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HomeMy WebLinkAboutBCOI-24-70 2027 fi?' .1. 0) TOWN OF YARMOUTHtnm Office of the Building Coissioner -4 . t 14 '' - til - 1146 Route 28, South Yarmouth, MA 02664 AA'7.• . -':'''. *2..77-7 Ar 508-398-2231 ext. 1260 Fax 508-398-0836 .. 4,,..efi.at. ,./41,0b i ...... ,„..,-- APPLICATION FOR CERTIFICATE OF INSPECTION April 01,2026 PAYABLE UPON RECEIPT (X) Fee Required$200.00 ( ) 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: L175 R4 , 2 il 71 Name of Premises; Lope cod fa LI qb a rtajw e Tel: SC 4120-cog so Purpose for which permit is used: ',)`—chi License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to Cap Cod ColktbOrahve Tel 508 1100-ioT SO Address: lriS 16 -2..s, ',kfukk LiaiirokAil, i-(44 0a4/pi-i Owner of Recoil of Building (a pi Cod, cojicahjy-a live Address lid exwips 6i.fscr 420,-A.0( Ociel lit H/4 oalps-5- ,t tit 1 Present Holder of Certificate reialfd 470na4— ignature of person to whom Title Certificate is issued or his agent JIMA, Date Email Addri,-,ss: J. anetre,03 Ci) eqperDi,-OR abora-frivr,or3 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 USA COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF iNsPECTIoN. Certificate of Inspection If_ BCOI-24-70 05/01/2026-05/01/2027 AC o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDD/YYYY) (MWDD25 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 Darla DuckwItz CCMSI PHONE FAX do Cannon Cochran Management Services,Inc. IAIC.No,Elm:(217)-444-1186 talc,No);(217)-444-6669 E A 55 Walkers Brook Drive ADORW1LEss; dduckwltz@ccrosLcom Suite 402 INSURER(S)AFFORDING COVERAGE NAIC f Reading,MA 01867 INSURERA:MEOA PROPERTY&CASUALTY GROUPinc. INSURED -'- ----+_— -- �—_-_-- INSURERS: CAPE COD COLLABORATIVE 418 BUMPS RIVER ROAD INSURER C: OSTERVILLE,MA 02655 INSURER D: 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 TYPE OF INSURANCE ADDL SUER POLICYEFF .- POLICYEXP. LIMITS LTR INSD W POLICY NUMBER IMWDoI MI YYYYI-(MDD/YYY'Y{. COMMERCIAL GENERAL LIABILITY /'l �3';fACH OCCURRENCE $ DAMAGE TO RENTED —CLAIMS-MADE (- )OCCUR t; ,,:- '': T PREMISES(Ea occurrence)_ $ " MED EXP(Any one person) $ _ %' PERSONAL 8,ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER �... GENERAL AGGREGATE $ POLICY L J PRO I_ J LOC PRODUCTS-COMP/OP AGG $ Jt{:7 OTHER: $ AUTOMOBILE LIABILFTY AEL 7\ COMBIINNEDtSINGLE LIMIT $ ANY AUTO �- ',:, , - BODILY INJURY(Per person) $ _ OWNED SCHEDULED f `. BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS F HIRED NON-OWNED PROPERTY DAMAGE • AUTOS ONLY _ (AUTOS ONLY ,x (Per accident) $ $ UMBRELLA LIAB OCCUR / EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DEC I RETENTIONS (.1, NA $ WORKERS COMPENSATION 4 '= PER OTH- ANDEMPLOYERS'LIABILITY YIN <, GI X STATUTE ER ANYPROPRIETOR/PARTNE:R/EXECUTNE E.L.EACH ACCIDENT $ 1,000.000 A OFF ICER/MEMBEREXCLUDED7 I_ NIA WC 05240025 7/112025 7N/2026 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ It yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION CAPE COD COLLABORATIVE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 418 BUMPS RIVER ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN OSTERVILLE,MA 02655 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I 101988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CertRecID:731862 PRID:347457733 AGENCY CUSTOMER ID: LOC#: ACOR EP ADDITIONAL REMARKS SCHEDULE Page 1 of 1 _ AGENCY NAMED INSURED CAPE COD COLLABORATIVE 418 BUMPS RIVER ROAD POLICY NUMBER OSTERVILLE,MA 02655 WCX3405240025 CARRIER NAIC CODE EFFECTIVE DATE: 7/1/2025 ADDITIONAL REMARKS THIS ADDITIONAL RE MARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: Acord 25 FORM TITLE: Certificate of Liability Insurance Schedule of Named Insureds and Locations 01 CAPE COD COLLABORATIVE 918 BUMPS RIVER ROAD 918 BUMPS RIVER ROAD OSTERVILLE MA 02655 06 CAPE COD COLLABORATIVE 78R ELDREDGE PARKWAY 78R ELDREDGE PARKWAY ORLEANS MA 02653 07 CAPE COD COLLABORATIVE 24 CANDLEWOOD LANE fir 24 CANDLEWOOD LANE DENNIS PORT MA 02639 kg, ,, 08 CAPE COD COLLABORATIVE Va3Wo YARMOUTH 1175 ROUTE 28 S YARMOUTH MA 02664 4 ear. " , YEA F ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MEGA PROPERTY & CASUALTY GROUP INC. WORKERS COMPENSATION AND EMPLOYERS LIABILITY COVERAGE DECLARATIONS PAGE 1. Insured: CAPE COD COLLABORATIVE Address: 418 BUMPS RIVER ROAD OSTERVILLE MA 02655 Member#: X340524 00 Agency: ARTHUR J.GALLAGHER RISK MANAGEMENT SERVICES,INC. Entity: Public Entity 200 GLASTONBURY BLVD Policy#: WCX3405240025 GLASTONBURY CT 06033 Risk Id#: 767008 FEIN#: 042566040 2. The Policy is effective from 7/1/2025-7/1/2026 12:01 AM Standard Time,at the Insured's address unless provided otherwise in the policy. 3. A. Workers Compensation Insurance:Applies to the Workers Compensation Law providing Statutory Limits of the states listed here: Massachusetts B. Employers Liability Insurance:Applies to work in each sate listed in Item 3A. The limits of our liability under Part B are as follows: (1)Bodily Injury by Accident $ 1,000,000 (each accident) (2)Bodily Injury by Disease $ 1,000,000 (policy limit) (3)Bodily Injury by Disease S 1,000,000 (each employee) C. Other States Insurance:Applies to the states,if any,listed here: See Endorsement WC990399 D. This Policy includes the following endorsements and schedules:See attached schedule. 4. The Premium of this Policy will be determined by our Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit: Minimum Premium: $268 Experience Modification: 1.10 Expense Constant: $338 Premium Discount ($16,243) Total Estimated Premium: S187,671 Premium Payment Schedule: Annual Premium Adjustment Period: Annual 7/2/2025 Countersigned: Authorized Representative Date • Date Issued:7/2/2025 PolicyRecordiD:347457733 MEGA PROPERTY & CASUALTY GROUP INC. SCHEDULE OF NAMED INSUREDS AND LOCATIONS Insured: CAPE COD COLLABORATIVE Agency: ARTHUR J.GALLAGHER RISK MANAGEMENT SERVICES,INC. Policy#: WCX3405240025 Effective Date: 7/1/2025 01 CAPE COD COLLABORATIVE 418 BUMPS RIVER ROAD 418 BUMPS RIVER ROAD,OSTERVILLE MA 02655 FEIN: 042566040 06 CAPE COD COLLABORATIVE 78R ELDREDGE PARKWAY 78R ELDREDGE PARKWAY,ORLEANS MA 02653 FEIN: 042566040 07 CAPE COD COLLABORATIVE 24 CANDLEWOOD LANE 24 CANDLEWOOD LANE,DENNIS PORT MA 02639 FEIN: 042566040 08 CAPE COD COLLABORATIVE YARMOUTH 1175 ROUTE 28,S YARMOUTH MA 02664 FEIN: 042566040 Date Issued:7/2/2025 PolicyRecordlD:347457733