Loading...
HomeMy WebLinkAboutBCOI-23-1756 2027 ,(g ' M TOWN OF YAROUTH 400 Office of the Building Commissioner ,oi ' - *ti-N5 1146 Route 28, South Yarmouth, MA 02664 N ;�► 508-398-2231 ext. 1260 Fax 508-398-0836 NAtTACHEESC '~C,,?,,_ ..,,, `` '" APPLICATION FOR CERTIFICATE OF INSPECTION August 24, 2026 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) 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: 11 `N 4 Y)t Lan `C Name of Premises: 511,PP`I15 Pry( . gr shu rcir-1- Tel: _5b8.3C6i5S---(-' Purpose for which permit is used: License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency C E I V E IRE SEP 09 2026 Certificate to be issued to % 15 it ur- ✓i tTel: [ Address: 11 Ne�Jk-1 1 A G14,0 q H u .�. .�NT Owner of Record of uilding 5.Kf) pit L.C Address Pb 31 U S, l Qti ji't ) � 62.6a V Present Holder of Certi cate 5 a rc ' 6 & a bk-' V L C- _______ yl/GPO ( Signature of person to whom Title Certificate is issued or his agent ( k c,( Datc Email Address: 5 pushona) Cl.()f, 60,47") 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 j 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-23-1756 12/31/2026-1 2/31/2027 DATE(MM/DD/YYYY) _ ACERTIFICATE OF LIABILITY INSURANCE 06/15/2026 PHIS 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 THE OCEANSIDE INSURANCE GROUP NAME: 08084400 PHONE (508)771-1660 FAX (508)775-1135 PO BOX 38 (A/C,No,Ext): (A/C,No): WEST DENNIS MA02670 A ADD DREDRE SS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Hartford Fire Insurance Company 19682 INSURED INSURER B: SKP1M, LLC.,731 MAIN STREET LLC,277 S. SHORE INSURER C DRIVE LLC DBA SKIPPY'S PIER 1 PO BOX 370 INSURER D: SOUTH YARMOUTH MA 02664-0370 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. 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED $ PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO: LOC PRODUCTS-COMP/OP AGG $ JECT OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ _ _ _ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ _ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ $1,000,000 A OFFICER/MEMBER EXCLUDED'? N/A 08 WEC AD1A4A 05/30/2026 05/30/2027 (Mandatory in NH) 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) Those usual to the Insured's Operations. CERTIFICATE HOLDER - CANCELLATION For Informational Purposes SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED PO BOX 370 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED SOUTH YARMOUTH MA 02664-0370 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED/(� REPRESENTATIVE U mot - ACORD 25(2025/12) ©1988-2025 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD , i�' '� �. �; .. .