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Home My WebLink About0180 FALMOUTH ROAD/RTE 28 ''q Town of Barnstable' . ,. Tnt. ., o t�This. r g So T✓-fr►a1w,.�t-x,is. ;U�s�bT B aPlarnsn,Msustt abeba.Rel#ae rd M'eu sfaise,Ked„X"; fl in y ndthi ,h. . .. r ,< �.,..E.. �.k 7<� .,,,y :.. Y ,?.�;�, ..,y: ,,. ., <., :. �" ,:: 1 Y•-5.4�".. s ect on.Has B een= ade,� :z • ed,U. tt Fina(:In i M-� ct ficate,:.of Occu an wis Re u�>?ed suchMBu�ldin shall Not be Occu ied.,un#i,a,�F�nal Ins,ectron...bas been made r e rmit P2rni t No. B-17-1175 Applicant Name: MAYFLOWER CAPE COD LLC Approvals Date Issued: 06/28/2017 Current Use: Structure Permit Type: Building-Amusement/Social/Recreation Expiration Date: 12/28/2017 Foundation: Location: 180 FALMOUTH ROAD/RTE 28, HYANNIS Map/Lot 311 001 Zoning District: SPLIT Sheathing: Owner on Record: MAYFLOWER CAPE COD LLC _ �ContractorName Framing: 1 Aa Address: PO.BOX 167928 ontratorUcense 2 r �:, Est Project Cost: $0.00 Chimney: IRVING,TX 75016-7928 � y: Description: carnival in parking lot June 12 to 18,2017 r�it Fee: $210.00 Insulation: Fee Paid $210.00 Project Review Req: carnival in parking lot June 12 to 18,20177, l ®ate ", 6/28/2017 Final: Plumbing/Gas x Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work a thontedt,by this permit is commenced within si months 4ftdr issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents=for which thrs permit has been granted. All construction,alterations and changes of use of any building and structures shallFb�e in compliance with the local zoning law a 1d codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical RIM The Certificate of Occupancy will not be issued until all applicable signitures by the Building and,F" a Officials are provided on this'permit. Service: Minimum of Five Call Inspections Required for All Construction Work:? 1.Foundation or Footing Rough: 2.Sheathing Inspection , ' 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall.not proceed until the Inspector has approved the various stages of construction. .. ".Perso.ns contracting with unregistered.contractors..do,not havp.access to..the guaranty fund"las set forth;.in MGL c.142A) merit Fire Depart Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # — J Health Division ��l ��' �a Date Issued 612, E�c Conservation Division 44PR2 Application Fee Planning Dept. T W 4 ?®�j Permit Fee 13 Date Definitive Plan Approved by Planning Board N�` �&Ns-i Historic - OKH _ Preservation/ Hyannis �mp,!51_� S � Project Street Address 1 80 Falmouth Road Rt 28 Hyannis (Rear Parking Lot) Village Hyannis/Barnstable Owner__ Simnn Prnperi-y gaup Address 793 Tyannough Road Hyannis MA Telephone 508-771 -0201 Permit Request Carnival in parking lot June 12 to 18, 2017 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Amusement Rides Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Parking Lot Proposed Use Carnival area APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name New F.ngl and Rid s & Amusements Telephone Number 401 -934-1 560 Address 10 Red Oak Drive License # Johnston, RI 02919 Home Improvement Contractor# Email hfera@aol.com Worker's Compensation # WCP0004372-01 7 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE z��5V_ I l r! a FOR OFFICIAL USE ONLY t APPLICATION# DATE ISSUED MAP/PARCEL NO. f ' ti ADDRESS VILLAGE OWNER r DATE OF INSPECTION: FOUNDATION FRAME >r . INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ,c 9,4e De ment of,Public Safe License#: MA-flog p Safety License to;Operate Amusement Devices Expiration Date: 6/15/2017 Certified Maintenance Mechanic Rockwell Amusements&Promotions,Inc: (401)934-1560 David Fera Harold Fera Rockwell Amusements 10 RED OAK DRIVE JOHNSTON RI 02919 Talia Fera i U.S.I.D. #. Device U.S.I:D. # Device U.S.I.D. # Device 10120 Super Siide 10395 Gondola Wheel 00562 Tiki Town Fun House 10121 Mini Jets 10419 Merry Go Round 08170 Orbiter 10132 Yo Yo 10504 Bumble Bees 08249 Cliff Hanger 10188 Z klonCoaster Y 10509 Zipper 08439 Rock N Tug 10219 Mardi Gras Glasshouse 10561 Circus Train 09560 Pharoah's Fury 10352 Orient Express 10599 Gravitron 10083 Dragon Wagon 10366 Bear.AfNr . 10600 Fly Surf 10084 Tempest 10372 Round,Up 10702 Wind Glider 10087 Rio Grande Train 10373 Scooters 10870 Himalaya 10089 Hampton Combo 10384 Hampton Combo 10874 Tornado 10092 Gondola Wheel 10385 Dizzy Dragon 13035 Vertigo 10094 Fun Side Fun House 10386 Merry Go Round 13356 Tilt A Whirl 10114 Euro Bungee 16381 kenegade 13360 Euro Bungee 10118 Swinger 10388 Zipper PP 13363 Wacky Worm Coaster C! 101DI I?O)U Matt Carlin Issued Date Page 1 of 2 Conrmissloner of Public Safety i { I' j- i i F I ' i E F De artment of Public Safe License#: MA-009 p Safety License to Operate Amusement Devices Expiration Date: 6/15/2017 Certified Maintenance Mechanic Rockwell Amusements&Promotions,Inc. (401).934-1560 Harold Fera i David Fera Rockwell Amusements (� . 10 RED OAK DRIVE JOHNSTON RI 02919 f_ Talia Fera U.S.I.D. # Device U.S.L.D. # Device U.S.I.D. # Device 13434 Fun Slide I_ . IU01986 Moon Walk 13441 Full Tilt/Rock Star 1002515 Inflatable Train 13442 Scrambler 1 13452 Wave Runner 13453 Puppy Roll 13632 Hy5 Ferris Wheel 1 13633 Ali Baba/Rainbow j 13634 Scrambler 13635 Round Up 13642 Frolic 13643 Yo Yo 13730 Samba Balloon 1 13760 Scrambler 1001985 Moon Walk ! i I i Matt Carlin Issued Date Page 2 of 2 Commissioner of Public SafeV l i I I { f 1 � • I N i i i i Cane Cod M 11 6-14-17 to 6-18-17 C 01r) c e ss i o�h C� 1g � S �► � � CtAn e,/f n �Ici i Town of Barnstable Geographic Information System March 23,2016 0 0 V 1#9218 ' 312034 g ^A 79n s #730 , .� 294017C 294055 ;F� " v it 312030 1116 294019 #660 0104 ® 311092 329D03 294046 #480 294078 #793 . t � a 293019� � � � � �� f»;_� ® #00 311104 � 311102 #88 2 #610 #600 93039 #720 s, #793 #702 293018 311011 a F ��t2ii d #686? 311086 .: k A, . , #654 293022 *ems �c 311013 29#158 2 #142 Fap #158 293023 `��`` 311009 , x a 2930?A " zrx #685 �i #793 s krb. � . ., k m, � 311014 293044 293040 �� " t�, °% a #614' 293015053 #115` � y `a� e #127 #1531 1 zU, #11 13 293015054 #133 #109 d sn � td g:= 1 • "�. .q 311010 #707 01 493014 �F'� �E�w r. #855 a 311004 r � k 293046 293013 r yn � 311008 311089 # #83 #31 f y #793#48 293029 311096# 293048 C 29330049 o a.' 21 #71 VO. #63 293037 311006 #42 #645 II , #677447 2930 ` <"51, 3110 t 3#88 #88 s 293050 s^1 r� k •' h`. 1 f `311005 WE #47 i F>rh3ShDR{r5` 311001 #102;..�-^^�`#76 283001 283007 293010 293030 2 F. 293033 283043 #180 311072 #548 #322 293027 293038 293029001 #230 #226 #81 15 e r v; #0 311071 r #32 #306 293031 o 311075 311074 311078 3#95 3 #73 #276 SA:µ + nvvao�t. #.167 #123 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:293 Parcel:023 o boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:FEDERATED RETAIL HOLDINGS Total Assessed Value:$9375800 Selected Parcel 1"=100'may not meet established map accuracy standards. The parcel lines on this map are only graphic representations of Assessor's tax parcels. They are not true property Co-owner: Acreage:7.42 acres Abutters boundaries and do not represent accurate relationships to physical features on the map such as building locations. Location:793 IYANNOUGH ROADlRTE 132 Buffer ! C� CAPE COD MALL A SIMON MALL . February 24,2017 Town of Barnstable 367 Main Street Hyannis,MA 02601 To Whom It May Concern, This letter is to inform you that Rockwell Amusements has entered into an agreement to lease a portion of the mall parking lot to host a carnival from June 12-18,2017. If you have any questions,I can be reached at 508-771-0201. Sincerely, Alena Reardon Director of Marketing&Business Development Cape Cod Mall 7691yannough Road,Hyannis,MA 02601 T 508 7710201 SIMON.0061 i ACORO® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/21/2017 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 endorsements. PRODUCER C NTA T Sue Vereker Allied Specialty Insurance,Inc. NAME: 10451 Gulf Blvd PH(At N Eft 727 547 3059 a No: 727 367 5695 Treasure Island,FL 33706-4814 EMAIL svereker allieds ecial ADDRESS: tY•com p INSURERS AFFORDING COVERAGE NAIC# INSURERA: T.H.E.Insurance Company 12866 INSURED Rockwell Amusements&Promotions,Inc.ETAL INSURERB: P.O.Box 338 INSURER C: North Scituate,RI 02857 INSURER D: INSURER E: 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. I EXP N SR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MWDD CY EFF MWDD YY LIMITS A X I COMMERCIAL GENERALLIA131UTY CPP0101470-06 06/15/2016 06/15/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS MADE �X OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea o.rm"ce $ MED EXP(Any one person) $ NA PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JEa LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY (CEO, SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A UMBRELLALIAB X OCCUR ELP0010329-06 06/15/2016 06/15/2017 EACH OCCURRENCE $ 1,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABILr Y Y/N STATUTE I ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Dates:June 12 to 18,2017 Additional insured:Town of Bamstable-Hyannis,MA;Cape Cod Mall As respects to the operations of the named insured. CERTIFICATE HOLDER CANCELLATION Town of Bamstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 367 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ REPRESENTATIVE ©1988-201 CORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD I ACO® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1 03/09/2017 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 endorsements). PRODUCER CONTACT Allied Specialty Insurance,Inc. NAME: 10451 Gulf Blvd PHONE FAX c Ext• ac No Treasure Island,FL 33706-4814 E-MIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: T.H.E.Insurance Company 12866 INSURED Rockwell Amusements&Promotions,Inc./ INSURERS: New England Rides INSURER C: P O BOX 338 INSURER D: North Scituate,RI 02857 INSURER E: 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. iLTR TYPE OF INSURANCE ADDL SUBR POLICY POLICY NUMBER MWDDI EFF MPWDDI EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ M'OTHER: L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JECOT- LOC PRODUCTS-COMP/OPAGG $ $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per a.dd t $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LU1B CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X SR AND EMPLOYERS'LIABILITY A YIN WCP0004372-017 03/29/2017 03/29/2018 PER ATUTE E ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? ❑Y NIA (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 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Coverage is afforded in the State(s)of:CT,FL,MA,ME,NH&RI Excluded from coverage: Harold&Deborah Fera Dates: June 12 to 18, 2017 CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 367 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORI REPRESENTATIVE L;�w a jawA� ©1988-201 CORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD t Application number..... . .�..`....... Q Al `�(/ /jj Fee.................. . . �01<1 2��0 J. Building Inspectors Initials....................................... DateIssued:................................................................ 9 Map/Parcel...... ......... . TOWN OF BARNSTABLE- -- - -- --- EXPEDITED PERMIT APPLICATION: ROOF/SED NG/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBE STREE & VILLAGE Owner's Name: � klxy�A—ZW Phone Number 5CO. 77 Email Address: f kV'�-�By� ®��t Cfty6ell Phone Number Project cost$ Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize Ca V e to make application f a permit in accordance with 780 CMR Owner Signature: Date: G . P' i9 TYPE OF WORK Siding 0 Windows (no header change)# ED Insulation/Weatherization 0 Doors(no header change)# Commercial Doors require an inspector's review D Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. t APPLICATION NUMBER............................................................ *For Tents Only* JAn ,)� Date Tent(s) will be erectedOS Removed on , number of tents total I Does the tent have sides?Yes �N� (If yes please attach floor plan with exits marked) Dimensions of each Tent X X Additional tent dimensions can be attached on a separate of paper. L�V°L a�r.!('D ' Purpose of Event LAM Check one: this event is a: for profit on-profit event �'� . ti Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan.with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No . ,if yes, a gas permit is required. Natural Gas Yes No ,if yes, a gas permit is required. Iffood is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE �-17�/ � Signature Date All permit41ions are s�jectto a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents = MW Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �Please Print Le 'bl Name(Business/Organization/Individual): /� Address: - - City/State/Zip: Phone#: ',y 3—q : Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time). * have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑.Demolition workingfor me in an capacity. employees and have workers' Y P tY• f 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: _ Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D for insurance coverage verification. I do hereb certi udder the pains and penalties of perjury that the information provided above is true and correct. Signature: 1 Date: i Phone#. 03 ' 4� Official use only. Do not write in this area,to be completed by city or town official 1. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants , Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 vvww.mass.gov/dia —_J ego y4 1 � — lS — o�GcBg' makimum capacity 1000 �$0 1201ilfhPte t` FIRE EXTINGUISHER Maximum[apacity:with,stage:800 Maximum capacity tables&chairs SW Seating Shown for350 NO SMOKING = I ACl ft EfeE E ... ... ( a l e 30D : � aL...... 7 i€ ]]] 5 3 I ......... -4 --t- i. l errrnnNCE i<ztr $ F7s ' .. ...�... . ............'.:........ 1� �S - 4 - I ." Legend ♦ c � � � �� Parcels B Town oundary g � Railroad Tracks IFS' oS 7 3E K Buildings r Approx.Building x J 311010 F '.. i Buildings 71I7 Painted Lines 4 Parking Lots . Paved •."M �° r ' Aa' ., 1 `'' Unpaved g Driveways 4s � € 0 Paved i3x , �. .�e a L - :.:i Unpaved Jim V: X 3 Roads ? f - rz iz .- `aa € Paved Road '. >� 3 r a A y , �,.;. Unpaved Road z n NF .� u r s Bridge u ? � IF Paved Median x fir: € i V E�: % 79 £ :sf Marsh ', A � � e 3f1QQ$ I' Water Bodies y �NOet�� N. 97 ti INK IN All ft 311075 TV '3F F7 ' k' 2. r/ ❑� .❑� Aar ? q ;;- •� .rjF k ti Or Map printed on: 6/18/2019 This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 36'7 Main Street,Hyannis,MA 026o1 O 83 167 0 an on-the-ground survey.It maybe generalized,may not accurate relationships to physical objects on the map 508-862-4624 reflect current conditions,and may contain such as building locations. Approx.Scale: 1 inch= 83 feet cartographic errors or omissions. gis@town.barnstable.ma.us �, �: _ �� ` � �' � a �� r a= � '� � `i\: � fr y �� \ �' \ ��\ � � F ,� � ._ _ � } F �� a A �i � < e '�^ 7.�a . \• \F,.m2 .Z,�, Ern Rd ��' ��_ \ y. r ,.:. xa R vu � �� F�k l�� _ _2 i � � ` 1�� '�. e' _ ii �' :. Cam=. _"� F�� yr: nA. V+ �. h � ��l gg �X.- � � � tV�.. �`� c � W � � � � ti Y a z� t +�' � i.. x�k �f ;A ', L '. s �i ��` �.�. _� �;; �'n a `^ e 3� 9% Town of Barnstable r. � � -�� ' � � . � , =FY Building . Post Tfiis Card So That rt s�V�s�ble From the Street2 Approved'Plans Must,be,Retamed on,Job and tfiis.Card^Must be>Kept �ARh*a3TAgZ.L.. .:.µay. 3 '" +i �;'✓ , .. v> t v a: %" �,,. `\ "Ff a� '� \`*. v 6 Posted Untrl Final Inspection Has'Been Made > a �� 3 SP a V.e m� . i ,. :r➢ �, * � � . � Permit Where a Certificate of Occupancy�s Required,sucfi Builtlmg shall NoLbe Occupied until a Finallnspection has been made ..,«�z A:.a.., ".,... .... .._.::- � L. ,.m. ..,. ,h.. vma.. _.:..,. M� «..�.�. ,G.. ,. r.s... . .. �. ;�.,.. *, . .s�..;a�;....;n:� .z... ..m.. ... Permit No. B-19-1323 Applicant Name: Harold Fera Approvals Date Issued: 06/07/2019 Current Use: Structure Permit Type: Building-Amusement/Social/Recreation Expiration Date: 12/07/2019 Foundation: Location: 180 FALMOUTH ROAD/RTE 28,HYANNIS me Map/Lot: 311-001 Zoning District: SPLIT Sheathing: Owner on Record: MAYFLOWER CAPE COD LLC Contractor Name:= Harold Fera Framing: 1 Address: PO BOX 167928 Con tractor License 2 IRVING,TX 75016-7928 i s Est Protect Cost: $300.00 Chimney: Description: erecting amusement rides in parking lot of mall June 12 to 16, Permit Fee: $210.00 p g P g 2019 4 Insulation: f Fee Paid, $210.00 Project Review Req: Date 6/7/2019 Final: Plumbing/Gas A x Rough Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within 0i,,xficiiftfis after issuance. Final Plumbing: All work authorized by this permit shall conform to the approved application and the'approved construction docume�"nts for whicF.,,this permit has been granted. All construction,alterations and changes of use of any building and structuresshall be in compliance with the local zoning by to s -d codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. ?! �' Final Gas: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provid re ed on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work:,,,,, 1.Foundation or Footing Service: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue] , ining is installed �, � � � Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Final: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Rough: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: C } � Application Number..................f..`.............. ..... .. f . s • Ass. Permit Fee.:.........cz Ao.............Other Fee........................ 16;q. TotalFee Paid............................................................... ...... TOWN OF BARNSTABLE Permit Approval by....to-9 ........ ...........on..... ... ... � BUILDING PERMIT ® ® Mai.... ...... /.............Para l.............. .............................. APPLICATION Section 1 — Owner's Information and Project Location Project Address 180 Falmouth Road Rt 28 Village Hyannis• Owners Name Rockwell Amusement & .Promotions Inc. Simon Property Owners Legal Address 10 Red Oak Drive 793 Iyannough Road City Johnston State .RI -Zip 02919 Hyannis MA 02601 Owners Cell# 401 -934-1 560 E-mail ctwhite825@gmail.com Office 5 0 8-7 71 -0 2 01 Section 2—Use of Structare Use Group - ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet ❑ Single/Two Family Dwelling Section 3 —Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure' ❑ Change of use ❑ Demo/(entire stricture) ''❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar z d C ❑ Renovation ❑ Pool ❑ Insulation ? G) Other—Specify Carnival M Section 4 -Work Description Erecting amusement rides in parking lot of mall s�� . •� June 12 to 16, 2019 v~ T Act Tmdated:2/9/201 S ApplicationNumber.................................................... Section 5 Detail Cost of Proposed Construction 300.00 : Square Footage of Project Age of Structure Dig Safe Number #.Of Bedrooms Existing Total#Of Bedrooms(proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics Wiring ❑ Oil Tank Storage ❑ Smoke Detectors s ❑ Plumbing _ ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney' ❑Add/relocate bedroom Water Supply Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District _ ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: , I am using a crane El Yes El No a Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No Section 8—Zoning Information ZoningDistrict Proposed Use , Lot Area S .Ft. P q Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard . Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last undated:2/9/201 S Town of Barnstable Geographic Information System March 23,2016 u., 312034 �O20F (� �� '294018 ,9 � #730 µ :M Y.xkS 2948061 �%g?L 312030 294055 .s4� .r :.#660 329003 #116 294019 ® 311092 #480 #104 294046 294078 � #793 294045 #87 311104 - #630 311102 283018 y x s #610 #600 #88 ;t 1 #720293039 s Vie. #793 311011 k283018 x $ #686f 311086 #654 311013 293021002 293022 #142 2830 311009 # 311014 #614 293044 ®" 293040ti 293015053 #11 #115- r 293016064311010 9 a � �293014 ,. #8rr5 e � 04 "IR2a I0 311008 as 311089 46 #594 ® 293013 Y+293052 k 311086" #31 i . '; #83 y t#48 293o2s #21 .A ,�[t_ #793 a ` I� a r 311006 293048 O 293049 #71 Z` #%0. #63 293037 - #151 #42 a #645 3#885iJ 293047 293026 311094 #88 a e y , #574x 7 v ,` # 31100b 8 283050f , 1 311003 f l#76 .� #47 ,� 7 311001 #102r 'a FY$Sl1 '�nd ! #180 311072 293030 �� 293043 +�#91 293001 re. #b46 293010 1: #32 293029001 293033 #226 r 311071 15 e #322 2s3027 M.038 ^9 #000 1 #230 311073 #73 e i#32 #306 293031 ' " ''' . " 311075 311074 311078 #95 f nvvaoR. #,157 #123 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:293 Pa reel:023 Selected Parcel boundary determination or regulatory Interpretation. Enlargements beyond a scale of Owner:FEDERATED RETAIL HOLDINGS Total Assessed Value:$9375800 1'=100'may not meet established map accuracy standards.The parcel lines on this map Co-owner. Acreage:7.42 acres Abutters are only graphic representations of Assessor's tax parcels.They are not true property boundaries and do not represent accurate relationships to physical features on the map Location:793 IYANNOUGH ROADIRTE132 Buffer such as building locations. CAPE COD MALL A SIMON MALL April 18,2019 i Town of Barnstable 367 Main Street Hyannis,MA 02601 To Whom It May Concern, This letter is to inform you that Rockwell Amusements has entered into an agreement to lease a portion of the mall parking lot to host a carnival from June 6-16,2019. If you have any questions,I can be reached at 508-771-0201. Sincerel , r Alena Reardon Director of Marketing&Business Development Cape Cod Mall 769 Iyannough Road,Hyannis,MA 02601 T 508 7710201 51•.4GPLC0\i Cape Cod Mall 06-06-19 to 06-16-2019 C0tir) ce cs E C ) C G C-1 f ACORO® DATE(MMIDD/YYYY) CC CERTIFICATE OF LIABILITY INSURANCE 04/19/2019 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 Sue Vereker Allied Specialty Insurance,Inc. NAME: 10451 Gulf Blvd A/CC,N Ext: 727 547 3059 A C Noy 727 367 5695 Treasure Island,FL 33706-4814 EMAIL d lli k svereer aes ecial ADDRESS: @ P ty•com INSURERS AFFORDING COVERAGE NAIC# INSURERA: T.H.E.Insurance Company 12866 INSURED Rockwell Amusements&Promotions,Inc.ETAL INSURER B P.O.Box 338 INSURER C: North Scituate,RI 02857 INSURER D: INSURER E: 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. IN TR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM/DDI PLICYEFF MMIDDI EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CPP0101470-08 06/15/2018 06/15/2019 EACH OCCURRENCE $ 1,000,000 ❑X DAMAGE RENTED CLAIMS-MADE OCCUR PREMISS( ES Ea occurrence) $ 100,000 MED EXP(Any one person) $ NA PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 1,000,000 POTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A UMBRELLA LIAB X OCCUR ELP0010329-08 06/15/2018 06/15/2019 EACH OCCURRENCE $ 4,000,000 nDED EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Dates:June 3 to 16,2019 Additional insured: Town of Hyannis;Town of Barnstable;Cape Cod Mall As respects to the negligence of the named insured. CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ DREPRESENTATIVE (;W ©1988-201 CORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD A�® CERTIFICATE OF LIABILITY INSURANCE DATE 3/25 019) 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 Sue Vereker Allied Specialty Insurance,Inc. NAME: 10451 Gulf Blvd acNr o Et: 727 547 3059 'C No): 727 367 5695 Treasure Island,FL 33706-4814 E-MAIL d lli k svereer aes ecial ADDRESS: @ P ty.com INSURERS AFFORDING COVERAGE NAIC# INSURERA: T.H.E.Insurance Company 12866 INSURED INSURER B: Rockwell Amusements 8 Promotions,Inc.ETAL P.O.Box 338 INSURER C: North Scituate,RI 02857 INSURERD: INSURER E: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICYNUMBER MMIDD MMIDD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO_7 CLAIMS-MADE OCCUR PREMISES (E.oRENTED ccurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT ❑LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER ER AND EMPLOYERS'LIABILITY A YIN WCP0004372-019 3/29/2019 3/29/2020 R STATUTE ANYPROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA (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 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Dates: June 3 to 16, 2019 CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main .Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 AUTHORD REPRESENTATIVE ©1988-201 CORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD r SQX The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Ihsurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organiration/indmdual): Rockwell Amusement & Promotions Address: 10 Red Oak Drive City/State/Zip: Johnston RI 02919 Phone#: 401 —934-1560 Are you an employer?Check the appropriate bog: Type of project(required): 1.® I am a emP to er with 4 0 4. I am a general contractor and I Y have hired the sub-contractors 6. ❑New conch action employees(full and/or part-time).* 2.El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers'comp.insurance comp•insuranceJ required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ME]Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance reT red.]t c.152,§1(4),and we have no 130 other Carnival employees.[No workers comp.insurance required.] *Airy applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. 1 t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional shed showing the name of the sub-contractors and state vyhether or not those entities have t .employees. if the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: T.H.E. Insurance Company Policy#or Self-ins.Lic.#: WCP 0 0 0 4 3 7 2—01 9 Expiration Date: 0 3/2 9/2 0 2 0 Job Site Address: 180 Falmouth Road City/Sta#e/Zip: Hyannis, 'MA02601 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fime up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify der the p ' d penalties of perjicry that the information provided above is true and correct Simature: x Date: Phone#: 401 —934-1 560 O fonly. Do not write in this area,to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector. 6.Other CoutactPerson• Phone#• Office of Public Safety and [nspections License#: MA-009 :. License to Operate Amusement Devices Expiration Date: 6/15/2019 Certified Maintenance Mechanic Harold Fera (401) 9 34-1560 David Fera Rockwell Amusernents & Promotions. Inc. Rockwell Amusements 10 Red C iak Drive Johnston R1 02919 TaIia Fera U.S. I.D. Device l .S. I.D. # Del-ice U.S. I.D. # Device I if 120 Super Slide 101419 \•1cm•Go Round 0056-1 Tiki'fou-n Fun House I01.21 Mini lets If► 04 humble Bees 18170 Orbiler 101371 Yo Yo I Usu9 Zipper 08249 t:liff Flangcr 10219 Nfardi Lira.Glasshouse 10561 Circus`train i18439 Rock \Tug lu352 Orient Fvpre;� ! I U:l_i99 Graviiron 09560 Ph roah's Fury 1037"1 Round tlp 1(1600 FI% Surf 10083 Wagon Wagon 10373 Setnrterc I11702 Wind Glider 100 t tempest I0'.S l 11am�t�1n Combo 7 1 IUl�,Ct Ifirnalaya 10197 Rio(.irande Train 10385 Dire•Draaon It1ti7-1 Tornado 10089 Hampton Cornho 10386 �lcrn Go Round 13035 Vertigo 10092 Gondola Wheel 10.387 ReneL-ade 13356 Tilt:A Whirl 1 094 Fun Side Fun House 1t1+87+ Zipper I I360 Euro Bunzec 10114 Euro Minuet 1039- Gondola tlheel 13363 Wack% tbomi Coaster Charles Borstel Jssucrl Drrle Page I oft Commissioner or Public Sajetp and lusperriun m1-4-5 ;=r Office of Public Safety and Inspections License-": MA-009 License to Operate Amusement Devices Expiration Date: 6/15/2019 Certified Maintenance Mechanic Harold Fern. (�10 I ) 9�4-I AGO David Fcra Rockwell Amusements &. Promotions. Inc. Rockwell Amusements 10 Red Oak Drive Johnston R.1 02919 Talia Fera U.S. I.D. # Device U.S. I.D. # Device U.S. I.D. # Device I?-89 Tractor, 13760 Scrambler 134.34 I mi Slide 1 3795 tilotorcvclec 13441 Rock-Star 13797 Frog I lopper 13442 Scrambler 14'•P Tca`Ctrpss 13452 Nave Rumor 15703 Joker's Wild 13453 Puppy Roll 1 3;1 Orient lapress 13632 Hy5 Ferris Wheel 13634 Scrambler 13635 Round Up 13677 Scrambler 1 1678 Wild Cat Coaster 1373A Samba 11allocm I A02/ Charles Bowel Issued Dale Page?o1•' Cimimissinner Of Public•Safe{;'and hupectiou s Application Number........................:.....'............. Section 9—.Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell# I understand m re onsiblities under the rules and Y sP regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date Section..10-Home Improvement Contractor Name Telephone Number Address City State Zip Registration Number Expiration Date ! I understand my responsibilities under-the rules and regulations for home.Improvement Contractors in accordance with 780 E CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your ILLC... Signature Date Section 11—Home Owners License Exemption p; Home Owners Name: Rockwell . Amusement & Promotions 10 Red Oak Dr Johnston, RI 02919. Telephone Number 4 01 -9 3 4-1 5 6 0 Cell or Work Number - 4 01 -4 7 4-710 0 I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code: I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature xDate Print Name Harold Fera Telephone Number 401 -934-1560 r. E-mail permit to: ctwhite825@gmaii.com Section 12 —Department Sign-Offs m Health Department © Zoning Board(if required) El Historic District ❑ Site Plan Review(if required) Fire Department ❑ Conservation For commercial work,please take your plans directly to the fire department for approval. Section 13—Owner's Authorization as Owner of the-subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: 126 'ao 01annis (Address of job) x -- Signature of Owner date Print Name f i Last undated 2I9/2018 . Town of Barnstable Bunaing ,-" va ., y, >" s 'g;r..' 43 f.,: -.:i >'r Post This Card So That Wt 'S25 isible,;From the Streets A4pi o ed_Plans Must be Retain-6 -Job and:;-this Cartl Must be Kept •A1t2Vt}'CX>�18. y .;_ .x ,": • M" Posted Until Final InspeetionHas'BeenMaaxade y , .`' � ,a Where"aCertficateof Occupancy;is�Requred,such Bwldmg shall Perm "-"CCU pied until a FinalInspect�on has been made it Permit No. B-18-1160 Applicant Name:. Approvals bate Issued: 05/24/2018 Current Use: Structure Permit Type: Building-Amusement/Social/Recreation Expiration Date: 11/24/2018 Foundation: Location: 180 FALMOUTH ROAD/RTE 28, HYANNIS Map/Lot 311-001 Zoning District: SPLIT Sheathing: { w f Owner on Record: MAYFLOWER CAPE COD LLC Contractor:Name: Framing. 1 Address: PO BOX 167928 Contractor'.License 2 a� IRVING,TX 75016-7928 _ S Es't Project Cost: $0.00 Chimney: x " y: Description: Carnival in Parking Lot of Mall June 13 to 17, 2018 ' Permit Fee: $210.00 Insulation: Fee Paltl $210.00 Project Review Req: INSPECTIONS REQUIRED. �. k' Date` 5/24/2018 Final: s L Plumbing/Gas V Rough Plumbing: B Ming Official T Final Plumbing: This permit shall be deemed abandoned and,invalid unless the work authorized by this permit is commenced within slxmonths issuance. Rough Gas: All work authorized b shall conform to the y this permit approved application and the approved construction documents forwhichthis permit has been granted. All construction,alterations and changes of use of any building and str cturesishall b in compliance with the local zone gby taws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street orroad a`nd shall be maintained open for public inspection for the entire duration of the work until the completion of the same. ' Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Builtling and fire Officials aresrprouided o�n thIs permit. Service: Minimum of Five Call Inspections Required for All Construction Work: k; �` 1.Foundation or Footing Rough: .. 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firestflue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: -6.Insulation Low Voltage Final' 7.Final Inspection before Occupancy ,Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION FOP As:L S F'a Map 311 Parcel 001 Application 46 A- ) lkaHealth Division Date Issued -5� Z�l /T kS OV Jok- Conservation Division �� Application Fee a Planning Dept. Permit Fee �oD 0o Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 180 Falmouth Road Rt 28 Hyannis (rear parking lot) Village . Hyannis/Barnstable Owner Simon Protery Group Address 793 Iyannough Road Hyannis, MA Telephone 508-771 -0201 Permit Request Carnival in parking lot of mall June 13 to 17, 2018 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District S Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No -if yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ M9Itia-Fam`y(# units) Age of Existing Structure Historic House: ❑Yes? Na l®r Older iing's Highway: ❑Yes ❑ No N g-�N12 Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other a N -�c1ti1N�` Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Non-residential Proposed Use Carnival APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Rockwell Amusement & Promotions Telephone Number 401 -934-1 560 Address 10 Red oak Drive License# Johnston, RI 02919 Home Improvement Contractor# Email hfera@aol.com Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE � _� t FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. - zjj Department of Public Safety License MA-009 License to Operate Amusement Devices Expiration Date: 6/15/2018 Certified Maintenance Meebanic Rockwell Amusements & Promotions. Inc. ( 101 ) 934-1560 David 1=c`ra Harold Fera Rockwell Amusements 10 RED OAK DRIVE- JOHNSTON RI 02919 Talia Fora` U.S. I.U. # Device U.S. I.U. # Device U.S. I.D. N Device 1n1'I Mint Jets I�t;ft�) �tpper Q(i5f;2 1'ikt'I'own Fun linusc 1n132 Yir Yo 10561 Circus Frain 08170 Orbiter 11.1-19 Nlardi Gras f itron 08249 Clitl•!-fanacr 10352 Urient Express 10601) FN Surl' 08439 Rock>v'fug I0372 Round Up 1070, Wind C;lider 09S60 1'baroah's I'un 10371 .Scooters 10870 f firnalava I0081, Dragon Wagon 10384 1 lampton Combo I[)ti74 To mado 1u084 Tempest It 3N5 Drv3 Draeon 111133,5 Vertigo li,UK- Rio GrandeTrain I11t8@ Mern 6:j Round 133i6 Tilt A Whirl IOUS�► 1-famplon Combo I( 3S7 Renecadr I;260 ' f:un? f3uiiner 11i092 Glondola Wheel - lii3ti8 I,ppei 1?3h+ \1`ack� Worm loader 1 UCIyr l�un Side Fun House I t:r_�i5 Gondola\1'berl I?•134 I•'trn Slide 1!il 14 Furo[iuneer 11,1419 Merry(io Round 1 3.1•41 RoCk Star 111120 Super Slide I+15f14 Bumble flee, 1:3442 ticrambler &/7/`.)-0/7 :1lunhrl� ,110 au Issuer!Date I ot,_' Cimunis:sioner of l'uhlic S•ufgr ''2 ` evieai1.4 a/ Department of Public Safety License : ti1A-009 License to Operate AntUsernent Devices Expiration Date: 6/15/2018 Certified Maintenance Mechanic Rockwell Amusements & Promotions. Inc. (401) 9 34-1560 David Fern Harold Fern Rockwell Amusements 10 RED OAK DRIVE JOHNSTON RI 02919 Talia Fern l.:.S. I.D. # Device U.S. I.U. M Device U.S. I.D. # Device 134-32 Wave Runner 134-53 Puppy Roll 13632 11%5 F ris Wheel 13633 Rainbow 13634 Scrambler t 36 3 5 Round Up 1367 7 Scrambler 13678 Wild Cat toaster 13730 Samba Balloon 13760 Scrambler 13797 Frog.Flopper i s?a4 Tel C tlpss Matthew Jlt) da /s.Cued Dare Pace 2 of2 Camarissioner of Public Vgfgr � K 00 O O N - � vO O O f , ACORa DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/04/2018 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: Sue Vereker Allied Specialty Insurance,Inc. 10451 Gulf Blvd PH ON c , 727 547 3059 FAX No): 727 367 5695 Treasure Island,FL 33706.4814 E-MAIL svereker allieds clal Com ADDRESS: G pe ty INSURE S AFFORDING COVERAGE NAIC# INSURERA: T.H.E.Insurance Company 12866 INSURED INSURER B: Rockwell Amusements 8 Promotions,Inc.ETAL P.O.Box 338 INSURER C: North Scituate,RI 02857 INSURERD: INSURER E: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICYNUMBER MM/DD/YYYY) (MWDDNYM LIMITS A X COMMERCIAL GENERAL LIABILITY CPP0101470-07 06/15/2017 06/15/2018 EACHOCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE FXI OCCUR PREMISES EaENTEDoccurrence $ 100,000 MED EXP(Any one person) $ NA PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 1-1PRO- 1-1JECT LOC PRODUCTS-COMPlOPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident F 1 1 $ A UMBRELLA LIAB X OCCUR ELP0010329-07 06/15/2017 06/15/2018 EACH OCCURRENCE $ 4,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $ 4,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Dates:June 11 to June 17,2018 Additional insured:Town of Hyannis; Town of Barnstable; Cape Cod Mall As respects to the negligence of the named insured. CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ REPRESENTATIVE a ©1988-201 CORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents m Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Rockwell Amusement & Promotions Inc. Address: 10 Red Oak Drive City/State/Zip: Johnston RI 02919 Phone#: 401-934-1560 Are you an employer?Check the appropriate box: Business Type(required): L kj I am a employer with 4 0 employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers' comp.insurance required]* 11.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, . with no employees. [No workers' comp.insurance req.] 12.®Other amusement company *Any applicant that checks box#1 must also Sll out the section below showing their workers'compensation policy information. "*If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box M. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: T.H.E. Insurance Company Insurer's Address: 10451 Gulf Boulevard City/State/Zip: Treasure Island, FL 33706 Policy#or Self-ins. Lic.# wry n n n a 37 2-01 S Expiration Date: A:4 1;,n 12 a Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce fy,under the pain�dpenalh_ies of perjury that the information provided above is true and correct. Signature:' Date: - Phone#: 401 -934-15 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: ACORU® DATE(MM/DD/YYYY) A� CERTIFICATE OF LIABILITY INSURANCE 03/30/2018 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 Allied Specialty Insurance,Inc. NAME: 10451 Gulf Blvd aHcoN o ac No): Treasure Island,FL 3370&4814 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURERA: T.H.E.Insurance Company 12866 INSURED Rockwell Amusements&Promotions,Inc./ INSURERB: New England Rides INSURER C: P O Box 338 INSURER D: North Scituate,RI 02857 INSURER E 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. ILTR TYPE OF INSURANCE ADDL SUB POLICY NUMBER MM/D POLICY EFF DDILICY EXP LIMITS COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE T RENcu PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO- ❑ JECT LOC PRODUCTS-COMPlOPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION /� STATU ERH A AND EMPLOYERS'LIABILITY YIN WCP0004372-018 03/29/2018 03/29/2019 TE ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUE �Y NIA (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 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space Is required) Coverage is afforded in the State(s)of:CT,FL,MA,ME,NH&RI Excluded from coverage: Harold&Deborah Fera June 13 to 17, 2018 CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHO REPRESENTATIVE C�4w a C 1988-201 CORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD o o Town of Barnstable Geographic Information System March 23,2016 294020. 294018 312034 #0 #921 _ #790 #730 294017 ,* #867 312030 294055 N N; #660 Pq 294019 #104 "+ 311092 329003 It 480 294046 294078 #793 294045 #87 a 'p 411? 311104 #630 311102 293019 #610 #600 #88 293039 #720 #793 #702 293018 311011 #64 i Ij #686, 311086 6 �'�S✓ #654 Qi 311013 3021002 293022 �� #624 #158 293023 29 #142 �r��lip � �''� 4 lil; y #793 293024 #6859#793 l 311014 293044 �" 293040 s ;r #614 293015053 K #167 #1531 #11 #11513 ' �y 293015054 #I1 #133 #109 311010 #707 3 #655 a 311004 #854 #621 311008 311089 293046 293013 #31f #594 3052 311096 at #48 293029 #21 293048 O 293049 #793 1 311606 #71 #70, #63 293037 #15 #42 #645 311095 ® 293 #5047 293026 311094 . #88 0 _74 #96 to 8 293050 \\ 311003 `3005 #76 A 4a 047 �� 311001 #76 °* leSh PatTd #180 #102' 4.. 293030 293010 #32 ` 293033 293043 .�^ 3#91 2 293001 #322 293029001 #226 311071 293027 293038 � -; #0 #230 w 311073 15 e �#32 #306 293031 to 311075 311074 311078 #95 #73 �.- #276 w dr<e t. #"157 *123- rn7 Via;. DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:293 Parcel:023 , bounds determination or regulatory into retation. Enlargements beyond a scale of Selected Parcel ED rP r9 boundaryy caner:FEDERATED RETAIL HOLDINGS 4 Total Assessed Value: 9375800 1"=100'may not meet established map accuracy standards. The parcel lines on this map O $ are only graphic representations of Assessols tax parcels. They are not true property Co-Owner: Acreage:7.42 acres Abutters ' boundaries and do not represent accurate relationships to physical features on the map Location:793 IYANNOUGH ROAD/RTE132 such as building locations. Buffer -��/ V V CAPE COD MALL A SIMON MALL March 14,2018 Town of Barnstable 367 Main Street Hyannis,MA 02601 To Whom It May Concern, This letter is to inform you that Rockwell Amusements has entered into an agreement to lease a portion of the mall parking lot to host a carnival from June I1-17,2018. If you have any questions,I can be reached at 508-771-0201. Sincer , f Alena Reardon Director of Marketing&Business Development Cape Cod Mall 7691yannough Road,Hyannis,MA 02501 T 508 7710201 SIMON.COM 1 Town of Barnstable Building Post This Card So That it:is Visible From the Street Approved Plans`Must be Retained on"Job and this Card Must be Kept°� *6�3ct, WPohs6teerad aU,nCteirlt F!fi ncaal t eln ospf eOccfciounp aHnacsy Bise eRne qMuairdeed;a;s`uch`'B u'it ld,m g�.s hall��N"'o�t�b�e�O�c'cup-di �`un#"��t'�iI'a` Final Inm�s$p ect"iYo�n Rhas beenm T ade� # `:`�G# Permit Permit No. B-18-539 Applicant Name: Approvals Date Issued: 02/21/2018 Current Use: Structure Permit Type: Building-Sign Expiration Date: 08/21/2018 Foundation: Location: 180 FALMOUTH ROAD/RTE 28,HYANNIS Map/Lot 311-001 Zoning District: SPLIT Sheathing: Owner on Record: MAYFLOWER CAPE COD LLC Contractor Named Framing: 1 Contractor " Address: PO BOX 167928 ,,,,-License:;-,", 2 ` Est Project Cost: $0.00 IRVING,TX 75016-7928 i , i Chimney: Description: 3'X 20'TEMP SIGN-SIGN INSTALLED ON FENCE - 'Permit'Fee: $50.00 r Insulation. T Fee Paid-) $50.00 CC BOAT SHOW&SEAFOOD FESTIVAL j Date 2/21/2018 Final: INSTAL 5/28/18 Plumbing/Gas REMOVE 5/29/18 a Rough Plumbing: Project Review Req: Z Wing Enforcement Officer Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months;afi&lssuance. Rough Gas: All work authorized by this permit shall conform to the approved application and th6::approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. Final Gas: $, This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public mspection for the entire duration of the work until the completion of the same. , *� Electrical The Certificate of Occupancy will not be issued until all applicable signatures bythe Buildmgland Fire�Officials are'provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work I bE x "« * p q ± � Rough: F rF g 1.Foundation noting 2.Sheathing Inspection 3.All Fireplaces must be inspected atthe throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT r What: Why Participate: Pricing Per Square Foot: First Annual Cape Cod Boat Show • 40,000 + Sq Ft of display 100-250 $3.00 space available 251 -500 $2.50 Where: • Only Cape Cod Boat Show of 501 plus $2.00 Cape Cod Mall Rear Parking Lot the spring If you lease at least 500 Square Feet When: • Excellent opportunity to show you will receive: Memorial Day 2018: May 26 - 28 off your products & services • An additional 100 sq. ft. for: • Expectation of at least 2500 * Retail Sales Who's invited: attendees * Flea Market 1 • Boat Builders • Sponsorship opportunities • Entry into a $ 100 gift card • New Boat Sellers • Excellent parking drawing • Brokerage Boat Sellers • 24 hour security on site If you lease at least 1000 Square • Marinas • Large support staff on site Feet you will receive: • Marine Services • Free access for your • The space shown above • Marine Accessories & employees • $ 100 gift card •Supplies • Easy access during show Entry into a $250 gift card drawing • Cruises, Tours & Lessons hours • Boat Rentals • Early set-up available on See our website • Marine Insurance Providers Friday, May 25`" www.eventsnewengland.com • Marine Finance Providers for details • Marine Associations Questions? • Merchandise Vendors Call 508-737-1532 • Seafood & Beverage Vendors neemcapecod@gmail-com i New England Event I' f � Management, Inc. i Cape Cod Mall Site Map The First Annual i _ 0 � � d I' Exhibitor Staging & Storage 9 9 9 Attendee Parking I Show CAPE COD BOAT SHOW & SEAFOOD FESTIVAL May 26-28, 2018 Cape Cod Mall Hyannis, MA New England Event ' Management, Inc. Tony Crookshank Vice President-Planning neemcapecod@gmail.com 508-737-1532 Town of Barnstable Building Department pF1HE 1p� o Brian Florence, CBO Building Commissioner B�IRNSTABI,E Y MM9rABM 9 1KA33. .Kc°xsaxsxw sn ;�e zas`'r+ems 200 Main Street, Hyannis,MA 02601 1636.1U14 HIED MA'S a www.town.barnstable.ma.us 5175 Office: 508-862-4038 Fax: 508-790-6230 Temporary Sign Permit Application/Registration 16 Applicant "9G `�`'M ' Map & Parcel -3 t 1 00 1 Telephone Number - �31- �b��Z Email P--ff01 Clr)O C C -GP&I Type of sign t IER-iP . &<0 Number of signs / Dimensions of sign 3� x � Zoning District 46 Install date � Removal Date Sign Location VR)o tt,kAot i N > o _,W v Street address Additional Location List attached ❑ Sign Text/Event s � � C �� -ems Tr-V al- Annual event application ❑ Legend Parcels Town Boundary w Railroad Tracks Buildings Painted Lines `• Parking Lots S £: Paved �` ` •• - a.-w,.,.,.,� Unpaved }` id Driveways 1'®! F � Paved — x Unpaved Roads Q Paved Road t kc 793 :Unpaved Road i t I Bridge ati*. } x_ "'`' T T ' _ •- _ 13 Paved Median Streams t ° 3 k Marsh #,'.93.6 .. :° ,r fr• Water Bodies ]ry Jr i;•�„1"rtiX''�,`.' 123 2[7 d't`` yY^ Jwtiy➢ ..•_T�lr.'r„• 'kj t ii„adt+ar. fl K Y;. T L4k� t t . %. f ,.'' t -+,i 1 #rJ�l�� >, #r''.' ,:. s t•`s iiF l 9') s� - ' w't f i S i 474,42 Map printed on: 2/15/2018 This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA 026m O 167 333 0 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map 5o8-862-4624 reflect current conditions,and may contain such as building locations. Approx. Scale: i inch= 167 feet cartograpli c error-oromissions. gis@town.barnstable.ma.us BUILDING DEPT New England Event FEB 14 2018 Management, Inc. TOWN OF BAPNSTABU P.O. Box 657, West Yarmouth, MA 02673 2/13/2018 To: Robin Anderson — Town of Barnstable — Building Department From: Tony Crookshank — VP — Planning Subject: Cape Cod Boat Show & Seafood Festival — Flags & Banners Reference: Our Conversation Today Thanks again for your time today, Robin. Based on our conversation, I've put together the attached examples of our location and what we would like to do in the way of signage. We initially planned on having a mixture of American flags and pennants atop the fencing we will have around the property, however, we will now plan on just having American flags. We would like to be able to have directional signs telling people where we are, plus signs on site indicating where certain facilities are located, and would like to understand the town rules and regulations on that matter as well. Please let me know what the Building Commissioner decides and I'll put together the sign permit for review and approval. Regards, t Attachme 'ts 508-737-1532 neemcapecod@gmail.com Chain Link Banner Set up on Fencing Grommets @ 2 ft Cape Cod Boat Show 72 in & 36 in Seafood Festival � 240 in 120 in Cape Cod Boat Show � ® & ® 3 EK a � 0 Seafood Festival 20 Banner constructed of 13 oz matt white vinyl with grommets every 2 feet Cape Cod Beet Show&Seafood Festival A3 M Afi M A A8I.JAIO A11 1 1 A16 At) B A.L A90 BO 81 W 84 88 BB BR 88 f B2 I Be U811 I B12 813 810 818 516 B11 B18 B18 820 821 822 B23 820 I B25 B2B 821 1829 BA B30 B31 CO C1 W W Cd W CB C1 W I CB C10 C11 I C12 C13 Ctd C18 C16 =C17 C21 CR2 C23 CV I WS C26 C2R I C20 CiA C30 W1 M. O1 DR W M 08 08 OR DBF09 D10 D11 D12 O13 Old 0/8 O16 DtR D1B Dte D20 021 022 0M 101 926 01 I D21 ORB 02B D30 . AWIo E1 ER E3 Ed E8 EB El EB EB Efo E11 E12 E13 E1d E15 E1B E1R E1B E10 E20 E21 E21 E22 ER3 E2d ERe E28 E2! E2B E2B Gill12 F3 Fd FS FB Fi F8 FB F10 F11 112 F13 F14 F18 F16 F1R F18 119 FPO F21 \ 01 fiR G3 G1 G8 G6 GR GB G9 G10 0/1 G1R / ` 20 rev pK Grano V Boat Show (a - 4"'*� Ea [� 18 Food Festival 24 Constructed of 4mm Coroplast with H frame wire stands ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 311 Parcel .001 Application # Health Division E?1l/C®//VQ Date Issued S 31) Conservation Division ,/�V'�''��P' �Application Fee Planning Dept. A�R2 4 20 Permit Fee a Date Definitive Plan Approved b Planning Board pp Y g Historic - OKH _ Preservation / Hyannis Project Street Address 1-80 Falmouth Road Rt 28 Hyannis (rear Parking lot) Village Hyannis/Barnstable Owner_ Simon Property Group Address PO Box 167928 Irving, TX 75016 Telephone 508-771 -0201 Permit Request Carnival in parking lot July 5 to July 9, 2017 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Amusement Rides Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Parking Lot Proposed Use Carnival area _ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name New Fncll and Rides R Amusements Telephone Number 401 -934-1 560 Address 1 o Red oak nR;ve License # Johnston, RI 02919 Home Improvement Contractor# Email hfera@aol.com Worker's Compensation # WCP0004372-01 7 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ' ADDRESS VILLAGE _s OWNER e DATE OF INSPECTION: 1 Lt FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH t, FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ;F DATE CLOSED OUT ,r ASSOCIATION PLAN NO. m i Pa.("C C [ Oo t Town of Barnstable Geographic Information System March 23,2016 E020 K ��284018 312034 '#921 r..Iy #790 ° ' #730 294017 x Qr #887 312030 284055 x,.! n ,.3 ,^:� ,, #660 #115 294019 3 #104 a 311092 32900 p #480 900 294046 294078 #793 s ; 294046 �1 = 4 �283018 -' `° <' 3111L #63U 311102 #88 r: 4610 #600 793 311011 n 293018 #84 �aa :aa h Tx 7d 311086 311013 293021002 293022� . h is ✓� � h �y�a 7z rx �� #824 t o #158 #142 293023 L311009 �`�? r #783 ; r 293024 42 §' �#685 � . 311014 ' 15t� 293040 #614 293044 2930153063 . #11 #11513 a « s` 29301 #133 #109 311010 s �293014 k ti' ," #855 a 311004 ® #95 & #621 293048)� p 311008 311089 #594 2930t3 rx 4ta< #31! #� 293052 311096 ... ^. y #48 293029 #21 293048 N 32g 049 #793 a 311006 #71 Z' #70 ' #63 293037 #15 #42 F #645 ® 293047 293026 w_ 311094 3110 #98■ #574 _J'#86 41 �► #Sg 293050 l 311005 .s #47 r 311003 # 311001 76 Fresh Pond #180 #102 2 293030 3110 293001 293007 293010 r 283043 293029001 311071 #548 #322 #32 rY #230 #226 #91 293027,293038 �� x#0 15 e a f#32 #306 293031 suo 311075 311074 311078 311073 073 #276t r«~ nddanA. #,167 #123 # 95 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:293 Parcel:023 Selected Parcel boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:FEDERATED RETAIL HOLDINGS Total Assessed Value:$9375800 ' 1'-100'may not meet established map accuracy standards. The parcel lines on this map are only graphic representations of Assessor's tax parcels. They are not true property-- Co-Owner: Acreage:7.42 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:793 IYANNOUGH ROAD/RTE 132 ✓; '` such as building locations. Buffer ? / Department of Public Safety License#: MA-009 License tol�operate Amusement Devices Expiration Date:6/15/2017 1' Certified Maintenance Mechanic Rockwell Amusements&Promotions,Inc: (401)934-1560 Harold Fera David Fera Rockwell Amusements 10 RED OAK DRIVE JOHNSTON RI 02919 {� Talia Fera i U.S.I.D. # Device U.S.I.D. lf. Device U.S.I.D. # Device I IWU Super Side 10395 Gondola R'heel 00562 Tiki Town Fun House € 1012I Mini Jets 10419 Merry Go Round 08170 Orbiter ! ! 10132 Yo Yo: 10504 Bumble Bees 08249 Cliff Hanger £ 10188 Zyklon Coaster 10509 Zipper 08439 Rock N Tug i 10219 -Mardi Gras Glasshouse 1056) Circus Train 09560 Pharoah's Fury 10352 Orient Express 10599 Gravitron 10083 Dragon Wagon 10366 Bear Affair. 10600 Fly Surf 10084 Tempest 10372 Round;Up 10702 Wind Glider 10087 Rio Grande Train f 10373 Scooters 10870 Himalaya 10089 Hampton Combo j 10384 Hampton Combo 10874 Tornado 10092 Gondola Wheel !( 10385 Dizzy Dragon 13035 Vertigo 10094 Fun Side Fun House i 10386 Merry Go Round 13356 Tilt A Whirl 10114 Euro Bungee E ` 16381 kenegade 13360 Euro Bungee 10115 Swinger 1 10388 Zipper, 13363 Wacky Worm Coaster ; Matt Carlin Issued Date Page I of 2 CI�mmissioner of PabGe Safety I j. is i i Ii I i. �I I 1 1 1 i i Cape Cod Mall 7-6-17 to 7-9-17 ci 5 �l tin ex-c, ci n i E Department of Public Safety License#: MA-009 Licens eto! Operate Amus ement Devi ceS Expiration ton Date.6i15/2017 Rockwell Amusements&Promotions,Inc. (401)04-1560 Certified Maintenance Mechanic Harold Fera David Fera lug Rockwell Amusements 10 RED OAK DRIVE JOHNSTON RI 02919 Talia Fera U.S.I.D. # Device j U.S.LD. # Device U.S.1.D. # Device 13434 Fun Slide -I001986 Moonvvaik 13441 Full Tilt/Rock Star 1002515 Inflatable Train 13442 Scrambler ' 13452 Wave Runner i . 13453 Puppy Roll i 13632 Hy5 Ferris Wheel 13633 Ali Baba/Rainbow 13634 Scrambler 13635 Round Up } 13642 Frolic 13643 Yo Yo 13730 Samba Balloon 13760 Scrambler 1001985 Moon Walk i i ; �..�.�. Matt Carlin Issued Date Page 2 of 2 Commissioner of Public!Sa,fiery 3 1 i i 1 - i i i (MWDDNY CERTIFICATE OF LIABILITY INSURANCE DA04/21/2017 Y) 04/21/2on 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(les)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 Sue Vereker Allied Specialty Insurance,Inc. NAME: 10451 Gulf Blvd PHONN 727 547 3059 ac Nu 727 367 5695 Treasure Island,FL 33706-4814 EMAIL d svereker allies cla ADDRESS: Pe nyCom INSURERS AFFORDING COVERAGE NAIC# INSURERA: T.H.E.Insurance Company 12866 INSURED Rockwell Amusements 8r Promotions,Inc.ETAL INSURER B: P.O.Box 338 INSURER C: North Scituate,RI 02857 INSURER D: INSURER E: 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. ILTRR TYPE OF INSURANCE in=ADDL SUER POLICY NUMBER MMIDDIPOLICY EFF MPWDCDY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CPP0101470-06 06/15/2016 06/15/2017 EACHOCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ NA PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ A UMBRELLA LIAB X OCCUR ELP0010329-06 06/15/2016 06/15/2017 EACH OCCURRENCE $ 1,000,000 X EXCESSLUI6 CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNEWEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Dates:July 5 to July 9,2017 Additional insured:Town of Bamstable-Hyannis,MA;Cape Cod Mall As respects to the operations of the named insured. CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 367 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ REPRESENTATIVE (��w a ©1988-201 CORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ACO® DATE(mmmi:,YYY1� L� CERTIFICATE OF LIABILITY INSURANCE 03/09/2017 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 Allied Specialty Insurance,Inc. NAME: 10451 Gulf Blvd PHONE FAX C o A/C No): Treasure Island,FL 33706-4814 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURERA: T.H.E.Insurance Company 12866 INSURED INSURER B: Rockwell Amusements&Promotions,Inc./ New England Rides INSURER C: P O BOX 338 INSURER D: North Scituate,RI 02857 INSURER E 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 TYPE OF INSURANCE DL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD MMIDD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE PREMISES S(Ea occurre RENTED nce) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY RCT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION �/ $ WORKERS COMPENSATION X STATUTE ERH A WCP0004372-017 03/29/2017 03/29/2018 AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN N E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBEREXCLUDED? —Y NIA (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 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if mom space is required) Coverage is afforded in the State(s)of:CT,FL,MA,ME,NH&RI Excluded from coverage: Harold&Deborah Fera Dates: July 5 to July 9, 2017 CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 367 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 AUTHORV REPRESENTATIVE ©1988-201 CORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD CAPE COD MALL A SIMON MALL Febivary 24,2017 Town of Barnstable 367 Main Street Hyannis,MA 02601 To Whom It May Concern, This letter is to inform you that Rockwell Amusements has entered into an agreement to lease a portion'of the mall parking lot to host a carnival from July 5-9,2017. If you have any questions, I can be reached at 508-771-0201. Sincerely, i Alena Reardon Director of Marketing&Business Development Cape Cod Mall 7691yannough Road,Hyannis,MA 02601 T 508 7710201 SIMOPI.COM TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3 Parcel y1 Application #Z Health Division Date Issued Conservation Division �� Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ HyannisG ?l� 1 Project Street Address �31i1 ear parkin lot) . Village Hyannis/Barnstable Owner Simon Property Group Address 793 Iyannough Rd Hyannis, MA Telephone 508-771 -0201 Permit Request Carnival in parking lot June 6 to 12, 2016 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Amusement rides Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other BUILDING DEPT Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wo dAR Z/co�all�s�tove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size --V�B/ppa� rn: ❑ existing ❑ new size_ T—U OF Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use parking lot Proposed Use carnival area APPLICANT INFORMATION - (BUILDER OR HOMEOWNER) Name Rockwell Amusement & Promotions Telephone Number 401 -934-1 560 Address 10 Red Oak Drive License # Johnston, RI 02919 Home Improvement Contractor# Email- hfera@aol.com Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO n/a Dumpster contr cted to remove trash. � c SIGNATURE DATE i 10 �y FOR OFFICIAL USE ONLY 5 i APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION s FIREPLACE r + ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH - FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r VV CAPE COD MALL A SIMON MALL January 26, 2016 Town.of Barnstable 367 Main Street Hyannis,MA 02601 To Whom It May Concern, This letter is to inform you that Rockwell Amusements has entered into an agreement to lease a portion of the mall parking lot to host a carnival from June 6th-12th, 2016. If you have any questions, I can be reached at 508-771-0201. Sincerely, � I Adra G. Cohen General Manager Cape Cod Mall 769 lyannough Road,Hyannis,MA 02601 T 608 7710201 SIMON.COM The Commonwealth of Massachusetts _ Department of Industrial Accidents . Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Auulicant Information Please Print Legibiy Name (Business/Organization/Individual): Rockwell Amusement & Promotions Inc. - New England Address: 10 Red Oak Drive City/State/Zip: Johnston RI 02919 Phone#: 401 -934-1 560 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 38 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp.insurance.t required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. Other food comp.insurance required.] Carnival Rides *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: T.H.E. Insurance Company Policy#or Self-ins.Lic.#: WCP 0 0 0 4 3 7 2—01 6 Expiration Date: 3—2 9—2 01 7 Job Site Address: 793 Iyannough Road City/State/Zip: Hyannis-, MAi Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceT under t ai and penalties of perjury that the information provided above is true and correct Si ature: Date: 3 a, Phone 401 -934-1560 ` Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/02/2016 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 Allied Specialty Insurance,Inc. NAME: 10451 Gulf Blvd PHONE FAX AIC No Ext: VC, C No): Treasure Island,FL 33706-4814 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: T.H.E.Insurance Company 12866 INSURED INSURER B: Rockwell Amusements&Promotions,Inc./ New England Rides INSURER C: P O BOX 338 INSURER D: North Scituate,RI 02857 INSURER E 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICYNUMBER MM/DD MM/DDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COEa aMBINED SINGLE LIMIT ccident $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident r 1 $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY WCP0004372-016 03/29/2016 03/29/2017 X STATUTE ER ANYPROPRIETORMARTNER/EXECU I— Y/N E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? Y NIA (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 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Coverage is afforded in the State(s)of:CT,FL,MA,ME,NH&RI Excluded from coverage: Harold&Deborah Fera Dates: June 6 to 12, 2016 CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 367 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ REPRESENTATIVE C�V/a lu A- ©1988-201 CORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Department of Public Safety License#. MA-009 License, to Operate Amusement Devices Expiration Date: 6/1 5120 1 6 Rockwell Amusements& Promotions, Inc. (401)93:4=1560 Certified Maintenance Mechanic Harold Fera David Fera Rockwell Amusements 10 RED OAK DRIVE JOHNSTON Rt 02919 Talia Fera U.S. I.D. # Device Device U.S. I.D. # Device I U 121 M nn Jets 00562 Tiki Town Pun 1-louse 10504 Bumbie Bees•- • 10132 yo yo 08170 Orbiter - 10509 Zipper 10188 Zyklon Coaster 08249 Cliff Hanger 10561 Circus Train 10210 Mardi Gras Glasshouse' 08439 Rock N Tug 10599 Gravitron 10352 Orient Express,. 09560 Pharoah's Fury10600 Fly Surf' 10083 Dragon Wagon 103,G6 Bear;Aflair 10702 Wind Glider 10372. Round.Up. 10084 Tempest 10870 Himalaya 10037 Rio Grande Train 10373 Scooters 10874 'Tornado 10384 1-lmpton Conibo 10089 Hampton Combo 13035 Vertigo 10092 Gondola Wheel 10385 Di>.zy Dragon 13356 Tilt A Whirl 10094 Fun Side Fun House 10386 Merry Go Round 13360 Euro Bungee 10114 Euro Bungee 10387 Renegade 13363 10389 Zipper Wacky Worm Coaster 10118 Swinger 13434 Fun Slide 10395 Gondola Whccl 10120 Super Slide 13441 Full Tilt/Rock Star 10419 Merry Go Round 13442 Scrambler Commissioner of Public Safety Issued Date Page I oft Department of Public Safety License#: MA-009 License to Operate Amusement Devices Expiration Date: 6/15/2016 Rockwell Amusements& Promotions, Inc. (401)934=d°560 Certified Maintenance Mechanic Harold Fera David Fera Rockwell Amusements 10 RED OAK DRIVE JOHNSTON RI 02919 Talia Fera U.S. I.D. # Device Device U.S.1.D. # Device 13452 Wave Runner - 13453 Puppy Roll 13730 Samba Balloon 13760 Scrambler 1001985 Moon Walk 1001986 Moon Walk 1002515 Inflatable Train Commissioner o Public Sae 6 f f tY i suer[ ate Page 2 of 2 U //v � ' O TOWN OF BARNSTABLE BUILDING PERMIT APPLICATI6N Map I Parcel Application # Health Division Date C� � Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis 3_ �l ft�r ®t;C Project Street Address 9=—TaW x1e�d Rear Parking I,at) Village Hyannis/Barnstable Owner Simon Property Group Address 793 Iyannough Road Hyannis, MA Telephone 401 -934-1 560 Permit Request Carnival rides in parking lot July 12 to 16, 2016 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new FirsfTlo"orLR@,p6m�C�ouunt T. Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing Awood�/Aifstove: ❑Yes ❑ No %OwNOF�n Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn.,6P-ekisting,L❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use parking lot Proposed Use carnival ride area APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name New England Rides & Amusements Telephone Number 401 -934-1 560 Address PO Box 338 N Scituate, RI 02857 License # Home Improvement Contractor# Email hfera@aol.com Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO n/a Dumpster c ntracted for trash removal SIGNATURE DATE — — `� FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ..s 6 ADDRESS VILLAGE ' F OWNER DATE OF INSPECTION: t FOUNDATION FRAME INSULATION FIREPLACE Q ELECTRICAL: ROUGH FINAL E_ PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. f 1 CAPE COD MALL A SIMON MALL January 26,2016 Town of Barnstable 367 Main Street Hyannis,MA 02601 To Whom It May Concern, This letter is to inform you that Rockwell Amusements has entered into an agreement to lease a portion of the mall parking lot to host a carnival from July 12th-16th,2016. If you have any questions,I can be reached at 508-771-0201. Sincerely, Adra G. Cohen General Manager Cape Cod Mall s 769 lyannough Road,Hyannis,MA 02601 T 508 7710201 SIMON.coM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Business/Organization/Individual): Rockwell Amusement & Promotions Inc. Address: 10 Red Oak Drive City/State/Zip: Johnston RI 02919 Phone#: 401 -934-1 560 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 40 4. I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance.t required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a4homeowner doing all work officers have exercised their It. Plumbing repairs or additions myself.-[No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is thepolicy andjob site information. Insurance Company Name: T.H.E. Insurance Company Policy#or Self-ins.Lic.#: WCP 0 0 0 4 3 7 2—016 Expiration Date: 3—2 9—2 01 7 Job Site Address: 793 Iyannough Road City/State/Zip: Hyannis,MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.,Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pa' s and penalties ofperjury that the information provided above is true and correct Si ature: - Date: - ,- " Phone#: 401 -934-1560 Of use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I _ t DATE(MMIDDIYYYII) AC40RL>® CERTIFICATE OF LIABILITY INSURANCE 03/02/2016 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 Allied Specialty Insurance,Inc. NAME: 10451 Gulf Blvd pHCNNo Ext: I A/C No Treasure Island,FL 33706-4814 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURERA: T.H.E.Insurance Company 12866 INSURED INSURER B: Rockwell Amusements&Promotions,Inc./ New England Rides INSURER C: P O Box 338 INSURER D: North Scituate,RI 02857 INSURER E 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ OCCUR DAMAGE TO RENTED CLAIMS-MADE PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY❑ PRO- ❑LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ OTH- A AND EMPS YERS'LSA IONILIT WCP0004372-016 03/29/2016 03/29/2017 X PER STATUTE ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN N E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? ❑Y NIA (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 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Coverage is afforded in the State(s)of:CT,FL,MA,ME,NH&RI Excluded from coverage: Harold&Deborah Fera Dates: July 10 to 16,2016 CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 367 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ REPRESENTATIVE C�iw a ©1988-201 CORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD - = 37- e -Glm Department of Public Safety License#: MA-009 License to Operate Amusement Devices Expiration Date: 6/15/2016 Certified Maintenance Mechanic Rockwell Amusements& Promotions, Inc. (401)934-1560 David Fera Harold Fera Rockwell Amusements 10 RED OAK DRIVE JOHNSTON RI 02919 Talia Fera U.S.I.D. # Device U.S.I.D. # Device U.S. I.D. # Device 10121. '1iiticts 10504 BumbieBees 00562 Tiki Town Fun House 10132 Yo Yo 10509 Zipper 08170 Orbiter 10189 . Zyklon Coaster 10561 CIrCLIS Train 08249 Cliff Hanger 10219 Mardi Gras Glasshouse 10599 Gravitron 08439 Rock N Tug 10352 Oricnt Express 10600 Fly Surf 09560 Pharoah's Fury .10366 Bear Affair 10702 Wind Glider 10083 Dragon Wagon 10372 Round Up 10870 Himalaya 10084 Tempest 10373 Scooters 10874 Tornado 10087 Rio Grande Train 10384 1 lanipton Combo 13035 Vertigo 10089 Hampton Combo 10385 Dizzy Dragon 13356 Tilt A Whirl 10092 Gondola Wheel 10386 Merry Go Round 13360 Euro Bungce 10094 Fun Side Fun House 10387 Renegade 13363 Wacky Wonn Coaster 10114 Euro Bungec 10388 Zipper 13434 Fun Slide 10118 Swinger 10395 Gondola Wheel 13441 Full•Tilt/Rock Star 10120 Super Slide 10419 Merry Go Round 13442 Scrambler Commissioner u/'Public Safety Issued Date Page I of 2 - Jk � = Department of Public Safety License#: MA-009 License to Operate erate Amusement DevicesExpiration Date: 6/15/2016 p Certified Maintenance Mechanic Rockwell Amusements& Promotions, Inc. (401)934-1560 David Fera Harold Fera Rockwell Amusements 10 RED OAK DRIVE JOHNSTON RI 02919 Talia Fera U.S.I.D. # Device U.S:.I:D. 0. Device U.S. I.D. # Device 13452 Wave Runner 13453 Puppy Roll 13730 Samba Balloon 13760 Scrambler 1001985 Moon Walk 1001986 Moon Walk 1002515 Intlatible Train 0,0 Commissioner of Public Safety /sued ate Page 2 of 2 �cJ O �� J PROJECT NAME: ADDRESS: �'�''� a vi vv S PERMIT# S�{ PERMIT DATE: M/P: LARGE ROLLED PLANS ARE IN: BOX [a� SLOT ' G Data entered in MAPS program on: c-;t, l a BY: t q/wpfiles/forms/archive TOWN OF BARNSTABLE SIGN PERMIT PARCEL ID 311 001 GEOBASE ID 22996 ADDRESS 180 FALMOUTH ROAD (ROUTE PHONE HYANNIS` ZIP LOT LOTS A- BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT NY PERMIT 52517 DESCRIPTION SUMMER WIND REAL ESTATE/12 SQUARE PERMIT TYPE BSIGN TITLE SIGN PERMIT CONTRACTORS: Department of Health, Safety. ARCHITECTS: and Environmental Services TOTAL FEES: $25.00 1NE CONSTRUCTION COSTS $.00 �T Qi► p 8 753 MZSC: NOT CODED ELSEWHERE : BARN3TABLE. *' MASK. B 039. A� ED MI�►I BUILDING DLVI§ION B DATE ISSUED 04/03/2001 EXPIRATION DATE I .x Town of Barnstable Regulatory Services Q" Thomas F.Geller,Director LUMST KASSS.g Building Division 1639. ♦� 'O�Ep��► Elbert C Ulshoeffer,Jr. Building Commissioner 367 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Tax Collector Treasurer Application for Sign Permit Applicant: —�,Sj�Z/�—� :Z� Assessors No. Doing Business As: Telephone No. Sign Location WI ZC1 � �3 � Street/Road: � �/,z � �/GG Zoning District:, Old Kings Highway? Yes/No Hyannis Historic District? Yes/No Property Owner ///�%� Telephone:_ t'0� Name: — (,( Address: J /��-�(.C%vv l( Village: Sign Contract r Name: Telephone: Address: Village: Description Please draw a diagram of lot showing location of buildings and existing signs with dimensions,location and size of the new sign. This should be drawn on the reverse side of this application. Is the sign to be electrified? Yes/No (Note:If yes, a wiring permit is required) I hereby certify that I am the owner or that I have the authority of the owner to make this application, that the information is correct and that the use and construction shall conform to the provisions of Section 4-3 of the Town of Barnstable Zoning Ordinance. Signature of Owner/Authorized Agent: Date:,, 3 Size: - Permit Fee: - J Sign Permit was approve Disapproved: Signature of Building O - Date: Signl.doc rev.8/31/98 r�Y{>•! 1240M1 < '{ y�� `< «::;: DING.SE��•:V«. •:: •:.,,• n.. R soil- . ,,o; 6 ..........::...............: LDING RW ............................. .: .......... x.:.: BLOCK ...... �•. .. OU RD:y HErV NI - �.::: :< ................ . ....... .. . . .. ....... ... . >< m NOR 4•.. . ;:BAN. G :•;: e .,:;. a %;::.::.;:. NER—IEEE AL EME is ti ti? :'•. y t CALLED —WILL BE REMOVED BEFORE 6 25 98 Ems 9 / / mm ME �.. x 4 TOWN OF BARNSTA,BLE - SIGN PERMIT PARCEL ID 311 001 GEOBASE ID 22996 i ADDRESS 180 FALMOUTH ROAD (ROUTE ' PHONE . HYANNIS ZIP - LOT LOTS A- BLOCK _ LOT SIZE DBA DEVELOPMENT' DISTRICT HY PERMIT 26498 DESCRIPTION BURT'S INSURANCE AGENCY. (27 SQ.FT. ) PERMIT TYPE BSIGN TITLE SIGN PERMIT CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: $50.00 BOND c CONSTRUCTION COSTS $.00 753 MISC. NOT CODED ELSEWHERE " I + IIAMSTABLF, # MASS. i639. FD INId-.-`l BUILD. G�' V 'ION B I ? i DATE ISSUED 10 22 1997 EXPIRATION DATE The Town of Barnstable 64 i (R = Department of Health, Safety and Environmental Services aa,9 Building Division �� 367 Main Street,Hyannis MA 02601 J. Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Application for Sign Permit Applicant: Burt, Insurance Ag No Assessors O 1—ZL--00-L Doing Business AS: Telephone y 8.0 8-7 7 8-1311 Sign Location -2 fP G Street/Road: Zoning District: Old Kings Highttay? 1' /1'0 0 Property Owner Name: cape cod Mall Tel lephone: aQg4 Address: Village: Sign Contractor Telephone: 7 71-4 0 .0 Name: J • Address: Enternri7P Village: c4 s Description Please draw a diagram of lot shoeing location of buildings and e:dsting signs vrith dimensions, location and size of the new sign. This should be drawn on the reverse side of this application. Is the sign to be electrified? Yee emote:Yjrs, a wiring permit isreQuiredl I hereby certify that I am the owner or that I have the authority of the ovmer to make this application, that the information is correct and that the use and construction shall conform to the provisions of Section 4.3 of the Town of Barnstable Zoning Ordinance. Signature of Owner/Authorized Agent:Sew W ��."`� Date: i o l a d 4 Permit Fee: O `l Size: 07� Sign Permit was approved: Disapproved: Daze: Z � Signature of Building Offi 'al: /D ? o got 36l �Y I � xa a a y Ham_ s qv ,.irJ„A, Fri+ y�` MI �IIo r a ; Nt 'a s> n; .f t.y CD a La f I' ry t e i t '- TOWN OF BARNSTABLE BUILDING PERMIT_APPLICATION Map "� Parcel �( ( Permit# Health Division = _ Date Issued 9 ,3 Conservation Division Fee �U GC) Tax Collector • Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board r. Historic-OKH Preservation/Hyannis Project Street Address . (,M�L M-0 WLL, -,63>lt.,(�_bC D UVVT--{ Fe = OPr-T Zi') VillageYYfLIC� r - ' .Owner C6+��G � �� '�b�i:i1� �IQzJTAddress Telephone 6211'S 1 Permit Request oti6n O' 4t'Sy-w e Nkwpr6�_ � .�'T��P m('ac[.C.:, Sri vro 1 (,_ .M, X IQ A"1514 0 Square feet: 1 st floor: existing proposed RtM 2nd floor:existing proposed Total new 0 Estimated Project,Cost " ' Zoning District lood Piain 2k� Groundwater Overlay< � Construction Type Lot Size Grandfathered: ❑Yes 0 No If yes,.attach supporting documentation.' Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: 0 Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full' ❑Crawl O Walkout_ ❑Other SLR D0 4:5;QAOL_�_ Basement Finished Area(sq.ft.) 610y' , Basement Unfinished Area(sq.ft) u Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing -,new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel:, ;9 Gas : 0 Oil ❑Electric 0 Other Central Air: XYes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes D No Detached garage:❑existing ❑new size Pool:O existing ❑new size Barn:❑existing ❑new size Attached garage:O existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded 0 Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Bl��.1/44 Q6 aCL M - ' n BUILDER INFORMATION Nam Lcrl f� Telephone Number q(g6'ct&0_b Address Wel. k6. �i �-. License# 6745_`I Home Improvement Contractor# Worker's Compensation# 12$S$17/e4 •ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT.WILL BE TAKEN TO - -/64eA , 'P Sam- r XA_a.._'V� SIGNATURE DATE c5—( I �i� FOR OFFICIAL USE ONLY - PERMIT NO. „r ' DATE ISSUED MAP/PARCEL NO. ADDRESS ' - VILLAGE' OWNER ' y 4 s ram. , t t: _ -,..t-^. •• , DATE OF INSPECTION: - • FOUNDATION -' �, '�. �• i • 3 w � "`• _ ' r T _ ,4- - ` FRAME ;'^ �, 4 i • _ , INSULATION{ y FIREPLACE ELECTRICAL: ROUGH FINAL _ PLUMBING: ROUGH FINAL, `GAS: ROUGH, t FINAL FINAL BUILDING r - w + I � •`", yr' _ .. . n-r y i = F •.7 .. .z - ..� ��' �. a:. - _.. DATE CLOSED OUT ASSOCIATION PLAN NO. ' , , AUG-10-1999 12:24 COL GAS MARKETING P.01 y 127"hire's f'cuh I .So. Yarmotith,AIA o2664 L N g , 2-800-548-8000 G A S C D M P A M Y Fr4c-508-394-2.56-1 i i August 10, 1999 Len Belli I fax# : 771-3329 i re: 180 Falmouth Read - Hyannis To Whom It May Concern: This is to inform you that on August 9 , IP99 we were at the above named property and cut and capped the gas line at the street . I Sincerely , Jayne Starck i Di6tribution Cle ; k a � I TOTAL P.01 08/10/1999 TUE 08:41 FAX 5087909370 Linda Roderick ppi Commonwealth Electric Company 4 lIc � Cranberry Highway War R�� Wareham,Maasachusetts 02571 'n'ETelephone (508)291-0950 484 Willow Street Hyannis, MA 02601 August 10, 1999 Mr. Len Bf,-I De. Advisors Inc. C/O CC Mall Route 132 Hyannis, MA 02601 Re: Removal of Service Cape Cod Mall Dear Mr. Belli: Please be advised that the service and meters at 180 Falmouth Rd.,Hyannis for the Cape Cod Mall were disconnected and removed on Saturday,August 7, 1999. If you Sneed any other information,please feel free to contact me at our Yarmouth office at 1-800- 642-7030 ext, 5777. Your• uly, Cla dcttc ldt. Moses . Customer Service Supervisor 08/12/99 09:02 BARNSTABLE WATER CO. 001 Bamstable AT F R 47 Old Yarmrnith Hoar WITO. Box 326 tti l Hyannis, Massachusetts 021301-0326 5=7S_0%3 August 30 , 1999 ttuildinq Inspector `Pawn of Barnstable Town Hall fiy lUT)i S MA 02.A 11 RE: service. # 1.322 Account 311 001 :service # EFR 1322 Aconunt 311 161) Hyanni n V i l.1 aqe Aqua rtn , Pcam l mo"t:h Road Dear sire This is to confirm that the water srevices at the Hyannis Village ;;c "are , Falmouth noad , have . i>�er:n _L;h1jt. off eat the requc st of the ownevs an the bui ldinq is to be demvlishcd. `service 41322 wus shut uF'f on €/4/1` 1D. The service for the fire sprinkler system #;SPR 1322 wan whul of'.f. on 6/10/1909 , havinj received the: necessary permit from the Hyannis Fire D npt . ,an erely, or nutnwle water cpmha"Y HYANNIS FIRE DEPARTMENT A, '.R .. js. 95 HIGH SCHOOL ROAD EXTENSION I-=__�►! HYANNIS, MASS. 02601ya' �o. SyFo�� F �B =� I. / jU HAROLD S.BRUNELLE ,CHIEFIE FIRE PREVENTION BUREAU �l � ro ,s 'CJ PREVENTION LT.DONALD H.CHASE,JR. LT.ERIC HUBLER Inspector Inspector ' r APPLICATION FOR PERMIT FOR FIRE SPRINKLER WORK 19 DAT - / NAME OF COMPANY 0�_6- wax-5 BUSINESS ADDRESS 99621 k�_� CITY/TOWN, STATE, ZIP CODE MASS. CONTRACTORS SPRINKLER LICENCE NUMBER A JOURNE11AN- S LICENSE IS NOT ACCEPTABLE TO OBTAIN- A PERMIT LOCATION OF BUILDING WORK IS TO BE DONE STATE CLEARLY PURPOSE FOR WHICH PERMIT IS TO BE GRANTED FEE $ 10.00 PER MASS STATE BUILDING CODE COPY OF INSURANCE CERTIFICATE STATING THAT THE CONTRACTOR IS IN TO CONDUCT INSTALLATION, SERVICING AND REPAIR OF FIRE SPRINKLER SYSTEMS (THIS SHOULD BE STATED CLEARLY N E CERTIFICATE) Signature of pe son grant i permit T -------------------, 19 Title Date FIRE DEPT. 775-1300 I TOWN LINE 790-6328 1 EMERGENCY 9-1-1 FAX 778-6448 rUvvnr vr-CTAMM lr%jaLrZ SEWER CONNECTION PERMIT OFFICIAL USE ONLY f.; .. .. ax..: Assessors Map No. _3 l � ► • �,,::::: Assessors Panel No �� ► �`Tr•. >_:; Stream Wlage: L C.. n PROJECT CONTACTS PROPERTY OWNER (MailingAddress SEWER INSTALLER Name: L qua eg- �L-Y J �e e�1��i tom. Nana: f eu-'�'" 4y CC"r C<5 Address: U)f( S yau•N Ate; 2- L-'7 d--i s- U.L 'e,5:e s v' 2.4o' I 1�P.J-✓Ton ��. C')L c.!S•� �C.t,d-W ` Phone: Phone: sou- - License No: OWNER'S AGENTIENGINEER Name: Le r► eP, �Q C>]° Vll�ce,ep rhonw: _ 7 S- 5- PROJECT DESCRIPTION REGULATORY REQUIREMENTS .....,:..x.•:.... � tea{.............: •.:.�«.. �.��.,�; . Y } fs%tyaxsxx .•'•�.A..�.... TN ir18fi811 ft of eM aewar must be done in er:cordance with the r:•.:s•::•x:ss::.::s•.......... xs. y.' ,ma",.<sr.. ::2:. 22 provisions of Article X*M, Tarn of BamsW)Ie General By laws and RESIDENTIAL regulations Issued by the Department of Public Works. Befona excavating %thin a Town Way the sewer kwWleir must also obtain a Road Opening COMMERCIAL_ perm t and comply with the Construction Standards and Spedications oudhw therein. At least 48 hours prior to the Installation,the applicant must RESTAURANT_ a�N D �The Inspector will Engineering �� ce INDUSTRIAL Sketch locP N g the Ir shWed Ilnes and connection. By signing the Application, the applicant acknowledges and understands the regulatory reWhff eats and STANDARD INDUSTRIAL.CLASSIFICATION NO. unclerstands the fa<hae to campy with#w shall be grounds far motion of the Server Connection Permlt and the denial of any future application. NO.,OF BUILDINGS NO.OF-BEDROOMS SIZE OF PARCEL ACRES ESTIMATED DAILY SEWAGE GALLONS PIPING:LENGTH _-DIAMETER EXPECTED INSTALLATION DATE SIGNATURE(1NSTALLER/AGEN7) J ) - DATE �. SIGNATURE(DPW APPROVAL) DATE �'� Department of Industrial Accidents Office 011HYES IT&Vns < 600 Washington Street r.. •' v �i� Boston,Mass 02111 Workers' Comyensation Insurance Affidavit name: ' LL location: Ws IcCIJ� CitV NeLL) LC pm6 Cl?,I sq phone# ❑ I am a homeowner performing all work myself. ❑ 1 am a sole proDrietor and have no one working in any ca amty ❑ I am an employer providing workers' compensation for my employees working on this job. cornnnnv name• address: city: phone#: insurance cn. I oiim# r I am a sole proprietor, general contractor, or hou er(circle one)and have hired the contractors listed below who �eWR5�xl LO the follo%%ing workers' compensation polices: , company name: 12. %-�t-1TPLTi address: l A4400LPH T'o � 5S f3 city: �W�-�' i~�U'T phone#- .... . . ..... . m90rnnCe Cn. comnnnv name: address. cite phone#� ::......:::..... insurance Co. ::;....; ::.,;:..:<;<.:... .. alley# Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one veers'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a ante of 3100.00 a day against me. I understand that a copy of this statement may be forwarded to the Ofnce of Investigations of the DIA for coverage verification. I do herehv c if}• nder the p d ies of perjury that the information provided above is trite and correct 0 Si2ia e pate JULJT i Print name l.-1 Phone# Ccont-act he only do not write in this area to be completed by city or town otIIcial town: petnnit/license f/ ❑Building Depat�ttennt Licensing Board k if immediate response is required ❑Selectmen's 019ce ❑Health Department person: phone#; Mother IM-A"-a 9,95 PJAI Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensatioL,for their employees. As quoted from the "law",an employee is defined as every person in the service of another under anv cow of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or anv two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the rec=ver trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds c: building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renew' of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neitherthe . commonwealth nor any of its political subdivisions shall enter=0 any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.---------------------- - /�� /M 7/ Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and °date the affidavit. The affidavit should be returned to the city or town that the application for the permit or liccease is .being requested, not the Department of Industrial Accidents. Should you have any questions regarding the`law"or if you are required to obtain a workers' compensation policy, please caU the Department at the number listed below. City or Towns '' � Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applic= PIease be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Departrneat's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Me of 1o11asugatlons 600 Washington street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 �� ` t �. ��i.;