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Home My WebLink AboutBLCI-18-004495-01 • • The Commonwealth of Massachusetts ' t, City\Town of i Is4141L- - YARMOUTH New and Renewal Certificate of Inspection In accordance with the Massachusetts State Building Code,Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name:WINDSOR NURSING&RETIREMENT HOME BLDCI-18-004495-01 Trade Name:WINDSOR NURSING&RETIREMENT HOME Identify property address including street number,name,city or town and county Certificate Expiration Located at . 265 NORTH MAIN ST 10/10/2019 SOUTH YARMOUTH,MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) 1-2 01st Floor 135 1-2 Institutional Hospital/Nursing Home 50 BEDROOMS-120 BEDS Allowable Basement/Lower 15 1-2 Institutional HospitaVNursing Home DAYCARE- Occupant Load 12 CLIENTS,3 STAFF This certificate of inspection is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall be framed behind glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to pose or tampering with the contents of the certificate is strictly prohibited Name of Municipal Name of Municipal Mark s Date of '�77 ��}7 Building Commissioner Inspection ��02� /U Signature of Municipal Signature of Municipal Date of Building Commissioner ^ /A % Issuance //,'n,/G U 4 vrr Q llt Fee:$150.00 • BLD_Certofnspection.rpt • ,.0 :aro __ TOWN OF YARMOUTH BUILDING �, ELEC1'RICAI. ..ryy�l 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 GAS PLUMBING call - Telephone(508)398-2231,Ext.1261 —Fax (508)398-0836 SIGNS --' _ BUILDING DEPARTMENT Inspection and License Report 6& S' �� 3�� 1 / Date / Address " A/6t't!1 274,' ' Sr Business Name wSnASo2 NU2S.'n6/ 67-fe Contact Phone During the Annual Inspection of your premises,performed In accordance with the provisions of Section 110.7 of 780 CMR(Massachusetts State Building Code),the Board of Selectmen,and/o r the Board of Healthearules,the following violation(s)were observed: ,Egress A( �f/ £fre 61/❑Emergency egresssigaageLocationrG7 L Emergency egress lighting location cv/filer 6 <r -�//g7, ` ' Pr kk� Oy4�tJ at E .J ❑Maiatenanaofesits Location y ��/ �• I t' OI null iciet U Guards/handrails Location C Yl4ar md, • ?U Signs oning Location iM" li/`9' /76,(C. 2 5 (J&//Tilv./I '(tc lath". ❑Parking Location (tier i r Jkye r//GLI 4t AL //t/ a> ❑ Other Location Mechanical ❑CombusdonAir Location ❑Storage in Boiler Room Location ❑Vents Location ❑Automatic door closures on boiler room doors Location ❑ Clothes dryer vents Larmion Other Location The State Building Code,Section 1001.3-Maintenance,provides that the owner as defined in Section 780 CMR shall be responsible for proper maintenance. In order to abate the above violation(s)von must; o Make corrections immediately and contact this office for a follow-up inspection. o Make corrections prior to opening and contact this office for a follow-up inspection. o Make corrections prior to your next annnal Inspection. o Make corrections withiny� days and contact this office for a follow-up inspection. Xiice LocalOfficiaVlnspecrpr � A/6� �,��} /�J//JJ ��y Received By 17--11/144-'1 /�'-�fr Title Revised 2/8/13 °l Y9R TOWN OF YARMOUTH o. '4,:" BUILDING DEPARTMENT • N "��'� - 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION • September 1, 2018 PAYABLE UPON RECEIPT (X) Fee Required $150.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: ZG Alor/ -i na v J/ ✓ Sov//t y .•M,v, H/9. 