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HomeMy WebLinkAboutBCOI-23-1763 application 4Y4 . TOWN OF YARMOUTH Office of the Building Commissioner - AifgAl1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 ��' NAYTAEHEESE ~CCiRPORATEO\k'' APPLICATION FOR CERTIFICATE OF INSPECTION August 24,2026 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Num ier: (13-3- , „—oA--- , 11 14 Name of Premises: 52 S O e £2,1 r Caet_ L art Tel: , 7j D$-7QC — O-1 Q 9 Purpose for which permit is used: License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency r .,Z E C V E D r SEP 16 2026 Certificate to be issued to Tel: 1 -; i Address: BUILDIt.G DEPARTMENT i Owner of Record of Building Address Present Holder of Certificate is r f f person to whom Title ��,//�, Cert . - is issued or his agent q-/&'` Date Email Address: �j�(U�e� / 0-I 1-D etkh ',' vi 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-23-1763 12/31/2026-12/31/2027 ACORD DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 9/9/2026 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:Acrisure East Insurance Services. LLC PHONE FAX 3 Sylvan Way (A/c,No,Ext):973-227-0025 (plc,Not;973-227-4026 Suite 200 ADr�SS: Parsippany NJ 07054 _ INSURER(S)AFFORDING COVERAGE - NAIC# —_—_ License#:BR-1797502 INSURER A:Markel American Insurance Company 28932 INSURED SONSOFE-01 INSURER B: Sons of Erin Cape Cod Inc -- - P 0 Box 403 INSURER C: South Yarmouth MA 02664 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:819853942 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 NOR ADDL SUER (—POLICV EFF POLICY EXP I — — -- - LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDD/YYYY)) LIMITS I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ F-1 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Eaoccurrence) $ MED EXP(Any one person) $ _ I I PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY T JEIf L I LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ - (Ea accident) ANY AUTO BODILY INJURY(Per person) (S OWNED I SCHEDULED BODILY INJURY(Per accident)!$ AUTOS ONLY AUTOS HIRED ' NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCEL LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ A WORKERS COMPENSATION AWC0016135-04 2/7/2026 2/7/2027 X STATUTEPER i OT AND EMPLOYERS'LIABILITY Y/N ER _ ANYPROPRIETOR/PARTNER/EXECUTIVE i E.L.EACH ACCIDENT $100,000 OFFICER/MEMBEREXCLUDED? N NIA (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $100,000 j If yes.describe under -- DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $500,000 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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. for insurance purposes only AUTHORIZED REPRESENTATIVE ACORD 25(2025/12) ©1988-2025 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD