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HomeMy WebLinkAboutBLDCI-15-0049922-06 The Comn o iwealth of Massachusetts } t amity\Town of 4-. 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: BLDCI-15-004922-06 Trade Name: HUNTERS GREEN MOTEL Identify property address including street number,name,city or town and county Certificate Expiration Located at 5/19/2023 553 ROUTE 28 WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) R-1 01st Floor 37 R-1 Hotel/Motel/Boarding House/Transient INCLUDES SWIMMING POOL&LOBBY 02nd Floor 38 R-1 HoteUMotel/Boarding House/Transient INCLUDES OFFICE 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 Date of Wg(2 Signature of Municipal G / Issuance Z Building Commissioner '-, Fee: $295.00 BLD Certoflnspection.rpt tYak TOWN OF YARMOUTH - A. . 2) BUILDING DEPARTMENT 0-01 `5�wT'� 5�,x�' 28,1146 Route South Yarmouth, MA 02664 .508-398-2231 ext. 1260 3.;iGy APR 2 9 2012 APPLICATION FOR CERTIFICATE OF INSPECTION N RTMLN� PAYABLE UPON RECEIPT • BUILd4I� �,Y� (X) Fee Required $292.00 �-_ ( ) 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: 5' c� J�p L)4 � 4? fo Name of Premises: i (on f ey 61Pee-1 Tel: btoir-7?S^6.61t(,a Purpose for which permit is used: License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Pear)Certificate to be issued to( t'i rr) 1nG 2>3R �t�ns br T 0dtY"7 7 J`�6 4 O Address: 553 Route e fie; (yqhrMev1€ , M/t- oil 73 Owner of Record of Building JM S Fy (-PATFL_ - Address Present Holder of Certificate M 2,4112-de � 'n . Signature of person to whom 4 y� Title • �a� �a Certificate is issued or his agent =_ Date Email Address: r et!' Qii 1 rS 1% "1101- .5 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# 05/19/2022-05/19/2023 .----"""1 SHRIINC-01 DDONOHUE A�ORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 3/28/2022 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). CONTACT Denise M. Donohue PRODUCER NAME:The Corcoran&Havlin Insurance Group PHONE Ext):(781)235-3100 271 FAX No):(781)235-1622 287 Linden Street E-MAI Wellesley,MA 02482 _Aviaat:5 DDonohue@chinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:TechnologV Insurance Company,Inc 42376 _ INSURED INSURER B: _ Shrim Inc dba Hunters Green Motel INSURER C: 553 Main St,Route 28 INSURER D: _ _ --- 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 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 SUER POLICY EFF POLICY EXP LIMITS LTR INSD POLICY NUMBER WVD (MMIQ0/YYYY) (MM/9D/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ — MA CLAIMS-MADE OCCUR PR PREMISES E S( RENTED (Ea occurrence) $ MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ — GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY I PE LOC PRODUCTS-COMP/OP AGG $ OTHER: $ COMBINED AUTOMOBILE LIABILITY Ea sodden()INGLE LIMIT $ ANY AUTO BODILY INJURY Leer person) $ __ OWNED SCHEDULED AUTOSBODILY INJURY(Per accident) $ y� p AURTOS ONLY AUT ONLY AUTOS OS ONLY ,.•(R errac i Tent)p AM AGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N TWC4078441 2/8/2022 2/8/2023 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT A. OFFICER/MEMBER EXCLUDED? N I A 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ATE THEREOF, Parth Patel ACCORDANCE WITH THE POLICY P OVISIONSCE WILL BE DELIVERED IN 553 Main St Route 28 West Yarmouth,MA 02673 AUTHORIZED REPRESENTATIVE 9114.(5A-k)ghif IC ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD