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Home My WebLink AboutBLDX-26-610 application f Y=._ RECEIVED Office Use Only , 4.47 L. , Permit#1�O F a lDl O JUN 122026 ��,�.]/ Amount'� E 4v�° • aPORA,0,____ BUILDING DEPARTMENT EXPRESS BUILDING PERMIT APPLICATION LI TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 108 Bray Farm Rd. North, Yarmouth Port Ma 02675 OWNER: Taylor Bray Farm P.O. Box 66 Yarmouth Port, Ma 02675 508-326-5430 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Undercover Tent and Party 112 Great Western Rd. Unit 1 South Dennis MA NAME /, MAILING ADDRESS TEL.# EMAIL: M v r 3 t S `1-€_4 ❑Residential ) i Commercial Ti Est.Cost of Construction$ $1,000 XX Homeowner is Applicant? Yes - No Home Improvement Contractor Lic.# Construction Supervisor Lic.# 20 X 40 WORK TO BE PERFORMED Tent X Duration 06/18 to 06/22 (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 c tion�of s y E •f. . .secution/ / V ,.er M.G.L.Ch.268,Section 1. t�/)} Applicant's Signature: 2 � r 0 Date:��/( '/ i/OWners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 AW o® CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDD/YYYY) 05/182026 THIS CFRTIFICc?E 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 pollcy(les)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 Ileu of such endorsement(s). PRODUCER CONTACT Kimberly Tetreault NAME: Insurance Marketing Agencies PHONE t: (617)479-5500 iA1c (617)479-8761 we nw an WD.No): South Shore AODREas: KimDedy.TetreaullQimaagenry.com 400 Crown Colony Dr.Suite 103 INSURER(S)AFFORDING COVERAGE ANC• Quincy MA 02169 INSURER Arch Insurance Company 11150 INSURED INSURER B Wesco Insurance Co 2538 Undercover Tent 8 Party,Inc. INSURER C 112 Great Western Rd Unit 1 INSURER D INSURER E: South Dennis MA 02660 INSURER F: COVERAGES CERTIFICATE NUMBER: C12632752346 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. WSR AUDLZUSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE NNW WVD POLICY NUMBER (MMIDO/YYYY) (MMIDDIYren LIMITS EACH OCCURRENCE S Yl COMMERCIAL GENERAL LIABILITY 1,000.000 i DAMAGE 10 RENTED ICWMS-MADE OCCUR PREMISES(Ea marten.) S 3°°'°°° — MED EXP(Any one person) f 10,000 A PRPKG0008609 11212025 11/21/2026 pERAONALSADVINJURY s 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY❑7E6 LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: f AUTOMOBILE uAeXTY COMBINED SINGLE UNIT $ 1,000,000 IEe accident) X ANY AUTO BODILY INJURY(Per person) I A OWNED AUTOS ONLY AUTO SCHEOSULEO PRAUT00049 03 11/21/2025 11/21/2026 BODILY INJURY(Per accident) I — HIRED AUTOS ONLY PROPERTY DAMAGE AUTOS ONLY _AUTOS ONLY (Par accident) PIP-Basic s 8,000 UMBRELLA LAB _OCCUR EACH OCCURRENCE S EXCESS JAB CLAIMS-MADE AGGREGATE S DEO 1 I RETENTIONS f WORKERS COMPENSATION PER OT1L AND EMPLOYERS'LABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT f 1,000,000 B OFFICERIMEMBER EXCLUDED', ❑N NIA WWC3814197 1121/2025 11/21/2026 (Yaedatory11 NH) E.L DISEASE-EA EMPLOYEE S 1,000,000 I yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I Per Occurrence $1,200,000 A Blanket Equipment Coverage PRPK00008609 11212025 11/21/2026 DeducAble $2,500 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101,AMMiensl Remarks Schedule,may he Reached R more space is required) RE:June 20,2026 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Taylor Bray Fame ACCORDANCE WITH THE POLICY PROVISIONS. 108 Bray Farm Road North AUTHORIZED REPRESENTATIVE Vermouth Port MA 02675 , / 1/y1 ID 19138.2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonrvealth of Massachusetts as�' Department of Industrial Accidents J Office of Investigations • 1! 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: UnderCover Tent and Party Inc Address: 112 Great Western Rd, Unit 1 City/State/Zip:South Dennis, MA 02660 Phone #: 508-398-9000 Are you an employer? Check the appropriate box: Business Type (required): 1 . 0 I am a employer with 10 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no ?. ❑ 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]** 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, PartyRentals with no employees. [No workers' comp. insurance req.] 12.0 Other *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#I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:Wesco Insurance Insurer's Address:420 Maple Ave City/State/Zip: Yukon, OK 73099 _ _ Policy # or Self-ins. Lic. #WWC3814197 Expiration Date: 11/21/2026 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 certift, under the pains and penalties of perjury that the information provided above is true and correct. �"'� l �? Signature: �`��,�, Date: I 3 / G�- Phone #: 508-398-9000 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): 10Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6. DOther Contact Person: Phone #: www.mass.gov/dia � .r Page 1 +� `U p, Certificate of Flame Resistance f •t�� l / Kihc-c rc +_ ISSUED BY:REFERENCE REGISTERED MATERIAL VENDOR LISTING Registered Fabric of IN CHART BELOW FOR CORRESPONDING CA Concern Number REGISTRATION NUMBER Date Manufactured (SEE CHART) 4/9/2020 This is to certify that the materials described below are inherently flame retardant. Undercover Tent& Party Invoice Number: 0240382-IN VENDOR TRADE NAME CA REo Undercover Tent& Party Customer PO F-041901 CA COMBINING LAM TEX 31 American Way COVINSALES DOUBLE POLISNCLEARVIf P.OTTI01 South Dennis,MA 02660 Customer Number: UNDE026 COVINSALE5 FR TENT LINER F-067501 DAF PRODUCTS DAFDPC F.059101 OAF PRODUCTS DAFREINFORCED TENT F•059202 Certification is hereby made that the articles described below are made from a flame-resistant GLENRAVENINC FIRESIST F070101 fabric or material registered and approved by the State Fire Marshal for such use. Reference RERCULITEPROOL PATIO 500 F.0012501 chart to right for Trade Name of flame resistant fabric or material used and associated SERGE FERRARI PRECONT RAINT 502 F-044.01 SERGE FERRARI PRECONT RAINT T02 F0N405 registration number below. SNYDER MFG PRV-GROUP: F-014001 SERGE FERRARI 81510 F•101924 THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING Aztec Tents,2665 Columbia Street, Torrance, CA 90503 Alex Kouzmanoff President Name of Applicator or Production Supenntendent Name Title Additionally the fabric has been tested and passes the following flame retardancy standards: -NFPA 701-2019(Test Method 2) -UK BS7837:1996(2015) -Canadian-CAN/ULC S109-03 -European M2 ITEM CODE ITEM DESCRIPTION UNIT ORDERED PRODUCED CA REG# Z221Z30E1535 A30x15 JT/JT Lite End Top CLR EACH 2 2 F-077101/F-014001 w/SN4P Blockout White Trim w/4 Ratchet Tensioners (With New Clear Trim Details-Effective 4/1/13) Stock 20342a,20342b Z22130CM1035 30x10 Mid JT/JT Lite Top CLR EACH 2 2 F-077101/F-014001 w/SN4P Blockout White Trim w/2 Ratchet Tensioners (With New Clear Trim Details-Effective 4/1/13) Z210DV204002 20x40 1 pc DV Owiktop Only UW EACH 1 1 F-059302 w/Double Valance Blockout White w/(12)Rope Tensioners Taylor Bray Farm 40x60 & 20x40 Tents ,....,. ..., . .. . ..,.. . , ....7. . 1 43 a 10t. t ,...., I' oliza.. 4•04AR/..a w , roil I ..1•0111 4 f 4.. i ... k i 4.* 0 Arnal9arnate• Vic-,•' .... . . .,„ . , „, ..,.. . , .... , 108 kiray F arm '.. 1 i iHi 1 tklii etW-1 I # ,4 vor . :, ' ' , ‘-- i t ''-,,, „'.5,-::-- i*«••••• At . .. ,.. ,. . . . 4.401. . • , „, , '',, ' ' • r •„,. 0, ' Ar,- Ait . 0