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HomeMy WebLinkAboutBCOI-23-1765- s' r g YA % TOWN OF YARMOUTH i O.. X . ,,� Office of the Building Commissioner i21 ` � - ���� 1146 Route 28, South Yarmouth, MA 02664 0 ��a 508-398-2231 ext. 1260 Fax 508-398-0836 � '4,0--PoRATE0`61� 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: -1 \C\ \CX\r- Si '-\- DD Name of Premises:w��\ Q N 1c�� Cjc- �OC�S� Tel: `j O - a -U - O O \ Yc c�C.Jt� rr`.x.. . `--u .��.. Purpose for which permit is used: License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency -foo L. Sc -tw !j0c.:(4- 4 \c(..•\It). \Z.CW-ac YN C oYhN ne\ \ .c- v \ -r, Stkt c kr•n�vn Certificate to be issued to ..rT( „-N \ L"d. Tel: Soft - 3\•.k - 'Sock\ Address: "11,C\ \\c.‘„1 sk 1.k 2.tS So- N/c.,:r.-‘v-00,-, c.. 0 Q.lo is`k Owner of Record of Building-.e& v%e,,,., Kt.o \ Address `Uq Cwrr qe-c.. 1rc..,-...t_ ''—ec...•rr-. ,.,.N.� \--\c,�. 0.3..14 U Present Holder of Certificate later r�,(,.)� �ovS.c_ Lc� _,— f ),...„ ,..________ RECEIVEDi ignature o person to whom Title ' a Certificate is issued or his agent °k 13 t a tt SEP 04 2026 I Date i Email Address: \p&q-C- a'a.`1C�@ .` \c c `mac.�.tln �eS •• O [1 + ." "", J cm c i4i. (;)5a28- , 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-23-1765 12/31/2026-12/31/2027 OATE(M4MOdYYYY) ACCORD' CERTIFICATE OF LIABILITY INSURANCE 04/28/2026 TE CEERTI CERTIFICATE DOES NOT A ISSUED FFIRMATIVELTYER OF OR NEGATIVELY AMEND,EXTEND OR ALTER RIGHTSN ONLY AND CONFERS NO TH COVERAGE AFFORDED ABY THOEDER.POLICES 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 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 CNum ONTACT Loalctoe Affinity, LLC E866-836-3373 I(AIG,MoJ:913-652-7699 Loa7ctAn Affinity, LLC E-MAIL P. O. Box 879610 ADDRESS. Kansas City, HO 6 4 187-9610 INSURERISIAFFORDING COVERAGE MICA WSURER A:rracaxw1 mnrano.company,Inc. INSURED INSURER 8: Yarmouth Moose Lodge $2270 INSURERC: 769 Main Street, Route 28 INSURER D: WSURFR E: South Yarmouth, MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT,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 REIN rED BY PAID CLAIMS. .N. ADM./Mt POLICY Eft POLICY EXP DAOTS LTR TYPE OF INSURANCE ROD WVD POLICY NUMBER ImMODDATh)(MNDLYYYYYI A X COMMERCIALGOAL LIABILITY X FIC26GLOO10 05/O1/2026 05/01/2027 EACH OCCURRENCE S1,000,000 IC RENTEDl CLAPARAMIGF economical©OCCUR PREMISES(Ea economical 51,000,000 — General Liability/ ME)FEW(My one pmmn) $0 Liquor SIR pWiSONN,4 AOVPIIRY $1,000,000 GOER- AGGREGATE UNIT*CUES PER Applies per Policy CE,EtAL AGGREGATE $2,000,000 Terms &Conditions PRODUCTS-COMP.OP AGG 52,000,000 0 O� I DTI COMBINEDONGLE UPCs AurOMmBLELMaIfY (Ea ecc nn0 BODILY INJURY(Per tenon) S ANYAM —AU OJJN® —AUTOS ID BODILY INJURY(Per=PeM S -I-ImoTOS � PROPERTYDAMAGEPer accelone S NU®AUTOS AUTOS $ UMBRELLA LIAR (rl'F, EAcHOCClRRENCE S — DCESS LIAR OLAIMSMAOE AGGREGATE $ CFO I 1 RETENTIONS ppTT}}.� $ WORKERScospmNSAT(ON A STATUTE 1 1 ER __.. AND EMPLOYERS LIABILITY YiN ANY PROPRIEfOWPARTNER,EI ECUWE 0 N1A EL EACH ACCIDENT S M N�IXCLUD®? E1pSEASE-EAI4$,OYEES 10r.RIsabe under El.rYsecc.P01.ICY LR.R $ Di RIPRONOEility IONBDebly A Liquor Liability FIC268L0010 05/01/2026 05/01/2027 Occurrence $1,000,000 Aggregate $2,000,000 DESCRIPTION OFOPERATICNsi LOCATONs ivo4CLEs(ACORD101,Additional Remarks Schedule,may be attailsed it more space is required) Liquor License Renewal CERTIFICATE HOLDER CANCELLATION 3060919 South carmouth Town Hall SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ha-20 South 5!armouth,IRA 02669 41111CN2 �A 01988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 57546339 3066414