0266 r Name of Premises: 61/4/1,/or £4 S-, 11/Cri 0414)Tel: J f16"3 p y 3S/f/ 'Purpose for which permit is used: License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency 4v,7/, ? '""t �o Certificate to be issued to C14/1 4.o �ad Tel: 777- 2e 7-ZS-/s Address: 26r it/o-h', straiiv fjz 5, yo r•Y,.,,v)k ,y# a 266 y Owner of Record of Building fi/r)rt/j c.v.) Cact- JG2 Wee. -fl c Address �— Present� Holder of Certificate 1-44-- . /(toy/ r��--- . c5siC„✓ L� 4p!�� /%c44./4%a,C-' Signature of person to whom Title Certificate is issued or his agent 9- oC r ea/F I Date Email Address: era /I€>- r , 07 Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth, MA 02664 Return this application to: Building Inspector's Office Please note: Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified. Application must be received before the certificate will be issued. The building official shall be notified within ten(10)days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection #g/D-19-07) yy75-0 10/10/2018-10/10/2019 N4 4-4 CERTIFICATE OF INSURANCE ;; I DATE: 1 8/30/2017 COVERAGE IS INDEPENDENTLY PROCURED BY THE INSURED This certificate is issued as a matter of information only and Berkshire Indemnity Company SPC, Ltd confers no rights upon the Certificate Holder. This Certificate P.O. Box 1159 does not amend,extend or alter the coverage afforded by the 878 West Bay Road policies below. Grand Cayman, KY1-1102, Cayman Islands INSURED COMPANY AFFORDING COVERAGE Berkshire Healthcare Systems, Inc. (Together with the Other Insureds listed on the Policy) A Berkshire Indemnity Company SIC,Lid 725 North Street On behalf of BHCS Segregated Portfolio Pittsfield, MA 01201 COVERAGES .- This is to certify that the Policies listed below have been issued to the Named Insured 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. TYPE OF CO. POLICY POLICY POLICY INSURANCE LTR. NUMBER EFFECTIVE EXPIRATION LIMITS DATE DATE ANNUAL $3,000,000 GENERAL AGGREGATE LIABILITY PRODUCTS- $ COMP/OP AGGREGATE 7C COMMERCIAL A BHCS10117 10/01/17 10/01/18 PERSONAL $ GENERAL ADV INJURY LIABILITY EACH $1,000,000 OCCURRENCE X CLAIMS MADE FIRE $ DAMAGE OCCURRENCE MEDICAL $ EXPENSES EACH $1,000,000 PROFESSIONAL MEDICAL LIABILITY A BHCS10117 10/01/17 10/01/18 INCIDENT ANNUAL $3,000,000 AGGREGATE DESCRIPTION OF OPERATIONS/LOCATIONS/VECHICLRS/SPECIAL ITEMS(LIMITS MAY BE SUBJECT TO RETENTIONS) South Yarmouth Management Systems, Inc. d/b/a Windsor Skilled Nursing and Rehabilitation Center and its employees are covered under the terms and conditions of Policy No. BHCS 10117 which provides individual employee sub-limits of$IM/$3M. CERTIFICATE . ) CANCELLATION Should any of the above described policies be cancelled before the expiration date thereof,the issuing company will endeavor to mail written notice to the certificate holder named below, but failure to mail such notice shall impose no obligation or liability of any kind upon the company,to agents or representatives AUTHORIZED REPRESENTATIVES ZCbe C0111111011113taith of iiiIaggatijugetts License No. Serial No. 12064 DEPARTMENT OF INDUSTRIAL ACCIDENTS 902 =t/ i toe Whig S to Certifp that BERKSHIRE HEALTHCARE SYSTEMS, INC. AND ITS' SUBSIDIARIES of 75 North Street, Ste. 210, Pittsfield, MA 01201 , having conformed with the provisions of sub-paragraph( 2, b )of Section 25A of to be a . Chapter I52 of the General Laws is hereby licensed _ I SELF-INSURER This license is effective for a period of one year from the FIRST day of NOVEMBER 20 17 . at 12:01 A.M., unless sooner revoked DEP ; ENT OFINDU-- qDDp. • • T TD D /l T /l D