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HomeMy WebLinkAboutBLDCI-17-000324-07 The Commonwealth of Massachusetts City\Town of 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: BASS RIVER SPORTS WORLD BLDCI-17-000324-07 Trade Name: BASS RIVER SPORTS WORLD Identify property address including street number, name,city or town and county Certificate Expiration Located at 932&940 ROUTE 28 08/13/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-3 01st Floor 150 A-3 Amusement/Church/Gym/Library/Museum 150 PERSONS 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 Grylls Date of Building Commissioner Inspection (� Signature of Municipal Signature of Municipal Date of Building Commissioner Issuance Cj /j ,z Fee: $100.00 • BLD Certoflnspection.rpt :0_ -,„4 TOWN OF YARMOUTH sir1Q BUILDING DEPARTMENT ,ice , : H T''` v'� 1146 Route 28, South 1'arniouth, MA 02664 508-398-2231 ext. 1260 RECEIVED APPLICATION FOR CERTIFICATE OF INSPECTION July 1, 2022 PAYABLE UPON RECEIPT 1 JUL 14 2022 G 3a�1/4-10 P\-l/ Z- (X) Fee R 4GS PPARTMENT ( ) No Fee, eked__ 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: q lo39 00 Q'j Name of Premises:3N4k-5S 11- 1Vj(Z—Se1ZTS 1,30 j Tel: oQ 39(8' (0016 Purpose for which permit is used: `2 C 140) License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be ' sued tor6AS`- 1 02S o�5 (�o.2-t-t Tel: `09 31 Q,-(poi O Address: Ojt-\ \<- . r�i Q3 t C)o 'Bo x 12S c)o rr - L4PrJ21''.o om-1 1'\A- 0 2.f0(.,L, Owner of Record of Building legs s i'J 62_ 1Z c A LT` UL C....Address 2 1?LE�sA.is i S l i2 oo�r4 A Th- o 0 rE- nor 0 2co tee-( Present Ho of Certificate 0,0., .v c( Cp 0-42-" s t0 2-1--b, -LaS gnature of person to who Title ` Certificate is issued or his agent I l I oc b c). 1 Datc Email Address: 1 ,()‘ck1'n �-��DJ Cow cc,-.S+ . f1 Q+ 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# &LDC1—/7-C00307j 7 08/13/2022-08/13/2023 ACC)REP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 07/12/2022 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 CONTNAME: Rogers Rogers and Gray Processing BALDWIN KRYSTYN SHERMAN PARTNERS LLC lac No.Ext): (508)398 7980 FAX No): E-MAIL ADDRESS: mailG 9ers ra ro com 9 Y� 4211 West Boy Scout Blvd Suite 800 INSURER(S)AFFORDING COVERAGE NAM# Tampa FL 33607 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: BASS RIVER SPORTS WORLD INC INSURER C: INSURER D: PO BOX 183 INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 793732 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. ILICY EXP LT R ADDLTYPE OF INSURANCE INSD WVDSUBR POLICY NUMBER (MM/DDY/YYYY) (EFF MM/DD/YYYY) LIMITS LTR INSD WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED _ CLAIMS-MADE OCCUR PREMISES(Eaoccu nce) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE EER PER H AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N - E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A 6S62UB1K68658922 01/01/2022 01/01/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. 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 MA-28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD