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-naamed premises located at the following� � / addess: Street and Number: 2'01] 00 a)n :4 f (Vyo bi,L7 4( )%J/) C) W1 Name of Premises: htt irtt a 1 ( L'{44 /7pp, Tel: 0 - 71n I Purpose for which permit is used: License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency it. Certificate to be issued to ,,k I '141 ,) 61/4-6.14% Tel: _ .'L� /OD Address: ?6 i (7� Mal 1.) Yin lik- Owner of Record of Building '3(j Cy �jJ� Address �a V Present Holder of Certificate ��/1 ik0 ; . a A 4 vid e a' i, r. Signakire of person to whom Title Certificate is issued or his agent 1 1 /a.1 l,* _ Date Email Address: 1C ��jO L'(I a[ (eVl' , RECEIVED ' JAN 15 2026 BUILDING DEPARTMENT By --- 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-24-13_ 02/06/2026-02/06/2027 • • • asasa1NALi y_,1AA,.4•0 ' YV) .....is � MMIDD/1N ACc R� DATE( CERTIFICATE OF LIABILITY INSURANCE 12/OMOO/11 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(les)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 cm this certificate does not confer rights to the certificate holder In lieu of such endorsement(s)- PRODUCER CONTACT Gabriel DeSouza GIG NAME: Murray&MacDonald Insurance Services,Inc. PA FAX HONE,Eat): (508)540-2400 F No): (508)289-4111 550 MacArthur Blvd. E-MAIL gabriel@riskadvice.com ADDRESS: INSURER(S)AFFORDING COVERAGE ( NAIC# Bourne MA 02532 INSURER A: Mount Vernon Fire Insurance Co 1 26522 INSURED INSURER BWesco Insurance Co 1 Cultural Center Of Cape Cod Inc. INSURER C: 307 Old Main St INSURER D INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 25-26 Master REVISION NUMBER: THIS IS TO CERTIFY TI-AT 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 ANSDL Swvo POLICY NUMBER (MM ODY EFF JYYYY) (MMIDDYYYY) LIMBS EXP LTR TYPE OF INSURANCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE /'� OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence/ 5 MED EXP(Any one person) $ 5,000 A Y NPP2566508H 06/01/2025 06/01/2026 PERSONAL&AOVINJURY 5 1,)00,000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE S 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG 5 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE 5 AUTOS ONLY AUTOS ONLY (Per accident) 5 X UMBRELLA LIAB _ OCCUR EACH OCCURRENCE 5 A EXCESS LIAB CLAIMS-MADE CUP2552068H 06/01/2025 06/01/2026 AGGREGATE 5 OED ( 1 RETENTION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECl1 IVE Y/N EL EACH ACCIDENT S 1,000,000 B OFFICER/MEMBEREXCLUDED? n NIA WWC3784967 06/01/2025 06/01/2026 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 5 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 1,000,000 DESCRIPTION Or OPERATIONS/LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Town of Yarmouth is listed as additional insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth t MA 02665 s,;, ptce_ j 1w�/-., ,,,,,&,;_ I �' ©1988-2015 ACORD CORPORATION. All rights reserved. + ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD