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HomeMy WebLinkAboutCertificate of Inspection Nursing Home The Commonwealth of Massachusetts � � City\Town of = �_ 4 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: MAPLEWOOD MAYFLOWER PLACE SNF, LLC BLDCI-16-007125-02 Trade Name: NURSING HOME _ Identify property address including street number,name,city or town and county Certificate Expiration Located at 579 BUCK ISLAND RD 07/11/2020 WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) -2 01st Floor 72 1-2 Institutional Hospital/Nursing Home 72 BEDS Allowable Occupant Load 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 Gryl Date of Building Commissioner Inspection 815)/7 Signature of Municipal Signature of Municipal ` Date of Building Commissioner Issuance //� Z$f 5 Fee:$100.00 BLD_Certofl n spection.rpt TOWN OF YARMOUTH BUILDING ELECTRICAL .1 GAS i 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 .II, _ Telephone (508) 398-2231,Ext.I261 —Fax(508) 398-0836 PLUMBING SIGNS - BUILDING DEPARTMENT Co ((- dee' ' Inspection and License Report Q f� Date Vt_ l Address 5 79 Business Name 4?/3 j`f" LAAticx:/ , 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/or the Board of Health rules,the following violation(s)were observed: 1\ of d Emergency egress signage Location L'" Tr 4 (ZZP ✓ t..,..."0/ 4 U Emergency egress lighting Location 7 /24,5 /L? e-42 ✓L i(5 I-tie -Vale/�- �4' ❑Maintenance of exits Location Pf. '441 l/W 5e c'r' _eJ ffLCCT� Location e67 r1/t kfl ret3.6 C 't01 IV 1G�13 C-C- 1/ y -T , 1r/ L' i' _ Location %� 1 .J J . "l.1- C= Ji C-.e.7-L I� 14/tif-C -3 VVI Location C(/'e " 1 ,'-4/.e, /, 4st✓�L t Location y� liee �X/Crly si"�'� 1.°'/y/Je 7' 'LG`r c<194a- r N. _. Q..) Location //,�" !N_.01G4 AA e, V49 AZ 5/' v L n Location .,..:1i `✓ t 4--1 /S3 0 Yeats Location f�`< VG`l .�a 6,, 1(.60A 1 L k('%/ l C cch'w/'‹' ❑Automatic door closures �` /J ' on boiler room doors Location t /1 A/AlIs //� ji 1 k-'v 77/ Zjii/7 . ❑Clothes dryer vents Location /)54 fee. 4 red i h'lr - roc;Tl?f liar —e Of7 arc ,,,J C.' Odle Location 4 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)you 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 t annual inspection. o Make corrections within days and contact this office for a follow-up inspection. Local Official/Inspector 6 f 14-0 • r/4-1 Received By07.-.45 : Tide -e5 Revised 2/8/13 / , -,. ° 'Y"R• a TOWN OF YARMOUTH '''tort'•-.1 BUILDING DEPARTMENT A .t � �n �: �. ��.• fi 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext.1260 'W Id APPLICATION FOR CERTIFICATE OF INSPECTION June 11,2019 PAYABLE UPON RECEIPT (X) Fee Required 100.00 ( ) No Fee Required Massachusetts State BuildingCode,Section 110.7,I hereby apply for a 4. in accordance with the provisions of the Mas Certificate of Inspection for the below-named premises located at the following address: .4. Street and Number: 574 -Su ck__,�.slan,CAe \P A.),,a-eLettp Ol' lnt Name of Premises: Mitt !�/Mtlpr-'7)/dc . NILasin9°P a/(' '1i Tel: A-Of 957-7o07• Purpose for which permit is used: C f/fi CCef'e p�J eCT!0-1 - Itf a e License(s)or Permits)required for the premises by other governmental g cies: nn (� ° ` l� A i\ License or PermitAgency g y------. Ak\ 1/./ /12 . UVA, C 0 -3 /HAYS -gi LQLZ2-Q 0\ii Certificate to be isd to AIA/ ' ' 0210 7 Address: 5Z.Z.-C.Owner of Record of Building /P.f ti/b o?/DEG Address 700 /,y> A) 7-/d'u+44�raue �'0/w Da a---1" , / Pres-i• •er ••f Certificate , lt ��� 400 o via k1 ear Z `""� - •f person to whom Title // a z#A4e is doehis�gent Date Email Address: tS QCtir)//.C.)/41X4Tasc 4 ,41r/G d 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 t 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. \il PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. ,.. f Certificate of Inspection#73L..W. /` �'� S d L 7/11/2019-7/11/2020 j! ?ta �+�� /1 !„ P� Act CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �...."'"-- 06/17/2019 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 Christian Barber,CIC NAME: The Oceanside Insurance Group PHONE Extl: (508)775-0500 FAX (508)790-7955 (A/C No. (A/C,No): E-MAIL ADDRESS: 52 West Main Street INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURERA: Starstone Specialty Insurance Company INSURED INSURER B: Commerce 34754 Cape Cod Energy Solutions,LLC INSURER C: National Liability&Fire Insurance Co. PO Box 159 INSURER D INSURER E: Forestdale MA 02644-0159 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1961706995 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 AUDL SUNK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGETO RENTED CLAIMS-MADE n OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 — A G85591191AEM 06/14/2019 06/14/2020 PERSONAL&ADVINJURY $ 1,000,000 GEN-'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n JECT PRO- ❑ 2,000,CCC LOC PRODUCTS-COMP/OP AGG $ OTHER: Each CPL Pollution $ 1,000,000 AUTOMOBILE LIABILITY GOMBINC-0 SINGLE LJMIT $ 1,000,000 _ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED v SCHEDULED BBXP90 10/04/2018 10/04/2019 BODILY INJURY(Per accident) $ AUTOS ONLY /_� AUTOS XHIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) PIP-Basic $ 8,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 — A EXCESS CLAIMS-MADE G85604191AEM 06/14/2019 06/14/2020 AGGREGATE $ DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER >/1 OTH- AND EMPLOYERS'LIABILITY STATUTE "IN ER Y/N 1,000,000 C ANYCER/MEMBR/PARTNEREXECUTIVEEl N/A V9WC005681 06/15/2019 06/15/2020 E.L.EACH ACCIDENT $ (Mandatory in NH) EXCLUDED? 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addkional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsement of the policy. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE S.Yarmouth MA 02664 ge4e.e__________ I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD