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HomeMy WebLinkAboutBCOI-23-1768 4711-4.4 TOWN OF YARMOUTH �,� � Office of the'Building Commissioner 11 , 1146 Route 28, South Yarmouth, MA 02664 N 508-398-2231 ext. 1260 Fax 508-398-0836 MATTACHEESE 'cORPORATEC)\ APPLICATION FOR CERTIFICATE OF INSPECTION August 15, 2025 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) 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: SAS r-R aB Name of Premises: c Q.L 1\/ �f&\ ID l-e,. Uv�1-- Tel: . Purpose for which permit is us/e License(s)or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to' 1Ce.3CcaS Tel: Address: S \'ti Ck.A. it' Owner of Record of Building y me... at_S �Yu S Address 5 c - �(\A ✓\`^ -� - Present Holder of Certificate V j t e_0 i eX VP Signature of person to whom g,)aeDe ED Tie �- Certificate is issued or his agent R E C ' g���"" - Email Address:c v...:T11S 6)cionLc.i I .wnc\ SEP 12 2025 BUIini- i• T B i s- Town of Yarmouth Instructions: Make check payable to: 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 TIOF N INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR N. Certificate of Inspection#_BCOI-23-1768_ 12/1/2025-12/31/2026 REDFACEJ01 AREGULA A�� CERTIFICATE OF LIABILITY INSURANCE DATEIMMNDIYYYY) 8/29/2025 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 in lieu of such endorsement(s). CONTACT PRODUCER NAME: World Insurance Associates,LLC PHONE 771-8381 FAX 771-0663 34 Main St. (ac,No,EA:(508) (A/c,No):(508) West Yarmouth,MA 02673 E-MAILDESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Trisura Specialty Insurance Co. 16188 INSURED INSURER B:NorGUARD Insurance Company 31470 RED FACE JACK'S INC D/B/Al SCALLY'S IRISH ALE INSURER C:LLoyds of London 15792 585 ROUTE 28 INSURER D: WEST YARMOUTH,MA 02673 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 NUMBER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD wvo (MMIDDIYYYYI (MM IDDIYYYYI A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE I OCCUR 'OSU1009068 8/12/2025 8/12/2026 DREMISE�(AMAGE TO REEa_oNTED Pccurrence) $ MED EXP(Any oneperson) $ PERSONAL&ADVINJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY l PRO JECT WC PRODUCTS-COMP/OP AGG $ _ OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ — (Ea accident) ANY AUTO _BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY-INJURY(Per accident) $ _ NON-OWNEDPROPERTY DAMAGE — AUUTOS ONLY OS NL (Per accident)_ $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS[JAB CLAIMS-MADE AGGREGATE S DED RETENTION$ $ B WORKERS COMPENSATION PER STATUTE ER TH- __. AND EMPLOYERS'LIABILITY Y/N REWC694506 6/19/2025 6/19/2026 ANY PRRO/PMRIIEMNHTBOERR/PARTNER/EXECUTNE E.L EACH ACCIDENT $ Menda _- ( tory In )EXCLUDED? I l N 1 A E.LDISEASE-EAEMPLOYEE',$ If yes,describe under E.L DISEASE-POLICY LIMIT E C Property DESCRIPTION OF OPERATIONS below -- NMB032529 8/12/2025 8/12/2026 1,350,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY 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 MA 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE�_ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ,,�7-;% TOWN OF YARMOUTH b'� Office of the Building Commissioner O = 1146 Route 28, South Yarmouth, MA 02664 ICA O 508-398-2231 ext. 1260 Fax 508-398-0836 MATTACHEESE i q � '---"0RATE 9 f "" APPLICATION FOR CERTIFICATE OF INSPECTION August 15, 2025 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) 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: SS-S `RCU±L a•B Name of Premises: c5Q.I ky J'1r,,s1-\ P‘2_ �e-A&Q Tel: . Purpose for which permit is user ,t+r License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to. CL\Ct C'1 S Tel: Address: tj 'C`C\Ol t/r A L.Q U Owner of Record of Building me___ 01_0 -L ^T rU k Address 5W \'111fl1,un .Q-t - Present Holder of Certificate ot "Qt t Q ` 11 n,1C-, VP Signature of person to whom Tit e Certificate is issued or his agent ?jag a C r to RECE 'i .D Email Address:('-V--11-15 6)(jcY16t.t. ,c�jM SEP 12 2025 fi BU1 Q 1 _: ' f ibt s T ! 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-23-1768_ 12/1/202 5-12/31/2026