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HomeMy WebLinkAboutBCOI-23-1758 application g Y9�q TOWN OF YARMOUTH RECEIVED �: Office of the Building Commissione r 1146 Route 28,South Yarmouth,MA 02 6ts OCT 16 2026� '1 508-398-2231 ext. 1260 Fax 508-398-0 6 ...: " NC ``', °y 4/ BUILDING DEPARTMENT �RPORATED - APPLICATION FOR CERTIFICATE OF INSPECTION September 1,2026 PAYABLE UPON RECEIPT (X) Fee Required$100.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code,Section 110.7,I hereby apply for a Certificate of Inspection for the below-named�/ ,prem�ises located at the following address: Street and Number:S�v7 �� Z� dV4tcse NiCtrY4t4 0L!?q13 Name of Premises:a_ (-1�� N 4 Tel: t 9Z7 -57]S Purpose for which permit is used: V fy5( License(s)or Permit(s)required for the premises by other governmental agencies: AO° QLicense SS6or Permit Agency Zertlfiicate tome issue u Address: _I Owner of Record of Build jYl I Address l��X Present Holder of Cert irate i ture of pe to whom Ti l f• 'ficate is iss or his agent I `S ''� nn Date Email Address:I`ikonA171 -1aV 1S @ `ti. a✓ri o Instructions: Make check payable to: Town of Yarmouth 1146 Route 28,South Yarmouth,MA 02664 Return this application to: Building Inspector's Office Please note: Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified. Application must be received before the certificate will be issued. The building official shall be notified within ten(10)days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection 13C01-2+-1'S$ 10/01'2026-10/01'2027 • . � V I A��® DATE(MM/DD/YYYY) C CERTIFICATE OF LIABILITY INSURANCE 3i27/2026 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 3ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED tEPRESENTATIVE 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: Kim Ly Arthur J. Gallagher Risk Management Services, LLC PHONE FAX 508-658-6008 1 Research Drive (A/C.No. Ext): (A/C,No): Suite 300B ADDRESS: kim_Iy@ajg.com Westborough MA 01581 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Philadelphia Indemnity Insurance Company 18058 INSURED SOUTSHO-39 INSURER B : A.I.M. Mutual Insurance Companies 33758 South Shore Community Action Council Inc 71 Obery Street INSURER C : Plymouth MA 02360 INSURER D : INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: 2090118068 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 LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY PHPK2661534-005 4/1/2026 4/1/2027 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED CLAIMS-MADE l X J OCCUR PREMISES (Ea occurrence) $100,000 X ABUSE/MOLEST. MED EXP(Any one person) $5,000 X PROFESSIONAL LIA PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $3,000,000 OTHER: Prof Liab&Abuse S 1 M/$3M AUTOMOBILE LIABILITY PHPK2661535-005 4/1/2026 4/1/2027 {EOa aBINcci EDtSINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) Collision/Comp Ded. $2,000 A X UMBRELLA LIAB X OCCUR PHUB902653-005 4/1/2026 4/1/2027 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$ ln,nnn $ B WORKERS COMPENSATION WMZ-800-4001241-2025A 12/31/2025 12/31/2026 PER OTH- AND EMPLOYERS'LIABILITY YIN __ STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (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 CRIME PHPK2661534-005 4/1/2026 4/1/2027 EMPLOYEE THEFT $500,000 CRIME DEDUCTIBLE $5,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Shore Early Education & Childcare ACCORDANCE WITH THE POLICY PROVISIONS. 367 Rt 28 W Yarmouth MA 02673 AUTHORIZED REPRESENTATIVE USA ' / I I - -- © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD rz