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Home My WebLink AboutBCOI-23-1733 2027 Y9 , TOWN OF YARMOUTH 4 ''o ` � Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 y`J 508-398-2231 ext. 1260 Fax 508-398-0836 se - �MATT.ACH[ESC (c\,\ ., / 4 / �`°RPORATEC)\ APPLICATION FOR CERTIFICATE OF INSPECTION August 1, 2026 PAYABLE UPON RECEIPT ( X) Fee Required$100.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 954 1'-CX lC Dr ,2 Name of Premises:Z ASS gig&4Z 5ioc2.7S 1-L 1-Pic- Tel: 176(:)t 3q -to 0 l O Purpose for which permit is used: 412C-riPt License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be ' sued to ASs:j 1v€a- r-c t,Jo.2�-DD,,l�c Tel: yog-3 a-(�O`)0 Address: 13'1' V0ur oiSo, 1�0 'C I 6o yn+ lit=raM ooTt-i. v �4- 0?-1. Owner of Rec rrd of Building '3Vc L. TZE -113 Lt,Ci I Address Ili 1'I..EASA44.1- Si. ' c) Y yv�.v bU-T#t Cl-A-OILby (PO Ii3O>s 12)3 S. j 23MO01 .) P es ntHo e of e ific to -3WsS 12ivEa_ 5po irfS i..k30 JL-61 .LE c .gnature o person to whom Tiyle Certificate is issued or his agent 7.y I'2(p Date Email Address: 1,• 1)1 C\L I !1e II Di C' C�Quit.'CG$-4-. �►.Q� RECEIVED I JUL 24 2026 1.___-- BUILDING DEPARTMENT i By 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-23-1733 08/13/2026-08/13/2027 ACORD CERTIFICATE OF LIABILITY INSURANCE D6rz zD2Ts 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 MA EEACT Rogers and Gray Processing BALDWIN KRYSTYN SHERMAN PARTNERS LLC PWHcorrN EMI' (508)398-7980 I__Nat: ire: mail@rogersgray.com 4211 West Boy Scout Blvd Suite 800 INSURER(S)AFFORDING COVERAGE RAKE Tampa FL 33607 INSURERA:ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: BASS RIVER SPORTS WORLD INC INSURER c: INSURER D: PO BOX 183 MSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER:1232900 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MISR AWL SUER I POLICY Err POLICY EXP LIE TYPE OF INSURANCE NBD VNI) POLICY NUMBER MMNOM'VY)_(MMND/YYYYI, UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DAMAGE i O REMEO CLAIMrWarF OCCUR PREMISES IEa amarencal S MEDIXP(Aevone Person) S N/A PERSONAL A ADV INJURY S GENT.AGGREGATE LIMIT APPLIES PER jE LOG GENERAL AGGREGATE S POLICY PRODUCTS-COMP/OP AGG $ I I OTHER: $ 'AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ ANY AUTO (Ea accident) BODILY INJURY(Per person) S OWNED SCHEDULED N/A BODILY INJURY AUTOS ONLY _AUTOS aNdard)$ HIRED N PROPERTY DAMAGE $ AUTOS ONLY _AUTOS AUTOS ONLY (Per aodde t) $ UMBRELLA LABOCCUR EACH OCCURRENCE $ 1 EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DEC I I RETENTION5 S WORKERS COMPENSATION X I PAIUTE I 2RM. AND EMPLOYERS'UABILT' ANYPRA OFFFICEOW1NAItl�ABOEREXC UpE WA ILIA MA BS62UB1K68658926 01/01/2026 01/01/2027 CUT/VEEL EACH ACCIDENT s 1,000,000 (Mandatory In NH) EL DISEASE-EA EMPLOYEE$ 1,000,000 D y°aS describe Omar DESCRIPTION OF OPERATIONS babe EL ry oxen*.pDLIDy Lew $ 1,000,000 N/A 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.AUWUonai Rem.Schedule,may he aeamwe N mere space Is regWrml) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- I Coverage Verification Search tool at www.mass.gov/Iwd/workerscompensationfinvestigations/. I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUTHOREFD REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ®1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD