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HomeMy WebLinkAboutCerticiate of inspection The Commonwealth of Massachusetts _'-+ —* City\Town of m ��= YARMOUTH I 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: ST. DAVID'S EPISCOPAL CHURCH BLDCI-16-007007-03 Trade Name: SANTUARY/MEETING ROOMS Identify property address including street number,name,city or town and county tY Certificate Expiration Located at 205 OLD MAIN ST 06/18/2020 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group p Other A-3 101st Floor 79 A-3 Amusement/Church/Gym/Library/Museum 49 PERSONS ROOM 1 -10 Allowable STUDENTS Occupant Load ROOM 2-20 STUDENTS 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 ark Grylls, Date of �_�� Building Commissioner / -/� Inspection 1. Signature of Municipal Signature of Municipal Building Commissioner ate of (` Issuance ? . /i��� " / Fee:$50.00 I • I BLD_Certofl nspection.rpt • ,OR BUILDING TOWN OF YARMOUTH ELECTRICAL II r GAS C r = 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETIS 02664-4451_ PLUMBING Telephone(508) 398-2231,Ext.I261 —Fax(508) 398-0836 SIGNS BUILDING DEPARTMENT Inspection and License Report { y� c Date Address C O%$ Q(V/ �T/ ..7T Business Name $Z 90 Contact Phone cArcil f 7(/5,ei /44L 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: • Emergencycgresssignage Location ❑Emergency egress lighdi g Location 1/), t • ❑Maintenance of exits Location • ❑Guards/handrails Location 8 ❑Signs Location Parking Location ❑ Other Location a CombusdonAir Location ❑Storage in Boiler Room Location ❑Vents Location ❑Automatic door closures on boiler room doors Location ❑ Clothes dryer vents Location Dike 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)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 next annual inspection. o Make corrections within �i days and contact this office for a follow-up inspection. Local Official/Inspector 4 Received By Tide Revised 2/8/13 0 YAk40 TOWN OF YARMOUTH (� MA BUILDING DEPARTMENT ` TTA 4, .o..,n7.,$3[7„3 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION May 3, 2019 PAYABLE UPON RECEIPT (X) Fee Required 50.00 ( ) 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 rat the following address: Street and Number: 3( oQ� Vriiia f Vet k v.D Name ofPremisess: °��°� Tel: V Vil `112'22- Purpose for which permit is used: eititAav col - (64410',7wt "rpo.CP License(s) or Permit(s)required for the premises by other gov mental agencies: rAFCE License or Permit Agency !v D I clt:L. QlgRTMF_NT - {Certificate to be issued to � U C�l/V1' --s el: ?j q� �-�-�-.r ddress: 2 ' Old V11t owner of Record of Building l5q,.44C ddress Cc" b Id Y 51--, S resent Holder of Certificate- ,A W . — J < 1 � ignature of person to whom Title Certificate is issued or his agent (t/ 4 /1 C._'j 1 Date ,mail Address: ID ' � .cL" - .- c S'�dQtAd5 Lta. ag--- . c,61MC-u.s4- 1-3;3 . ri,e-1-. 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# aDC.t -,' ,- 6-740-7-o 6/18/2019-6/18/2020 7-1�-� ACOI�D y 1),, `', ,DATE(MM/DD/YYYY) — CERTIFICATE OF LIABILITY INSURANCE August 9,2018 • '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 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: Tracey Parent The Church Insurance Agency Corp PHONE FAX 210 South St,Suite 2 (ArC,No,Ext):(800)293-3525 (A/C,No):(800)557-1395 Bennington,VT 05201 E-MAIL ADDRESS: PRODUCER CUSTOMER ID th . INSURER(S)AFFORDING COVERAGE NAIC # INSURED INSURER A: Liberty Insurance Corp Diocese Of Massachusetts INSURER B: INSURER C: 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. INS S AUULSUBR FpF� - TYPE OF INSURANCE INSR'VI/VD POLICY NUMBER (MMM//DLD/YYy YYYF POLICY EX! • GENE�lBusry ) (MM/DD/YYYY LIMITS EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ • PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO-CT LOC $ Au I umuctlLABILITY I OMBINED SINGLE LIMIT Ea accident) NY AUTO BODILY INJURY(Per person) $ LL OWNED AUTOS :ODILY INJURY(Per accident) s. ,.CHEDULED AUTOS PROPERTY DAMAGE IRED AUTOS Per accident) ON-OWNED AUTOS MBRELLA LIAB I OCCUR' EACH OCCURRENCE s• CESS LIAB CLAIMS-MADE •GGREGATE DEDUCTIBLE -ETENTION $ WORKERS COMPENSATION WC STATU- OTH- A ANNDD EMPLOYERS'LIABILITY YIN Y X i WC7625900009018111 ; 9/30/2018 9/30/201 TORY LIMITS ER CUTIVEIETOR/PARTNER/EXEANY E.L.EACH ACCIDENT $1,000,000 r\FFIrcrumPMRFG e-,mi l inert', (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION St Davids Episcopal Church SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 205 Old Main St THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN South Yarmouth,MA 02664-4529 ACCORDANCE WITH THE POLICY PROVISIONS. e ,, ��4 The Commonwealth of Massachusetts Department of Industrial Accidents ;; �� Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print y Legibl Business/Organization Name: &lifrt �V. 5 _ER IC—: .srz o V-& Address: 90 j' (D\d, rneut,0i City/State/Zip: S , LI ba vl 1 J q • . I an employer? Check the appropriate box: Business Type(required): i7 am a employer with l.Y employees(full and/ 5• ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate, auto,etc.) employees working for me in any capacity. ,,� [No workers' comp.insurance required] 8. [ Ton-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing 4.tfo employees. [No workers' comp.insurance required]* 11.❑Health Care We are a non-profit organization, staffed by.volunteers, with no employees. [No workers' comp..insurance req.] 12.0 Other l ['Any applicant that checks box#1 must also fill 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 )rganization should check box#1. i am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. 'f� [nsurance Company Name: 1e., 5.4113l� �- AUX.11N &ir�D insurer's Address: .-( () SOU. S1 • City/State/Zip: .nviVu/1 6 5- L O I C� Policy#or Self-ins.Lic.# W C tl it ,),_S3 9 D q© � 9 c t 1 Expiration Date: l 13b !i f 1 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 Pine 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 Df 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. t do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Signature: i - - --'-"---- I lDate: ! 1-( I • Phone#: 6-61 J�`I Official use 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#: www.mass.gov/dia