HomeMy WebLinkAboutBLDCI-16-005897-06 The ' 1 m y'onwealth of Massachusetts
w= r, City\Town of
i=n it
i ' YARMOUTH
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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 BLDCI-16-005897-06
Business Name: BRENTWOOD MOTOR INN
Trade Name: BRENTWOOD MOTOR INN
Identify property address including street number, name,city or town and county Certificate Expiration
Located at 05/15/2023
961 ROUTE 28
SOUTH YARMOUTH, MA 02664
Use Group Floor Occupancy Use Group Other
Classifications(s)
46 R-1 Hotel/Motel/Boarding House/Transient 3 Buildings
R-1
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 / �7�
Building Commissioner Inspection (� O(pC
`
Signature of Municipal Signature of Municipal Date of
Building Commissioner ii
Issuance
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BLD Certoflnspection.rpt
F' 4N.. A TOWN OF YARMOUTH
oi' _ , ` .ice BUILDING DEPARTMENT
a:IS,:*;,:,;�' 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 $208.00
( ) 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: C,e( (.pl1 ''79 z-"2:2.2
Street and Number: f / if 7 .2.S 90; Y/4-1 Aid-u r p-1
Name of Premises: h f/Ai„0 0 v 1 C' i Aw Tel(c ) 3/T-c ( Z_
Purpose for which permit is used:
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency I R E c F v E D
y" MAY 03 2022
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BUILDS J N i
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Certificate to be issued to ...A,,0 cd pi o ice of Ted!' -0 q) . .sir— TT
Address: 9 / X T-
Owner of Record of Building H Y K FaMi(e, 7014si -
Address ... M,L f-z,✓ 4 c t_r:a c y ,4/.4 -ED r "7
Present Holder of Certificate / e S
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`Signaature of person to whom Title
Certificate is issued or his agent S"-L -2 Z
Date
Email Address:
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
Berkshire Hathaway GUARD
�� P.O. Box AH • 39 Public Square
,. Berkshire Hathaway Wilkes-Barre, PA 18703-0020
r Insurance 570-825-9900 (Toll-Free 800-673-2465)
/11 G U A R D Companies FAX 570-823-2059
www.guard.com
June 28, 2021
Brentwood Motor Inn Inc Agent: DOWLING & O'NEIL INSURANCE AGENCY
961 Route 28 973 Iyannough Road
S Yarmouth, MA 02664 P.O. Box 1990
Hyannis, MA 02601
Phone: 508-775-1620; Fax: 508-778-1218
Binder #: 000072144
Policy #: R2WC278941
Policy Period: 08/16/2021 - 08/16/2022
Customer #: 1150768
To Request Certificates of Insurance
You can either fax us at 570-823-2059 or call our Customer Service Department at 800-673-2465. Either
way, be prepared to provide the company name, address, fax number, and contact person of the entity
requesting the certificate.
Workers' Compensation Resources
To obtain a copy of your state's Posting Notices as well as managed care and/or claims information that may
need to be shared with your employees, visit: (OutputHeaderPostingNoticesAddress}.
To Obtain Service from a Specific Discipline
You can feel free to address your issue to the attention of the following individuals.
Department Contact Name Email Address Extension Fax Number
Claims Jason Volonakis GUARDCIaimsTeam@guard.com 1300 570-825-0611
Billing Lori Decker ar@guard.com 1300 570-825-6211
Loss Control Marissa Page LossControl@guard.com 1300 570-825-2990
Audit Tami Hoover PremiumAudit@guard.com 1300 570-829-4587
Underwriting Tami Hoover underwriting3@guard.com 1300 570-820-7968
We look forward to having this opportunity to serve your insurance needs. Please keep a copy of this letter
with your policy for future reference.
Thank you,
Berkshire Hathaway GUARD Insurance Companies
DocuSign Envelope ID:969C8163-7BD7-41B5-835B-85E950CF73B2
the use or occupancy of Borrower's properties,including without limitation,the Americans With Disabilities Act. Borrower
may contest in good faith any such law,ordinance,or regulation and withhold compliance during any proceeding,including
appropriate appeals,so long as Borrower has notified Lender in writing prior to doing so.
Inspection. Permit employees or agents of Lender at any reasonable time to inspect Borrower's operations and to
examine or audit Borrower's books, accounts, and records and to make copies and memoranda of Borrower's books,
accounts, and records. If Borrower now or at any time hereafter maintains any records (including without limitation
computer generated records and computer software programs for the generation of such records)in the possession of a
third party, Borrower, upon request of Lender, shall notify such party to permit Lender free access to such records at all
reasonable times and to provide Lender with copies of any records it may request,all at Borrower's expense.
Additional Assurances. Make, execute and deliver to Lender such instruments, documents and other agreements as
Lender or its attorneys may reasonably request to evidence Borrower's compliance with the terms and conditions of the
Loans.
LENDER'S EXPENDITURES. If Borrower fails to comply with any provision of this Agreement or any Related Documents,
including but not limited to Borrower's failure to discharge or pay when due any amounts Borrower is required to discharge or
pay under this Agreement or any Related Documents, Lender on Borrower's behalf may(but shall not be obligated to)take any
action that Lender deems appropriate. All such expenditures incurred or paid by Lender for such purposes will then bear interest
at the rate charged under the Note from the date incurred or paid by Lender to the date of repayment by Borrower. All such
expenses will become a part of the Indebtedness and,at Lender's option,will:(A)be payable on demand;or(B)be added to the
balance of the Note and be apportioned among and be payable with any installment payments to become due during the
remaining term of the Note;or,(C)be treated as a balloon payment which will be due and payable at the Note's maturity.
NEGATIVE COVENANTS. Borrower covenants and agrees with Lender that while this Agreement is in effect, Borrower shall
not,without the prior written consent of Lender:
Indebtedness and Liens. (1) Except for trade debt incurred in the normal course of business and indebtedness to
Lender contemplated by this Agreement, create, incur or assume indebtedness for borrowed money, including capital
leases, (2) sell, transfer, mortgage, assign, pledge, lease, grant a security interest in, or encumber any of Borrower's
assets(except as allowed as Permitted Liens),or (3) sell with recourse any of Borrower's accounts,except to Lender.
Continuity of Operations. (1) Engage in any business activities substantially different than those in which Borrower is
presently engaged, (2) cease operations, liquidate, merge or restructure as a legal entity (whether by division or
otherwise),consolidate with or acquire any other entity,change its name,convert to another type of entity or redomesticate,
dissolve or transfer or sell Borrower's assets out of the ordinary course of business, or (3) pay any dividends on
Borrower's stock, if applicable, (other than dividends payable in its stock), provided, however that notwithstanding the
foregoing, but only so long as no Event of Default has occurred and is continuing or would result from the payment of
dividends, if Borrower is a"Subchapter S Corporation"(as defined in the Internal Revenue Code of 1986, as amended),
Borrower may pay cash dividends on its stock to its shareholders from time to time in amounts necessary to enable the
shareholders to pay income taxes and make estimated income tax payments to satisfy their liabilities under federal and
state law which arise solely from their status as Shareholders of a Subchapter S Corporation because of their ownership of
shares of Borrower's stock,or purchase or retire any of Borrower's outstanding shares or alter or amend Borrower's capital
structure.
Loans,Acquisitions and Guaranties. (1) Loan, invest in or advance money or assets to any other person,enterprise
or entity, (2) purchase, create or acquire any interest in any other enterprise or entity, or (3) incur any obligation as
surety or guarantor other than in the ordinary course of business.
Agreements. Enter into any agreement containing any provisions that would be violated or breached by the performance
of Borrower's obligations under this Agreement or in connection herewith.
CESSATION OF ADVANCES. If Lender has made any commitment to make any Loan to Borrower, whether under this
Agreement or under any other agreement,Lender shall have no obligation to make Loan Advances or to disburse Loan proceeds
if: (A) Borrower is in default under the terms of this Agreement or any of the Related Documents or any other agreement that
Borrower has with Lender; (B) Borrower dies, becomes incompetent or becomes insolvent, files a petition in bankruptcy or
similar proceedings,or is adjudged a bankrupt.
RIGHT OF SETOFF. To the extent permitted by applicable law, Lender reserves a right of setoff in all Borrower's
accounts with Lender(whether checking,savings,or some other account). This includes all accounts Borrower holds
jointly with someone else and all accounts Borrower may open in the future. However,this does not include any IRA
or Keogh accounts,or any trust accounts for which setoff would be prohibited by law. Borrower authorizes Lender,
to the extent permitted by applicable law, to charge or setoff all sums owing on the debt against any and all such
accounts, and, at Lender's option, to administratively freeze all such accounts to allow Lender to protect Lender's
charge and setoff rights provided in this paragraph.
DEFAULT. Each of the following shall constitute an Event of Default under this Agreement:
Payment Default. Borrower fails to make any payment when due under the Loan.
Other Defaults. Borrower fails to comply with or to perform any other term,obligation,covenant or condition contained in
this Agreement or in any of the Related Documents or to comply with or to perform any term, obligation, covenant or
condition contained in any other agreement between Lender and Borrower.
Default in Favor of Third Parties. Borrower defaults under any loan,extension of credit,security agreement, purchase
or sales agreement, or any other agreement, in favor of any other creditor or person that may materially affect any of
Borrower's ability to repay the Loans or perform their respective obligations under this Agreement or any of the Related
3
The Commonwealth of Massachusetts
- Department of Industrial Accidents
4 = t r Office of Investigations
I_ IIMIKTrI 1 Congress Street, Suite 100
" — '" Boston, MA 02114-2017
. ' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: /?i-er-.1 t,,. � f','� 1 or 27L //✓
Address: c4 / A7
City/State/Zip: cc 7%y--i/14 n ii il4- Ai /' Phone #: •
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. El Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]** 11 ❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: i rkpi/p.•e ,4,77,%Au,A- c1. 4-e-t)
Insurer's Address: eit /
City/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$i,500.00 and/or one-year imprisonment, as weii as civil penalties in the form of a S"i OP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct.
Signature: L 4;.- r-- N.---,_ Date: i - . - P -Z
Phone#: (S of ) 7cjc - S' . 1 -2___
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
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