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HomeMy WebLinkAboutBCOI-23-1690 application (ff YA�de. �. TOWN OF YARMOUTH Office of the Building Commissioner - t�; 1146 Route 28, South Yarmouth, MA 02664 '0f' X- r y; 508-398-2231 ext. 1260 Fax 508-398-0836 ,` MATTACHEESE �` /' "oRA s0�b�q APPLICATION FOR CERTIFICATE OF INSPECTION April 01, 2026 PAYABLE UPON RECEIPT (X) Fee Required$50.00 ( ) 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 Num�e'r: C,> C. ) ' v t t f/- r711-6• t ) k A �f 2 6Name of Premises: b Or Lady.) vc +ilk 4 iQ{, kickTel:: 508- gc( 8— 2218 Purpose for which permit is used: C k U/kAl S t as o r G,t 1 License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to .+. P I V S X 0, Occ I'S Tel: 5 06 -,;9 0-2 z V e' Address: S ga to cv s Sf So U4.4 ya. rh Q v t1-) fi G L A 0 2 `f Owner of Record of B ' din St . Pisys )C <11 tit Li, Address i0`14 1Oufe 1-8) ,s'd✓+/, d, n, o1/4/ 01, l 4 o214,1 Present Holder of ertificate J3. VI'vs X h IJtCL /414f1PVI R E - - \._E Signature person o whom Title 10 i v Certificat is issued or his agent 50_b%�p,? 4 ' APR 16 2026 _ to _ _ ,, Email Address: o Fr; t o 0 S 4-�7 A vS X 5 y , co), eu���i ° ARTrn sy -----` 1 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-23-1690 05/01/2026-05/01/2027 _ _ . , _ ..„ - s. • `'A C ® R D DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/09/2026 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). PRODUCER CONTACT NAME: PHONE FAX (A/C.No.Ext).: (A/C,No): Massachusetts Catholic Self Insurance Group ADDRESS: Certificates@Ratiorisk.com 66 Brooks Drive INSURER(S)AFFORDING COVERAGE NAIC# Braintree MA 02184 INSURERA: Massachusetts Catholic Self Insurance Group INSURED INSURER B: Diocese of Fall River,MA INSURER C: St.Pius X Church INSURER D: _ 5 Barbara Street INSURERE: South Yarmouth MA 02664 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. LIMITS SHOWN ARE INCLUSIVE OF AMOUNTS REQUESTED BY THE CERTIFICATE HOLDER AND MAY NOT REFLECT POLICY LIMIT AMOUNTS IN EXCESS OF THOSE REQUESTED. *Not Applicable in WY INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXPD/ LIMITS LTR INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE _$ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION Certificate of Approval 03/31/26 03/31/27 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER y/N Commonwealth of _ _ ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBEREXCLUDED? N/A Massachusetts — — (Mandatory in NH) 3000001012026 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Inspection by Town of Yarmouth for Our Lady of the Highway Chapel, 1044 Route 28, South Yarmouth, MA 02664 CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE Amanda Kalathas ACORD 25(2025/12) ©1988-2025 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD