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HomeMy WebLinkAboutBCOI-23-1782 application e *4 TOWN OF YARMOUTH o RECEVED * ='' __ p - 0 Office of the Building Commissions — I 1146 Route 28, South Yarmouth, MA 0 6T 0 2 2026 0 £ _=y 508-398-2231 ext. 1260 Fax 508-398-0 36 A' MATa:.SE q� BUILDING DEPARTMENT �c°RF 0 R AT EO,y� By APPLICATION FOR CERTIFICATE OF INSPECTION August 24, 2026 PAYABLE UPON RECEIPT (X) Fee Required$100.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7,I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 2 7-1 R'at'Te. 6 A- Name of Premises: C ftal-p l E (1. k{UV S f% Tel: fro n i- 4(3 Lie Purpose for which permit is used: A-CCorn UC 1et/e11-14'663 ki6j G/limit/ fic-- License(s)or Permit(s)required for the premises by other governmental agencies: G/MA/C _ License or Pe it Agency A/A f /"4v 4/e PN(//e 6 t/L Afe-G 4C.LO c, Certificate to be issued to -34X7 Wffte2(N6 GL C-Tel: Address: f a fJgK /si ,69-tr- peA/ r , itit4 o 26%.0 r Owner of Record of Buildinj 7741T-jZ YA0 °vim Foxr-- (('C/l(/ olf Address Pc) Box is O' 4447— )c 441..f5 1-14 07-6&le Present Holder :f Certificate ?AK lam(, (Alit/xl-e,, a-C- /�: r AtCrfsea Signatur-/'f person to whom tle Certific. e is issued or his agent 10 /Z477-‘ �J Date Email Address: ` '/L4 ?4-x 72-�$-P f (.,1 Z{, Capi 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-23-1782 /v n'a� 12/31/2026-12/31/2027 /T/ ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOIYVYY/ 02/13/2026 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 NAME:CONTACT Carolyn Milano The Hilb Group New England,LLC MO N.Eats: (800)640-1620 I FAX No): AOORESS: cmilanoihlbgroup.com 9731yannough Road INSURER(S)AFFORDING COVERAGE NNCH Hyannis MA 02601 INSURER A: Northfield Insurance Co 27987 INSURED INSURER B: Capitol Specialty Insurance Corp 10328 Baxter Innkeeping LLC DBA Chapter House Cape Cod NO Baxter INsuRER c: Associated Employers Insurance Co 11104 PO Box 1503 INSURER o. Mount Vernon Fire Insurance Co 26522 INSURER E East Dennis MA 02641 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. ADULa BN POLICY EFF POLICY EXP LTR TYPE OF INSURANCE NSD WVD POUCY NUMBER (MMND/YYYY) (MWDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RCN FED 100,000 CLAIMS-MADE ®OCCUR PREMISES(Ea occunenre) $ X BI/PD DED:$500 MED EXP(Any one personi $5)000 A WS696085 02/11/2026 02/11/2027 PERSONAL&SOY INJURY $ 1'°°°•° GENII_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY❑JET ©LCC PRODUCTS-COMPIOP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _ (Ea anodem) ANY AUTO BODILY INJURY(Per Perron)— $ OWNED SCHEDULED BODILY INJURY(Per accident) $ _,AUTOS ONLY _AUTOS HIRED NWNED PROPERTY DAMAGE $ _AUTOS ONLY _AUTOS ONLY (Per accident) UMBRELLA DAB X OCCUR EACH OCCURRENCE $ 3,000,000 B X EXCESS DAB CLAIMS-MADE XS2302141903 02/11/2026 02/11/2027 AGGREGATE $3,000,000 DED] I RETENTION$ _ $ WORKERS COMPENSATION $TANTE I I EDRH AND EMPLOYERS'LIABILITY YIN C ANY PROPRIETOR/PARTNER/EXECUTIVE Li sic WCC50050243032026A 02/11/2026 02/11/2027 E.L.EACH ACCIDENT $ 500,000 OFFICE In NER EXCLUDED? (Mandatory In NH) EL DISEASE-EA EMPLOYEE $500,000 h yea,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Liquor Liability LQ2003262O 02/11/2026 02/11/2027 $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may Be attached N mom space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN U.S.SBA Go Cape B Islands Community Development Inc.dba ACCORDANCE WITH THE POLICY PROVISIONS. Coastal Community Capital AUTHORIZED REPRESENTATIVE ISADAATIMA,3 Patti Page Way Centerville MA 02632 I i ®1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD