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HomeMy WebLinkAboutBLDCI-16-005512-06 The Co o ealth of Massachusetts } =` if� ity\Town of :,,anti= YARMOUTH r �4 C f� a.is t 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:CAPE COD FAMILY RESORT BLDCI-16-005512-06 Trade Name: CAPE COD FAMILY RESORT Identify property address including street number, name,city or town and county Certificate Expiration Located at 512 ROUTE 28 04/15/2023 WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) R-1 01st Floor 69 R-1 Hotel/Motel/Boarding House/Transient 69 Guest Rooms • 1 Cottage-4 Employees Allowable Manager's Apartment Occupant Load 02nd Floor R-1 Hotel/Motel/Boarding House/Transient Owners 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 Grylls Date of Building Commissioner - Inspection 5 _ Signature of Municipal Signature of Municipal � Date of Building Commissioner Issuance /�//�(! vv v Fee:$334.00 • RI n CArtnflnsnprtinn rnt �°�_!`�o� TOWN OF YARMOUTH�-� ; . ad BUILDING DEPARTMENT k. t<`--, 1146 Route 28, South Yarmouth, MA 02664 .508-398-2231 a it. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION March 1, 2022 PAYABLE UPON RECEIPT (X) Fee Required $334.00 ( ) 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: c\ \c\\A 5 T U1 i y n. 1M d J r In, AA 4_ G oI C 73 Name of Premises: (q QC c vh i I i 'Qi' Tel: 17 e 7 5 S `1 c3-- Purpose for which permit is used: 14-0 - License(s) or Permit(s) required for the premises by other governmental agencies: RECEIVED License or Permit Agency [ MAR 0 7 2022 IeU E ?. NT SG\I Bn 6T Iv)( Certificate to be issued to S . Tel: 117. 3 ? S 5Lr(:)._ Address: S1 )., \/11-‘a 1 h 5 fi cs f i1w1c.) 14, /hr7 a d ( 73 Owner of Record of Building 654 c)--le )4c1\A l h G Address 5) ), Yi a ,,, S ,t w G itV"\--0 v \-, , M +- Present Holder of Certificate , g , iz. YVt 6 f- 1-y,c (0.6 4, CI fe Co D 1/1411,, 0+5G It 6 LA)vt PI"\ natur of person to whom Title ertificate is issued or his agent 3 I L1 Date Email Address: V 6 R, / " ei V 1CC\''t C. Ct) CV'V\G t L, C c Vsi 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# „(Bt,iiC I g(o-Q'rs/el-0& 04/15/2022-04/15/2023 DATE(MM/DD/YYYY) AGGR£3 CERTIFICATE OF LIABILITY INSURANCE 12/01/21 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). CON TACT Brian Allain PRODUCER NAME: PHAX Choice Insurance Agency (AiCO,NNo,Ext): 978-343-4853 (Arcc,No): 978-345-1007 376 Summer Street E-MAIL ADDRESS: ballain@choice-insurance.com Fitchburg,MA 01420 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: AmGuard Insurance Company INSURED INSURER B: Sandbar Management Inc INSURER C: Cape Cod Inflatable Park INSURER D: P.O.Box 481 West Yarmouth,MA 02673 INSURER E 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 COND TION 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY VUMBER (MM/DDNYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO I RENTED CLAIMS-MADE OCCUR PREM S )ES a occurrence) $ MED EXP(Any one person) $ _PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG S S 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 _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DED RETENTIONS $ WORKERS COMPENSATION PER X OTH- AND EMPLOYERS'LIABILITY Y!N STATUTE ER A ANY OFFICER/MEMBER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N/A SAWC283178 10/01/21 12/01/22 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Operations of Insured 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. Sandbar Management,Inc. P.O.Box 481 West Yarmouth,MA 02673 AUTHORIZED REPRESENTATIVE 11 I ?)Pk.,04,fr\' , * ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD