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HomeMy WebLinkAboutBLDX-26-94 Office Use Only Off` $ _ 1 a —ol 01 FEB 1 l0 2026 Permit# ie Y'S Ci � " l� ci-)1s,4 133 Amount L )ari LAC) MATTALMLL66 • \.. e, "p . EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: OWNER' Scally's 585 Route 28 W.Yarmouth, MA 02673 508-771-5225 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Bayside Tent 40C Whites Path S.Yarmouth, MA 02664 508-76-4025 NAME MAILING ADDRESS TEL.# EMAIL: ryan@baysidetent.com ❑Residential Iommercial/ ❑Est.Cost of Construction$ /d v Homeowner is Applicant? Yes No J Home Improvement Contractor Lic.# Construction Supervisor Lic.# ?0,3v /c;CL ° S'Zi'.l )oX 2-0 Crie pPc.? WORK TO BE PERFORMED Tent Duration 3 17 - 3/1 (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only *Demolition Raze Structure Solar System ESS System Chimney Fence *Please submit utility disconnect letters for electric& gas—structures over 75 years old require historical review *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of y license and for prosecution under M.G.L.Ch.268,Section 1. ., as ] L Applicant's Signature: 14 /_ ) ' � �l. Date: l 4/L 6 Owners Signature(or attachment) 11, '/`-'-• Date: 2 I/0/ G Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents y- Office of Investigations I - ' Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Bayside Tent Address:40C Whites Path City/State/Zip: S.Yarmouth, MA 02664 Phone #: 508-760-4025 Are you an employer? Check the appropriate box: Business Type(required): 1.1E1 I am a employer with 7 employees (full and/ 5. ❑Retail or part-time).* 6. 0 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. 8. El Non-profit [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, MO Care with no employees. [No workers' comp. insurance req.] 12.0 Other Tent Rental *Any applicant that checks box#1 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#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Mcshea Insurance � Insurer's Address: I(/ [c r 4 f"4 �� �/f1. 'J l(f, City/State/Zip: �j('✓m I Lv1 h7 f a(p a Policy#or Self-ins. Lic. #WCC-500-5013321-2025A Expiration Date:5/22/26 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under § 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 perjury that the information provided above is true and correct. Signature: Date: 2/10/26 Phone#: 508-246-6128 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License # Issuing Authority(check one): l.EIBoard of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia t-O ?& wr ." .,: . 6 1) 01116116.., ry gO?C3 it °� r F >.. , lr?il ( :`3 �" v. r 'Y. .V`;'r'. v. Y. Y � �.. �.'�. F •.1 �....t ,..( 1 "Y'!:'4 v"ry 6 ( � ''( "i :��.'r W Yr:� ( Y�:S v v:..`t .e. �r0?. r � � /�.,..;.F-r:.D.•.Y.n ( `4- '�r �`v .1' `Y. 1 t t ::r .r .n a. ap. ry n ..,,.. c• r. tr„ r ,. �•tt 1 t w _�-- -4wr.r a.� :.a�i1�iwe 3 v__�� _ 't ,( �. �S _.�( -�a�d��-- '�" 1 C r,4wd_Aw•1 I,;,l",d Liy.4.4e d_LW::�,��lid .m :•i ��=� .,�•L =".•.�l__it�t ".;,,�_,�'i�a.',Y-h�a.� Syu:t�l. �AJ�".�d.4s!.�.A�•,7._ �L4e"1.�a�-�l,di�:t�.,y�:1�eL1_ i..la"".I 1»'"i�Y':'";�.�tC�14�.4y�r i,"„_1(�•s� J. .i J o'w.A L1 fy ' e: Certificate of Flame Resistance ins: ' This is to certify that the materials described have been flame-retardant treated(or are inherently nonflammable) <' Issued By: ""' S; Celina Tent, Inc. Ff. fi 4 '' 5373 State Route 29 t ' s.' Celina, Ohio 45822-9210 ii'-‘, l www.CelinaTent.com 4 e „ .•sf ,: MANUFACTURER OF FINISHED TENT %,.•:,.::,. .,, PRODUCTS DESCRIBED HEREIN " '' "' ' Celina Tent, Inc. certifies that the fabrics used in its tent products are flame resistant.All tent,canopy, structure, and shelter products manufactured ' and distributed by Celina Tent, Inc.will display a"Tent Identification and Warning label" certifying that it has been made of a flame resistant material. F..4-.1 iti,),,, Tent fabrics have been independently tested to meet or exceed one or more of the following flammability specifications: '_', NFPA-701 CPAI-84 ASTM D 6413 i' 04 ' BS 5438 BS 7837(1996) DIN 4102-B1 1-� _ WAY F? Certification is hereby made that:The articles described on this Certificate have been treated with flame-retardant approved chemicals and that the <r' application of said chemical was done in conformance with California Fire Marshal Code, and is equal to or exceeds Specification: NFPA-701 rti ;I!:1,:..'.' ri Method of Application: IMPREGNATED Description of Item Certified:MASTER SERIES FRAME TENT F ''> F;i:' The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. { , J n ' This item is certified flame resistant or nonflammable, NOT FIRE PROOF. '-. ; The fabric will burn if left in continuous contact with any flame source. ::J. Open flames should never be used under any tent, canopy,structure, or shelter. WY::-.:- Tent Products Division—Celina Tent, Inc. :::ils% Ci4ara?ra liderta _____________ w.,-:‘, •: � Signed:CELINA TENT" Rev.20150709 1` ``" i �,,.,r p.m. ',.a..r.,�a 1 ^9 r., i. ,.:,:, •. m7 7..,,; ., , rmma r^ r,:� �a,mq r..:• r'^•v ..� :.Tr 7m*M ,.,�t fB-.,rl-..". t � a � r•'�''f:."°"�•r ,,xd 4": i r it r pT^r r�,S r� G'^,°G^r t"t^1�'T:y"'r' .�r ^I d �: �r d �,..i� n ,.c� ••v T,;"^M`1^^"!'r"�"t"":''�' :,'Y r� rh„ r., rd . »'9 n. M f'• d. A. ,5 t 1. .d. .n.. »i, '�`! 7, 4F rL .9• W! .i". 7 ,rn t;•:t : :V. , 14 x- ,. 'a... .:s• :�i L' ir'• :.' :•:v :r: :vr 4, .t:' ^s:: ,tt, .ek p.,4 4 ? r4 r1.;'' x ,�. A TA ;!. 4 '.h ,...�, e �l k �.t, A, i«,': � .�?;. � 4 Oc A,...,A A, .2�� h .,s: x .+'� �r,rd... t4.Ir .a is A,; t � 4 :.A ..4 1 1 . f .'7 I Y':.Y. -� Y 9 `i�..«Y �i. '0.):Y f. ��1'. '1y. •f.`'.'f�l�V'. ; wY 1 .�1 1'tt '4' f,��Y '.f f.V'/ f 'V�� f� 7'' �. �5� '`f-"1 Yf' i' V f;l 'K` V `7� f l i l�i 4 F '' Iz .,t� r'r.. n, -t. ,.< "u r u' t i ,Y: .,x,. .a... .},�, SJ',. Yw'c'rr'� r�`ii�._5 t.,f.., -0 ..d, t7nr "(;,, 1R.S i.. ••iRV. '1.CS: �7 R,x 67.'C 27; raw .ii �t.C.rr.,i t,Wi u.�,.i„,J i>s"�.4errl�lu�l i.a<�r.�— Ww•L!,�'" le�.,'�'�4�%9_4r:'�+��L":%�.}�-•„�,dl r���_a.�i 1r�_ _4y_��w�.4e{�L4'.rsd fr_3b,��l.�:dk ,4�'u••�A_•0.i t:.a i.,�„} �.>4r.11�';a�4w.u�1�4,�__�.r.i>>F.,�.�.�•!.�'S��w�..���. �i.�"2k�,,d1'�,:•tl,,.a,4���E ,,,,,)i.7„:::471, Certificate of Flame Resistance ? ,,,,;_„. ,ii r` This is to certify that the materials described have been flame-retardant treated (or are inherently nonflammable) '-& ; .' Issued By: x41, . a Celina Tent, Inc. �' {h ,z 5373 State Route 29 - �� ' , Celina, Ohio 45822-9210 ,' � . eSt 3 www.CelinaTent.com •;:; i.,5;,-' 4 , . v ,' -� MANUFACTURER OF FINISHED TENT ., t`'Y PRODUCTS DESCRIBED HEREIN 1<,, ' ,. Celina Tent, Inc. certifies that the fabrics used in its tent products are flame resistant.All tent,canopy, structure, and shelter products manufactured and distributed by Celina Tent, Inc.will display a"Tent Identification and Warning label" certifying that it has been made of aflame resistant material. e} Tent fabrics have been independently tested to meet or exceed one or more of the following flammability specifications: �., ._; NFPA-701 CPAI-84 ASTM D 6413 O��F V ,'z+ BS 5438 BS 7837(1996) DIN 4102-Bi Certification is hereby made that:The articles described on this Certificate have been treated with flame-retardant approved chemicals and that the ' ''= y4' application of said chemical was done in conformance with California Fire Marshal Code, and is equal to or exceeds Specification:NFPA-701 Ee _, 0 mot,; Method of Application: IMPREGNATED Description of Item Certified:MASTER SERIES FRAME TENT `r .j The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. i'�'`, X�.dl pip_:,,:' E -, This item is certified flame resistant or nonflammable, NOT FIRE PROOF. ,,P; The fabric will burn if left in continuous contact with any flame source. P ', ,:! Open flames should never be used under any tent, canopy, structure, or shelter. Tent Products Division—Celina Tent, Inc. fi- . = Signed: "> -, c1142; piz..,c' '. CELINA TENT' Rev.20150709 7rtru r7'a rr.'2r't:^,1+ i, i' t„rf ;a !�' P J '.17 "IdP .'t:' �.. .ii .AY, t .l C"' ,J. 1... �,.,r�.k m4 .., ., ,.. :.a 0 f,�•• r,.,. n ..J _, ... .'. ... .. rJ �:R d4. r5' i ,.. .;A 'A• ,A. A.•, A...� •� l� A) �}:;d � A .3y .9. 4,a1...� h, ,?A. �z .+. 4., .A ,� .d`h,.. Ai SA•,%�, $ a., rA. ,. eA, x.. .�g.::. 0,< +. >,e aA ,. !:? • tl. < > +� . a. /t r�, 9t '.tE .s'i.'',' 1 f 4 v e;..::. 4 . i J ,t t V'�a.' Y v::Y. "1" ,'1.. Yv:Y,,i.."i•'•.e rY,: W..�•,a.V'7•S''.. r,11'., ,l.. Y a'S,i`:••hi ;r W.,.:4":... .:_•'f r_ �. �•". :Y..• ,1. .i'�;;"Se;,;., •,5°'Q �.f.'+Y..��v.'Y.•.`•. 'Y"�.Y: ;v.,. }• 'Y r .a 4r. s�',tin. ,ti c n,a. „t„ .,f r.�„ Y r, n ,.'y,r ,`�r. i' .l. ,:r. �V`, Y .'.'. ♦,: Y • ,r i 'd, ,i 'ar Y.;�Y` Y ��,� Y 7 Ju ,•f il,r ","N '•'ta 1 r, nm, �� ,?Y •„fi. "'r, ,d d., :E';, 144.A ,fig „utZ,n 'a'„ 4.•.dt ,..i. ".a1' ,.1, al,w"'.'to-. 4�.i�J:'y",a lwd.+6w��✓ -4�._1�wL�u.d,.l,,��"a:yw��+_w:awS i',i�'ddyW"�'"� s".f�t�e'tl !�,. '�"�d�w�_�! 1,,,.1 L,,.�.lu�'.�.Guv�e4-0�'>24•,s•1 atMt L"'t't.4�s ra�, ;4 a irii�",t a� -6�wu�,•,< "7�'��14:�•ia_��1���"nd.�wra����1�+1E�!, i+•�va'.J_."1J�•ra k9,.~ .a • • ' "' �1 Certificate of Flame Resistance 1:,--r r, This is to certify that the materials described have been flame-retardant treated (or are inherently nonflammable) 1:1' f .di,, ter- Issued By: Celina Tent, Inca' 5373 State Route 29 3 • , Celina, Ohio 45822-9210 `' _ 1' www.CelinaTent.com 1.. t, 0`y V 4 }` MANUFACTURER OF FINISHED TENT } ( PRODUCTS DESCRIBED HEREIN Celina Tent, Inc.certifies that the fabrics used in its tent products are flame resistant.All tent,canopy, structure, and shelter products manufactured and distributed by Celina Tent, Inc.will display a"Tent Identification and Warning label" certifying that it has been made of a flame resistant material ti Tent fabrics have been independently tested to meet or exceed one or more of the following flammability specifications: -" NFPA-701 CPAI-84 ASTM D 6413 Rah {r— Y 1, ,,,, BS 5438 BS 7837(1996) DIN 4102-B1 OP f4,i, Certification is hereby made that:The articles described on this Certificate have been treated with flame-retardant approved chemicals and that the - application of said chemical was done in conformance with California Fire Marshal Code, and is equal to or exceeds Specification:NFPA-701 ,,, _alia Method of Application: IMPREGNATED Description of Item Certified: MASTER SERIES FRAME TENT L'r • >' a, The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. D. ty t :)".--- This item is certified flame resistant or nonflammable, NOT FIRE PROOF. ' The fabric will burn if left in continuous contact with any flame source. r1. x z Open flames should never be used under any tent, canopy, structure, or shelter. K" Tent Products Division—Celina Tent, Inc. , :,:,-!;,,, at41=1710 Signed:_,li,e �� _ ' CELINA TENT' j, Rev.20150709 ' [' ' a .. 7,',^,7 t'"i t,"!`„,.P7';T,..R',„,,t, TT, ,. 17„''f I 1 7 r:"r G,i1'4,`d"r„ FNn•'9 G:",A,,. 7,1 „i,,, ,T .., Tar''SJ r„to 7„7 T","vT P+.^,7 1„ 1;,"7 t',::' 1774, T�•7'i,„'. Y� t r—_-57 g,•,. .x. ,X ..,1. �'7 .L. � .d, ."'^C��"^".jl�:;T'�1—Pv t���- �.',�7 1 •s 'a `>! el....��,.� 4 ?'- .r, S. ? :tt. +, .:A� A 'h !. .54::;e Bl ti 1 '1: .A. '".'.A. A' :,. 4.. ,�.: ',�# 1 .'h" .:! ..+4. 4. �'�.' A. s',,,' x'�r , e�, on e x ?..' .a� '�..; e1s rt .+� �:, d�\ , <>tiv e4..: } Y �. '°. h .nA• ,..d. . .. � �4- ♦. � � 8s .� .-:��.7 y\_ ._ � •fk .�=`1. .�, ,w .'....'k't S_ . ACORO® DATE(MMIDDIYYYY) � � CERTIFICATE OF LIABILITY INSURANCE 06/10/2025 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). PRODUCER NAM: NAME: Sean McGrath ONE McShea Insurance Agency, Inc INC.No,�: (508)420-9011 is,NO);(508)420-9010 1645 Falmouth Road, Rt 28 BLDG D E-MAILDRESS: Sean@mcsheainsurance.com Centerville, MA 02632 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: PENN AMERICA INSURED INSURERS: Pilgrim Insurance 21750 Bayside Tent&Table, Inc. INSURER C: A>I.M. Mutual 40c Whites Path INSURER D: _ South Yarmouth, MA 02664 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00002179-449707 REVISION NUMBER: 3 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 ADOL SUBRI POLICY EFF [ POLICY EXP LIMBS - - LTN NW MAID POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY PAV0576226 05/17/2025 05/17/2026 EACH OCCURRENCE i$ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 XI POLICY ECa LOC PRODUCTS-COMP/OP AGG $ _ INC $ OTHER: B C AUTOMOBILE LIABILITY CSC00001015534 10/26/2024 10/26/2025 (Ea acBI dennt51NGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED I SCHEDULED BODILY INJURY(Per accident) $ k AUTOS ONLY X I AUTOS HIRED NON-OWNED I PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAR I OCCUR EACH OCCURRENCE $ EXCESS LIAR i CLAIMS-MADE AGGREGATE $ DED RETENTION$ i$ C AND EMPLOYERS'Lk46 WORKERS COMPENSATIO ITY WCC-500-5013321-2025A 05/22/2025 105122/2026 X STATUTEOTH- ER PROPRIETOPJP EXCLUDED?ECUTIVE Y N/A E.L.EACH ACCIDENT $ 500,000 OF(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Comp:Corporation owner Ryan Gillis is not included for coverage under the Workers Compensation policy 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 REPRESENTATIVE I -4 `1 trAUt- (SPM) ©1988-2015 ACORD CORPORATION. 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