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HomeMy WebLinkAboutBLDCI-19-000578-04 I Themonwealth of Massachusetts City\Town of YARMOUTH .ilto 7' a / 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 AT MILL HILL BLDCI-19-000578-04 Trade Name: MAPLEWOOD AT MILL HILL Identify property address including street number, name,city or town and county Certificate Expiration Located at 164 ROUTE 28 08/21/2023 WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) ` " A-3 01st Floor 48 A-3 Amusement/Church/Gym/Library/Museum 48 persons Allowable 02nd Floor 48 A-3 Amusement/Church/Gym/Library/Museum 48 persons r' Occupant Load Total occupancy:96 Ipersons 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 Grylls Date of ��� Building Commissioner _Inspection '�( Signature of Municipal Signature of Municipal / Date of Building Commissioner �, (/. Issuance l�zz Fee: $150.00 BLD_Certofl nspection.rpt _R a, TOWN OF YARMOUTH 4-p) BUILDING DEPARTMENT "" i=�A 1.146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION July 1, 2022 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: /t y /gyp v7 Z 'J f y vi/701/7f7 j No./ 0 Z 6 73 Name of Premises: //a 4 vtio oof at//ii/I /*// Tel: 7py-r7o-s/ 741 Purpose for which permit is used: / ,,/Gt4/6 C,-A 7y C f ri License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency RECEIVED AUG 02 2022 Certificate to be issued to / f/c �c�0 t� i i � DING DEPARTMENT /! /V / Y� Tel: �y y7 Y. Address: / y AT � G✓!I f Y.,ri- ,2c h / /�/. 02 G 7 3 - Owner of Record of Building AJw/e� � 2.�,L;.-1g✓,,v L.LG Address a,,rr_ Gvr-lr ram+-► .,�.1JQ _S E /00, I1) J1/v.^t) C. T 0G1d=0 Present Holder of Certificate ff / 'f '9,7/ Hi./l l/ 24; / Lam C //C l.f . I) P G77i , Signature of person to whom Title Certificate is issued or his agent 7—/J—.2 /// Date Email Address: /Vi ///!///esc/a ,t y/eA./Oa/St C04-'7 Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth,MA 02664 Return this application to: -" 7 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# 08/21/2022-08/21/2023 ACOREP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) kli.../ 7/13/2022 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 NAME: Commercial Lines Service Team M &T Insurance Agency, Inc. PHONE - 1 FAX 285 Delaware Avenue, Ste 4000 (A/C.No.Ext):716-853-7960 (A/c,No):855-595-4605 _ Buffalo NY 14202 ADDRESS: CLServicing@mtb.com INSURER(S)AFFORDING COVERAGE NAIC U INSURERA:MEMIC Indemnity Co 11030 INSURED MAPLE-5 INSURER B:TDC Specialty Ins Co 34487 Maplewood Mill Pond LLC 164 Route 28 INSURER C:StarStone Specialty Ins Co 44776 West Yarmouth, MA 06890 INSURERD:Federal Insurance Company 20281 INSURER E:National Fire&Marine Ins Co 20079 INSURER F: Bridgeway Insurance Company 35351 COVERAGES CERTIFICATE NUMBER:1437659955 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 LIMBS LTR DASD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) B X COMMERCIAL GENERAL LIABILITY Y LTP-01015-22 6/1/2022 6/1/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO 1 CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $100,000 MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY JET X LOC PRODUCTS-COMP/OP AGG $Included X OTHER: Shared Aggregate Policy Aggregate $10,000,000 D AUTOMOBILE LIABILITY 73594041 6/1/2022 6/1/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X 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) $ C UMBRELLA UAB OCCUR 82176D221AHL 6/1/2022 6/1/2023 EACH OCCURRENCE $13,000,000 E FNSC100124 6/1/2022 6/1/2023 F X EXCESS UM X CLAIMS-MADE 06012022 6/1/2022 6/1/2023 AGGREGATE $13,000,000 _ DED RETENTION$ GL Occurrence $ A WORKERS COMPENSATION 3102804908 6/1/2022 6/1/2023 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? N N/A (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 B Professional Liability LTP-01015-22 6/1/2022 6/1/2023 Per Incident 1,000,000 CLAIMS MADE Aggregate 3,000,000 RETRO 6/1/20 Policy Shared Aggr 10,000,000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Town of Yarmouth is listed as an additional insured on the General Liability if required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 /� ri3 Cl ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD