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HomeMy WebLinkAboutbldci-22-001978 i T ' ommonwealth of Massachusetts T n City\Town of ' YARMOUTH YT1 • New and Renewal Certificate of Inspection In accordance with 780 CMR, Chapter 1 (The Eighth Edition of the Massachusetts State Building Code)and Chapter 304 of the Acts of 2004(an Act to further enhance fire and life safety),this certificate of inspection is issued to the premise or structure or part thereof as herein identified. Identify Name of Establishment Certificate No. Issued to Business Name:Aiden By Best Western BLDCI-22-001978 Trade Name:Alden By Best Western Identify property address including street number, name, city or town and county Certificate Expiration Located at 476 ROUTE 28 12/31/2022 . WEST YARMOUTH. MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 —412ttd"Ffoor /11//� A-2 Nightclub/Restaurant/Bar/Banquet Hall / 4tili�tairLounge Allowable C k 4 --,i'i,Z_ 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 Philip Simonian Ill Name of Municipal Mark Grylls Date of Fire Chief Building Commissioner Inspection ! .72r`A f Signature of Municipal Signature of Municipal ate of Fire Chief Building Commissioner Issuance /0 j20 AI Fee: ;150.00 BLD_Certoflnspection.rpt BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2022 NAME: Aidan by Best Westerb-Lounge ADDRESS: 476 RTE 28 This log is to be signed by the appropriate inspectors upon a satisfactory inspection of your building/premises. When all signatures are obtained, this log shall be presented to the License & Permits office and/or the Health Department in order to obtain your license. Licenses will be withheld until all inspectors have signed. Building Commissioner Re . Date Comments Approved for License Issuance / 7.4.7 /0'../`/fj rdap No Fire Department Rep. Date Comments Approved for License Issuance • No Board of Health Rep. Date Comments Approved for License Issuance Yes No Plumbing/Gas Inspector Date "a/2//2-i Comments Approved for License Issuance �� es No Electrical Inspector Date Comments Approved for License Issuance Yes No Taxes Paid Yes No Rev.Sept.2003 1 .*•40.3 �, �Th TOWN OF YARMOUTH :i .'y) BUILDING DEPARTMENT MATTHtM 3[/�Y ��•,.,,«m 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION October 1, 2021 PAYABLE UPON RECEIPT (X)Fee Required 150.00 ( )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: 4 7 ��,/11) S Name of Premises: ,4/h4GZ, t,() STE'r2sU 7 sT e1: s'C) — 71P .15C)CT) Purpose for which permit is used: License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to .4/0/c-4 , % / ��s��` Tel: S'Cgi--'fj -/So 0 Address: 1/7G /0,f„, SA at.- Owner of Record of Building 07—eu.) 2 JL 7 , 7L LIC Address 3 f/,4 f/ plve �,p,,�r,A11 ,460. Present Holder of Certificate / 1' % Pa k Si ature of person to m . �`'�_ Title Ce ificate is issued or his agent_ lr.2/ Date Email Address: GM id1n ` arro► Q C n 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 ISSUF,YO DER IFICATE OF INSPECTION. Certificate of Inspection# AO()C' l clot ' ' k 12/31/21-12/31/2022 The Commonwealth of Massachusetts Department of Industrial Accidents t Office of Investigations t�41 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: Ak n \ `� c(\ GAIl ^, Address: 4 () rC g 1' 1 St City/State/Zip: V V , a., aoA MA. �� Phone#: Areyou an employer?Chec the appropriate box: Business Type(required): 1 I am a employer with D employees(full and/ 5. ❑ Retail ✓✓✓✓�� or part-time).* 6. R Restaurant/Bar/Eating Establishment IHcpp L. 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. ❑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.❑Manufacturing no employees. [No workers' comp. insurance required]** 11.0 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#1 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 employe Below is t ep licy information. Insurance Company Name:5 C, ._ CGI _ ;)(S i , Insurer's Address: `41-1- ` , 9,- ..., Si` City/State/Zip: 9 Q, (`(' RA-- M L•- Policy#or Self-ins.Lic.# WA�, - W bh* D-13,40 A Expiration Date: it !//) /2 I 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP 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 c lift,under„ the pair's r�ridp nalties of perjury that the information provided above is true and correct. Si afore: 1" '`� �� Date: /o ff Pho #: , 7g/r.�GYO" 0�gc 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 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Depai talent at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Form Revised 7/2010 DATE(MM/DD/YYYY) AC RL CERTIFICATE OF LIABILITY INSURANCE 10/1/2021 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 NAME: Jon Sullivan Sullivan, Garrity& Donnelly PHONE FAX 10 Institute Rd. (A/C.No.Ext): 508-754-1767 (A/C,No):508-754-1885 Worcester MA 01609 ADDRESS: jon.sullivan@sgdins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Trisura Specialty Insurance Company 16188 INSURED JAMSHOT-01 INSURER B: Federal Insurance Company 20281 Jamsan Hotel Management Inc. do Hitesh Patel INSURER C:Zurich American Insurance Company 16535 83 Hartwell Ave INSURER D: Lexington MA 02421 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1742368117 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 IADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY OSU1002222-00 11/1/2020 11/1/2021 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PE� X LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: Liquor Liability $1,000,000 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) 13 X UMBRELLA LIAB X OCCUR 78187751 11/1/2020 11/1/2021 EACH OCCURRENCE $25,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $25,000,000 DED X RETENTION$n WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Property CPP0196662-05 11/1/2020 11/1/2021 Building $7,000,000 BPP $750,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) S&H Hotel Yarmouth LLC dba Aiden by Best Western @ Cape Point-476 Main Street,Yarmouth,MA 02673 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 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 et:fif gofejit 4,4k, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD /�^-'--, JAMSHOT-01 JHOGAN W AROx DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 7/20/2021 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 PRODUCER NAME: EPIC Insurance Brokers&Consultants PHONE 781 455-0700 FAX 781 449-8976 144 Gould Street Suite 100 (A/C,No,Ext): ( ) (A/c,No):( ) Needham,MA 02494 ADDAIL RESS:certificates@roblininsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:AIM Mutual Insurance Co 33758 INSURED INSURER B: S&H Hotel Yarmouth,LLC INSURERC: Cape Point Hotel 476 Main Street 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 SUBR POLICY NUMBER M'POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DDIYYYY) (MM/DDYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I$ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(My one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO-JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: I $ ED AUTOMOBILE LIABILITY (Ea acccidentSINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON OWNED PROPERTY DAMAGE _ AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X I STATUTE I I OTH- ER AND EMPLOYERS'LIABILITY YIN WMZ-800-8006935.2020A 8/1/2020 8/1/2021 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 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) S&H Hotel Yarmouth LLC-Alden Hotel, 476 Main Street West Yarmouth MA 02673 Issued as Evidence of Insurance. CERTIFICATE HOLDER _ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Issued as Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE tre .. ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • THE COMMONWEALTH OF MASSACHUSETTS i4it, TOWN OF YARMOUTH ) BUSINESS CERTIFICATE 10 '4 \•.,-, ,,:- ,',:,-Z N:-.-'4112r , Date Filed: Certificate Type: ...„ ... _ _ .,._ Expiration Date: Certificate Fee: Certificate Number: Original Filing Date: In conformity with the provisions of Chapter One I lundred and Ten(110), Section Five(5)of the Massachusetts General. Laws, as amended, the undersigned hereby declare that a business is conducted under the title of: Business Title: S&11 Hotel Yarmouth LLC DBA Aiden By. Best Western (a) Cape Point business Address:476 Route 28, West Yarmouth MA 02673 Business Type: Hotel/Motel , , 13 U s i nes s Owners: Owner(s) Address: 20Ten Investment LLC 83 Hartwell Ave, Lexington MA 02421 Nikul Patel 30 Winter St, Lexington MA 02420 ..... — SS Tax Irm: 82- 1968776 Signatures: I" 'ce, - . "' KAMLESH PATEL LiajP .....,, NOTARY PUBLIC 1 I*- } — TH or kiAssAcuusers ' ) \ i/ MY COMMISSION EXPIRES 0 mARCH 02,2023 In accordance with the provisions of Chapter 337 of the Acts of 1985 and Chapter 110,Section 5, of Mass.General Laws, business certificates shall be in effect for four(4) years from the date of issue and shall be renewed each four (4) years thereafter. A statement under oath must be filed with the town clerk upon discontinuing, retiring, or withdrawing from such business or padriership, Copies of such certificates shall be available at the address at which such business is conducted and shall be furnished on request during regular business hours to any person who has purchased goods or services from such business. Violations are subject to a tine of not more than three hundred(S300,00)dollars and no1100 dollars for each month during which such violation occurs. On the above named person(s)personally appeared before me a ' nade and oath the foregoing ,... _ statement is true. i Notary Public: , Clerk:_ Commi , . • , ssion Expiration Dato: