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HomeMy WebLinkAboutBLDX-26-505 application RECEIVED Z `"Y Office Use Only Poi MAY 2 6 2026 Amount 110 , � BUILDING DEPARTMENT V.+ • �RPORA4J 8Y EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 ��( f'} (508) 398-2231 / / Ext. CONSTRUCTION ADDRESS: 3 "�`'e '(/1` (W+' `-,Grp V 4 `^( 'IA/1 7? OWNER: W e ). W ;,,J`4 12° AA (/ (x 7 I 56,1 • NAME PRESENT ADDRESS TEL. # / CONTRACTOR:1//jj /S�e r-/rf t7v c WAv*I1a S'A 11li'-Oa10t1t S - 7670i `1(9a5 NAME ( MAILING ADDRESS TEL.# EMAIL: r7Y�n S�7s t ' •CJ✓la Q'Residential ❑Commercial ❑Est.Cost of Construction$ 500 U Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# Construction Supervisor Lic.# 00/0 WORK TO BE PERFORMED Tent Duration (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 tha statements herein Mined 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 rev o y lice r pro tion under M.G.L.Ch.268,Section I. Applicant's Signature: Date: , Z lL Owners Signature(or attachment) ' r///�//4 Date: . ./ t6/!/ G Approved By: Date: Building Official(or designee) Rev 6/24 1 `i The Commonwealth of Massachusetts Department of Industrial Accidents —_ Office of Investigations ='il= Lafayette City Center • -=i_'�= 2 Avenue de Lafayette,Boston,MA 02111-1750 " r 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.® I am a employer with 7 employees(full and/ 5. ❑Retail or part-time).* 6. ❑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. [No workers'comp.insurance required] 8. ❑Non-profit 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.❑Manufacturing no employees.[No workers'comp.insurance required]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees.[No workers'comp.insurance req.] 12.111 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: City/State/Zip: Policy#or Self-ins.Lic.#WCC 500 5013321 2026A Expiration Date:5/22/27 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: lk•pr• Q,uti Date:5/26/26 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): 1 rBoard of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia AC `, \ DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05l2612026 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: Sean McGrath McShea Insurance Agency, Inc PHONE(AIc_No, xtl- (508 420-9011 F' } - (A/C,No): (508)420-9010 1645 Falmouth Road, Rt 28 BLDG D ADDRIESS: Sean@mcsheainsurance.com Centerville, MA 02632 INSURER(S)AFFORDING COVERAGE NAIL# INSURERA: PENN AMERICA INSURED INSURER B: Pilgrim Insurance Company 21750 Bayside Tent. & Table, Inc. INSURER C : AIM Mutual 40c Whites Path INSURER D : South Yarmouth, MA 02664-1212 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 00002179-0 REVISION NUMBER: 4 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 SHDWN 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 SUBRI POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD I (MM/DD/YYYY) 1 (MM/DD/YYYY) A 1 X I COMMERCIAL GENERAL LIABILITY PAV0634965 05/17/2026 05/17/2027 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED j CLAIMS-MADE [ Xi 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: GENERAL AGGREGATE $ 2,000,000 X I POLICY 1 PROT LOC r 1 PRODUCTS-COMP/OP AGG $ INC ---_ JEC OTHER: ' $ B AUTOMOBILE LIABILITY CSC0000101 55534 10/26/2025 110/26/2026 (a accl deDn SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ 20,000 OWNED SCHEDULED BODILY INJURY(Per accident) $ 50,000 AUTOS ONLY Ni AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY : AUTOS ONLY I (Per accident) $ I - UMBRELLA LIAB I OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ I DED 1 1 RETENTION$ . $ C WORKERS COMPENSATION WCC-500-5013321-2026A 05/22/2026 05/22/2027 X STATUTE EORH AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNEFJEXECUTIVE Y/N E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory in NH) E.L. DISEASE-EA EMPLOYEE $ 500,000 If yes.describe under DESCRIPTION OF OPERATIDNS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE -.4 -- (SPM) ACORD 25 (2025/12) © 1988-2025 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by SPM on 05/26/2026 at 10:20AM E o ` : O a) m 3 v o c v °C w0 la, mom bat 090 0 SR G• 0 0 0 04' ,_. 0 N ,_. \ L_ \1r+ 41 � VI N ao O W E) N Q' a O W L m ` Z 1° W _C Li H 0 n n Y Q On N 0 0 O OQ QQQ O O °o Qo Duo 000 QO O L -O L C '' O 06 v_co on 0 N O 000 OO v O QQ QQ 0 QQO 000 00 0 0 00 S .4- , 0 . , . . . , I e ..-!. . :--,,,,',4 ,... , „ . .... . „...., ....„-i„..,. -. ,„.... , .„ .,. ......,.,. .. ,. i ti gill , " i 0 , s A oi• I OP' . I • 4 '•- ,.• 1 _ Nk... ,•— .. . .., - ,* • P ' Ili. 0 .' . "/' '' ' 0. .. 600400000,:•:, 4* irj4:4 : i ''-;". ' .: -4• l. i *0> , • -,, . • *'. ..+6,. . * 46' . - ... '40 0 - ,-- ,, .. .,.., .. , -fr .' ,..4r.r".• 4 .. , .. , twrih_ •, ,t . '..r." 0, , ......„ .., ,...., v: ... .....,,,,,. 4 - ;•41' / r 4; . ,.,,, ttV , Otii, i„-- _,,, 4 i . . 371 CD Vt a.I ..0 - s - - 4: :-.0„-... ' \. . 1..': '- e•''' -.-....-.AA!'.i',:--004,101-4,-,-,.t.,,:...„ :,.-: .-,,,,, , o .,.__. ' ;.1''''''''' of A ,/*•!. '0 ;-,..! • -0 ' - if <..› -P. ...._. ! ... . ! a) , 5 . . ... (.., .- , cr. ...... ..: - .0.... ,, c. ,... , ' A • ,,...„,... 73. . - _I - • i u_ ! ! - , •! i ! 4 !! ..... , ,,. 0 I ° '';l0 • • _ _ . _ ._.... , Certificate of Flame Resistance REGISTERED ...nu% ISSUED BY nate of Manufacture ` FABRIC M J SON OUTD S INC. NUMBER _welabidwir fitGHAJ$TON, NEW YORK !3002 JANUARY 1 a9 R F•140.01 lea►ufaat•rers of tile Finest To Pr ,cts Describedide: _ Tells is to certify that the products herein have been manufactured from malarial Inherently flarro retardant as here alter specinad by the material supplier. NAME.. BAYSIDETENT iTy. SANDWICH,M t! t erttllcirt on is hereby made tba Thiii MR4 f &sorted oil Oft rairrifcafc have been mamfacturod with VI bgroared 11aarne retrum alafniuki in c npmB rbCe wain catiomLa Stale Aft marshal Coda, KFPA-701', Undenerf'M$ Laboratory of Crna a. er'd have 'brta't testad In aohredano with [ha ret6fraT Test Method SpIttirerbatiorts and meet Or exteaO Ina Mletlary Flame Specifications of MEi.-U-4.3i)()`}O. IType. color and weVyl of malarial l 14 OZ_WHITE BLOCKOUT . l?agavtlo i of tier certified. GENESIS 20' MTD 40 SECTION Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective ive For The Life.Of The Fabric Snyder ll anufacturins Inc. . �e�► ` ea of I1Ir $e Re dims V ti.!t.n so•• �rEor ae'►IIH't it L -••ORs t • Certificate of Flame Resistance REGIS i tREU ISSUED BY Qate of ManuMtri m FABRIC JOfINSON OUTDOORS NC.NUMBER BiNGHAMTON.NEW YORK 135102 JANUA1 Y 194$ F-140.01 actuests of the roust Tenn Products Described tle eei This is to codify that the products herein have barn manufactured from material inherently awns retardant as hers alter spaded by the material supplier* NAME. BAYSIDE TENT GITY- SANDWICH,MAAJ Corttfiartlon is hereby colds tit seed oft an approved tiaras raierdant Msled onk*becattlenoit in compliance set MO aedehs described on rats certificate Sow been nrenutect haveCad crake Stab Ftne Marstaic Cads meat or exceed Ito Weal eat ML-t bow t.3, inwMT+he federal Trash Method abcets i I Typo.color and waiON of a+aieriat 14 02,WHfrE BLOCKOUr Desalradon of Item oeMMaor G: v. 40X40 2PC TENT . Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric i • • Snydor Manufacturkg,Inc Uanuhrolutra of Name teem'.,4 Llogrgastes osp..ar,+t.,r,. ,m • • .Lises -- - •