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HomeMy WebLinkAboutBLDCI-16-007004-06 T Co nwealth of Massachusetts , ' City\Town of YARMOUTH Y 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: SUPER 8 MOTEL BLDCI-16-007004-06 Trade Name: SUPER 8 MOTEL Identify property address including street number, name, city or town and county Certificate Expiration Located at 41 ROUTE 28 05/15/2023 • WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) 01st Floor 20 R-1 Hotel/Motel/Boarding House/Transient 20 UNITS R-1 LOBBY Allowable 02nd Floor 20 R-1 Hotel/Motel/Boarding House/Transient 20 UNITS MANAGERS Occupant Load APARTMENT 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 G, s Date of �`� Building Commissioner Inspection 7,2 Signature of Municipal Signature of Municipal (:)* Date of Building Commissioner i ..,46i Issuance :;190.00 BLD_Certoflnspection.rpt •°� Y`�R TOWN OF YARMOUTH �$ ' ! `� BUILDING DEPARTMENT ti" MATTAGH3rf / 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION April 1, 2022 PAYABLE UPON RECEIPT (X) Fee Required $190.00 ( ) 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: L} 1 — al- far 7 S ‘0/7—? 7 y V Name of Premises: SI'Pf-2. S Tel: Sb 3 C"62— Purpose for which permit is used: #,off 01 (_ License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency JUN 0 2 2022 t f-P�L lb r - w ov- `P4j. i 1 :i R7dc._ u.tl— riDA1TM aF q AlA . Uct'l�tt7Ni NI 4 i BUILD BY--- Certificate to be issued to S oPe-r2 g Tel: I CO g r r r c'6 2--- Address: L-P I C-6+f 12-r 2g W.'I AgiA00#f 4.4,A-94 016-73 Owner of Record of Building l - 1 Irie2 lc PA'e-- Address 3 Prt-COZO4 Q 044 'DR • 94/R--ctld l 1 A-Met 0 03 Present Holder of Certificate cupee, $ ,A(}A------Th ?VI/W.A./Air gnature of person to whom Title Certificate is issued or his agent < 2t4 IOW__ Email Address: Au M k KP 1 A-hdd' Cc)ti( , 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# \/ 05/15/2022-05/15/2023 ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4or....„r, 04/06/2022 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 Caitlin Regan NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX (A/C,No,Ext): (A/C,No): 973 lyannough Road E-MAIL cregan@doins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Lloyds of London XS0123 INSURED INSURER B: Scottsdale Insurance Company 41297 Kishor K.Patel NO Kiran K Patel NO AUM CORP,Motel INSURER C: NorGuard Ins Co 31470 DBA:Super 8 Motel INSURER D: 3 Algonquin Drive INSURER E: Burlington MA 01803 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 ADDL SUER 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 DAMAGE T CLAIMS-MADE X OCCUR PREMISESO(EaENTED occu occurrence) $ 50,000 _ MED EXP(Any one person) $ 5,000 A N XSZ180160 08/26/2021 08/26/2022 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO-POLICY JECT X LOC PRODUCTS-COMP/OPAGG $ Included 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 X OCCUR EACH OCCURRENCE $ 3,000,000 B X EXCESS LIAB CLAIMS-MADE XBS0144195 08/26/2021 08/26/2022 AGGREGATE $ 3,000,000 DEO RETENTION$ $ WORKERS COMPENSATION X S ATUTE ERH AND EMPLOYERS'LIABILITY Y I N 500 000 C ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A AUWC286498 10/21/2021 10/21/2022 E.L.EACH ACCIDENT $ , OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.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 The Town Of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 _�,.-' � r"' I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD