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HomeMy WebLinkAboutBCOI-23-1793 application r. TOWN OF YARMOUTH (V- Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 y) 508-398-2231 ext. 1260 Fax 508-398-0836 0 ,__,„ , , -,_, fe --- --, ----, ~Co MATTAGHrESE ' RPpRATE�\bn" APP ICATIONIcup.4.WEVIICATE OF INSPECTION s August 24, 2026 1 PAYABLE UPON RECEIPT S� 1 Z 6 (X) Fee Required$100.00 1 0,� ( ) No Fee Required BL HLDl'i` In accordance with the provisions of:#he Massachusetts State-Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address:Street and Number: 51/ RI— 71 wit- f 11 lit AA,``p O) 6 l=� n ,, q Name of Premises: ala aiSh I Tel: 308 -7i 70,5 ,. '1 '1 / Purpose for which permit is used: f Q901// b� S � '� G(3.),S- License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to ��Q - Lio3h i Tel: )40W.- 1-710 Address: An g(-]$' west t ce, h M-A Uhl') Owner of Record of Building Address Present Holder of Certificate Signature of person to whom Title Certificate is issued or his agent Date Email Address: SClitlitt5i00 deb W;L-Coin► 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-23-1793 12/31/2026-12/31/2027 ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 09/16/2026 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 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 LON FAw NAME: Janet Li Soo Hoo Insurance Agency a/c°Nr o,Ext): 617-338-8168 FAX No): 123 Beach Street ADDRE anet@soohooinsurance.com ADDRESS: J INSURERS)AFFORDING COVERAGE NAIC# Boston MA 02111 INSURER A: Hartford Underwriters Insurance Company 30104 INSURED INSURER B: Hartford Insurance Company of the Midwest 37478 Saga Yarmouth Inc DBA:Saga Sushi INSURER C: Hartford Fire Insurance Company and its Combined Affiliates 00914 521 Route 28 INSURER D: INSURER E: West Yarmouth MA 02673 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD wVD POLICY NUMBER (MM/DDNYYY) (MM/DD/YYYY) UMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 5,000 A 08SBAAJ3NSY 11/10/2025 11/10/2026 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY JECT PRO LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: AUTOMOBILE LIABILITY (-UMBINEU SINGLL LIMI I $ (Ea accident) ANY AUTO BODILY INJURY(Per person) S - ALL OWNED -SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS - NON-OWNED PROPERTY DAMAGE $ _ HIRED AUTOS _ AUTOS (Per accident) Employment Pr $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 g - EXCESS LIAB CLAIMS-MADE 08SBAAJ3NSY 11/10/2025 11/10/2026 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X I H- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? n N/A 08WECAJ3NWK 11/10/2025 11/10/2026 (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 A Liquor Liability 08SBAAJ3NSY 11/10/2025 11/10/2026 $1,000,000 Per Com Cause,$2,000,000 in Aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Restaurant located at 521 Route 28,West Yarmouth,MA 02673 Restaurant located at 521 Route 28,West Yarmouth,MA 02673 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 Town Hall AUTHORIZED REPRESENTATIVE Yarmouth 02664-4492adejc. I / ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD