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HomeMy WebLinkAboutBLDCI-17-000280-06 The o monwealth of Massachusetts j R ri City\Town of YARMOUTH wa r J= 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: HABILITATION ASSISTANCE CORP. BLDCI-17-000280-06 Trade Name: HABILITATION ASSISTANCE Identify property address including street number,name,city or town and county Certificate Expiration Located at 07/02/2023 7 LONG POND DR SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) 1-4 01st Floor 160 I-4 Institutional Day Care(More than 5) Administration-63 persons 1st floor-160 persons: Allowable r Education&Institutional Occupant Load Total persons per the BOH-160 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 7 /, Building Commissioner Inspection Signature of Municipal Signature of Municipal fir Date of Building Commissioner Issuance 7 Z`/Z L ti'a Fee:$100.00 BLD Certoflnspection.rpt o, 21 aR'� boy „Y TOWN OF YARMOUTH rg _ 4 -f - k BUILDING DEPARTMENT ��x..,,;tr= 1146 Route 28, South Yarmouth, MA 02664 508-398-22 7 EIVED APPLICATION FOR CERTIFICATE OF INSPECTION J U N 212022 O29 j j June 1, 2022 PAYABLE UPON RECEIPT BUILDING DEPARTMENT (X) Fee ---- ( ) 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: j Street and Number: A3 k0`�5 PDnd ` Ir S \(aronoul-k ,1"\ 02-(o4 LI Name of Premises: \ o,b \\c0. 0(\ Qssl s-ka nCL Tel: 60S 7(0 917 0 Purpose for which permit is used: C\cu.k Y\c.kb License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency `,, II I Co(P Certificate to be issued to \--V00 t\l T l 0 ()SS►S4 co Ct. Tel: 5-8 7690 Q 77 0 Address: .4 3 Lo nC 1-4n nd i-Z 1 S y a c fvt c L Elm d"*C1 o Z(a 4 Owner of Record of Building J Address Present Holder of Certificate -\da.b ti � 11��-�0� Cl („rp u,:t,QA - Pcovary\ i r E.e.+car ignature of person to whom Title Certificate is issued or his agent CQ- 3-�.02.. Date Email Address: S b(Q.}I EC @ hoe_ . C'g_fifEr 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 IS E TIFICATE OF INSPECTION. Certificate of Inspection# I -ee vi -0 40 07/02/2022-07/02/2023 N� °. \Q QTOWN OF YARMOUTH o` ly BUILDING DEPARTMENT ``c"� :-.. ` $ 1146 Route: 28, South outh Yarmouth,:NIA 02664 �` 508-398-2231 ext. 1260 June 1,2022 Habilitation Assistance 43 Long Pond Drive South Yarmouth,MA 02664 Re: Inspection Date—07/02/2022-07/02/2023 Fee $100.00 Pursuant to the provisions of the Massachusetts State Building Code 780 CMR, Section 110.7 and Table 110,you are required to apply for a Certificate of Inspection for the building located at 43 Long Pond Drive, South Yarmouth, MA 02664 D/B/A Habilitation Assistance. Please complete the enclosed application and return it with the appropriate fee payment to the Town of Yarmouth Building Department, 1146 Route 28,South Yarmouth,MA 02664. Checks should be made payable to the Town of Yarmouth. Please note that as of September 15,2008, a revised fee schedule has been instituted. The new fee schedule includes re-inspection fees. IMPORTANT: One (1) re-inspection to confirm the abatement of any violations listed during the initial inspection will be included in the initial fee if the abatement is completed during the time period (typically 10 days) listed on the Inspection Report. Additional re-inspections will cost$80 each,which is payable in advance of the re-inspections. Unless otherwise requested, inspections will be performed unannounced. Typically the following elements/systems are inspected: fire protection equipment, means of egress, including emergency lights, exit signs, egress doors&hardware, clear path of travel, adequate lighting and occupancy total. Also, the building shall be maintained and adequate housekeeping provided to insure public safety. Rooms such as basements and attics are included. Violation details will be provided in the form of a Violation Notice and may delay the issuance of your certificate and/or license,if applicable. Note: After receiving your application a minimum of 3 weeks' notice is require for an inspection. Finally, applications and fees must be received within ten(10) days of receipt of this letter. Failure to comply may jeopardize your license where applicable, and/or the occupancy of the building. truly yo s 4( :4_ i ark . ,1 Building mmissioner ACORO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/8/2022 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 RogersGray, Inc. -Kingston Branch PHONE FAX 63 Smith Lane (A/C,No,Ext): 508-746-3311 (A/C,No):877-816-2156 Kingston MA 02364 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Philadelphia Indemnity Insurance Company 18058 INSURED HABIASS-01 INSURER B:American Zurich Insurance Company 40142 Habilitation Assistance Corp 434 Court St INSURERC: — Plymouth MA 02360 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:385737186 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 LIMITS LTR �f1 WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY PHPK2359838 1/1/2022 1/1/2023 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 X POLICY PRO X LOC JECT PRODUCTS-COMP/OPAGG $3,000,000 OTHER: $ A AUTOMOBILE LIABILITY PHPK2359835 1/1/2022 1/1/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) A X UMBRELLA LIAB X OCCUR PHUB796539 1/1/2022 1/1/2023 EACH OCCURRENCE $4,000,000 EXCESSLIAB CLAIMS-MADE AGGREGATE $4,000,000 DED X RETENTION$1n nil() $ g WORKERS COMPENSATION 6ZZUB-5B97148-4-21 11/13/2021 11/13/2022 PER ERH- AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) EL DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 A Commercial Property PHPK2359838 1/1/2022 1/1/2023 Blanket Buildings 674,666 A Employee Theft PHPK2359838 1/1/2022 1/1/2023 Limit 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) When Required by Written Contract the following Applies: General Liability—Additional Insured-Mortgagee,Assignee,or Receiver CG2018 04/13 Additional Insured-Designated Person or Organization CG2026 04/13 Automobile—Additional Insured Schedule(Form Number:Additional Insured Schedule/Edition Date:0100) Loss Payee Schedule(Form Number:Loss Payee Schedule/Edition Date:0100) Workers Compensation—Waiver of Subrogation(WC00031300-001) See Attached... 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 - South Yarmouth MA 02664 AU D REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: HABIASS-01 LOC#: AC RO ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED RogersGray, Inc.-Kingston Branch Habilitation Assistance Corp 434 Court St POLICY NUMBER Plymouth MA 02360 CARRIER NAIL CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Excess/Umbrella—Schedule of Underlying Insurance(PI-CXL-002 05/19) ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD