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HomeMy WebLinkAboutBCOI-23-1767 application %----YA TOWN OF YARMOUTH fb, ; r0,&of Office of the Building Commissioner --, 41 1146 Route 28, South Yarmouth, MA 02664 o "`_" = H; 508-398-2231 ext. 1260 Fax 508-398-0836 MATTACHE,E /�C T:CHTED��9 `' 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: 3 35 `.UGl 6 Name of Premises:—The.Ycxi tj �i,,t.ti. Tel: SOS- `1- I-CI ST-( Purpose for which permit is used: o_ . =License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to Ol ur1 4t S Vrv3e-f p r i%-eS Tel: Address: 33S MCsu.in S.\-,ks_A.* Owner of Record of Building y vkr.A4 se �� .erx JUZ.A.1 i r &N t Address . 3S Mail-n c;"\ t Present Holder of Certificate Signature of person to whom Title Certificate is issued or his agent $ Ia.$' Date ;" k , Email Address: (�'rv' �% Q�(Y1cu.L, Lore, i . _._._.�..._.___' 1 1 v i SEP 12 2025 1 1 F36:34:4?, ' 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-23-1767_ 12/01/2025-12/31/2026 2SDS S I '-132 ___-.."N KOUNADIS01 AREGULA ACORD r CERTIFICATE OF LIABILITY INSURANCE OATE(MM/DDIYYYY) �.- 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). C TACT PRODUCER N E_ World Insurance Associates,LLC PHONE — ----- ----- FAX INC,No,Ext):(508)771-8381 (AIc,No):(508)771-0663 34 Main St. E-MNL West Yarmouth,MA 02673 ADDRESS:- INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Hartford Casualty Insurance Company 29424 INSURED INSURER B:Associated Employers Insurance Company 11104 KOUNADIS ENTERPRISES D/B/A THE YARMOUTH HOUSE INSURER C:- 335 MAIN ST INSURER D ___ WEST YARMOUTH,MA 02673 INSURERS: 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. ILTRR ADDL SUBR POUCY NUMBER POUCY EFF POUCY EXP UNITS TYPE OF INSURANCE INSD WVDIMWDO1YYYYI IMMIDDIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 I CLAIMS-MADE X OCCUR 113SBABT5GWT 7/31/2025 7/31/2026 DAMAGE TO RENTED 50,000 PREMIS (Ea o ES currencel $ _. MED EXP(My one person) S - 5,000 1 PERSONAL&ADV INJURY S 1,000,000 _GENERAL AGGREGATE S 2,000,000 GENT AGGREGATE L MIT APPLIES PER: 2,000,000 POLICY I I gel- -1 WC PRODUCTS-COMP/OP AGG S OTHER: S COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY fEa acciden S ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS PROPERTY DAMAGE AUTOS ONLY NON-OWNEDOS NL (Per accident) S S UMBRELLA UAB OCCUR i EACH OCCURRENCE S t EXCESS UAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS S B WORKERS COMPENSATION I X STATUTE ER OTH- AND EMPLOYERS'LIABIUTY YIN WCC-500-5022314-2025A 6/8/2025 6/8/2026 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE I N I NIA EL EACH ACCIDENT $ FFICERR//MMEEMBEER EXCLUDED? 500,000 (Mandatory in NH) E.L DISEASE-EA EMPLOYEE S If yes,describe under 600,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ A LIQUOR Liability 13SBABT5GWT 7/31/2025 7/31/2026 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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. 1146MART28 South Yarmouth,MA 02664 - - AUTHORIZED REPRESENTATIVE .t10......, ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. 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