Loading...
HomeMy WebLinkAboutBLDCI-22-005150 The Commonwealth of Massachusetts • } h City\Town of 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: Ginter Hospitality LLC BLDCI-22-005150 Trade Name:Ocean Breeze Motel Identify property address including street number, name,city or town and county Certificate Expiration Located at 170 SEAVIEW AVE UNIT 1 4/1/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) R-1 01st Floor 16 R-1 Hotel/Motel/Boarding House/Transient 02nd Floor 16 R-1 Hotel/Motel/Boarding House/Transient Managers Apartment Allowable Lobby Occupant Load Coffee Room& • Kitchenette 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 Signature of Municipal Date of Building Commissioner Issuance /,_//� Fee:$166.00 BLD Certoflnsoection.rpt . Y R o TOWN OF YARMOUTH odd /�/z.i o . y BUILDING DEPARTMENT AT `" s�,.$� 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 ' RECEIVED APPLICATION FOR CERTIFICATE OF INSPECTION r .- PAYABLE UPON REF EtP I. (��2051 March 3, 2022, 2022 � _i0�_ (X) Fee Reglli dli1W. L a T11 ( ) No Feenire+ 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: j 70 S691//-4.,) ,4uc --S. T9c 4a.P (41 Q)266l�r Name of Premises: a&4/✓ Jf2EEa /007Ec- Tel: - Ug r 39e-2 62- Purpose for which permit is used: CcJ'- ` 617- 83c 7 C4 t' License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to (keg" 3fiV z C /1 0 Tel: SO8 -39a—3©� Address: /7 t0 .S 4vt O 6 6 22 Owner of Record of Building �t/ i ��-(�fit/— Address /70 Jz9-vtc..-d 41e- s ' .A. J Zd Present Holder of Certificate 3t✓2e2 /�?� ,Signa • . ._�'arim Title Certificate is issued or his agent . f k: / 2- 2_ Date Email Address: /0 � 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# 4/1/2022-4/1/2023 DocuSign Envelope ID:FD979B2B-4B44-4F4B-942A-3C04106C092E ACORD WORKERS COMPENSATION APPLICATION DATE(MM/DDIYYYY) 12/14/2021 AGENCY NAME AND ADDRESS COMPANY: A.I.M.Mutual Insurance Companies Richardson Insurance UNDERWRITER: 205 Hanover St APPLICANT NAME: Ginter Hospitality LLC DBA:Ocean Breeze Motel OFFICE PHONE: MOBILE PHONE: 617-835-4068 Hanover MA 02339 MAILING ADDRESS(including ZIP+4 or Canadian Postal Code) YRS IN BUS: 170 Seaview Ave SIC: PRODUCER NAME NAICS: CS REPRESENTATIVE South Yarmouth MA 02664 WEBSITE NAME: ADDRESS: OFFICE PHONE 781-826-5161 (NC.No.Ext): E-MAIL ADDRESS nginter@verizon.net MOBILE SOLE PROPRIETOR CORPORATION X LLC TRUST UNINCORPORATED PHONE; ASSOCIATION (A/C.No): 781-829 9287 PARTNERSHIP SUBCHAPTER CORP JOINT VENTURE OTHER: E-MAIL infor._�insurewithrichardson.com CREDIT ADDRESS: BUREAU NAME: _ ID NUMBER: FEDERAL EMPLOYER ID NUMBER NCCI RISK ID NUMBER OTHER RATING BUREAU ID OR STATE CODE _ SUB CODE: - EMPLOYER REGISTRATION NUMBER AGENCY CUSTOMER ID: STATUS OF SUBMISSION BILLING/AUDIT INFORMATION X QUOTE ISSUE POLICY BILLING PLAN PAYMENT PLAN AUDIT BOUND(Give date and/or attach copy) AGENCY BILL ANNUAL AT EXPIRATION MONTHLY ASSIGNED RISK(Attach ACORD 133) X DIRECT BILL SEMI-ANNUAL SEMI-ANNUAL QUARTERLY %DOWN: QUARTERLY LOCATIONS LOC# HIGHEST FLOOR STREET,CITY,COUNTY,STATE,ZIP CODE 170 Seaview Drive,Yarmouth,MA 02664 1 POLICY INFORMATION PROPOSED EFF DATE PROPOSED EXP DATE i NORMAL ANNIVERSARY RATING DATE RETRO PLAN PARTICIPATING 12/17/2021 12/17/2022 NON-PARTICIPATING PART 1-WORKERS PART 2-EMPLOYER'S LIABILITY PART 3-OTHER DEDUCTIBLES AMOUNT 1% OTHER COVERAGES COMPENSATION(States) STATES INS (NIA in WI) (N/Ain WI) $ 500,000 EACH ACCIDENT MEDICAL U.S.L.&H. MANAGED CARE OPTION MA $ 500,000 DISEASE-POLICY LIMIT INDEMNITY VOLUNTARY COMP $ 500,000 DISEASE-EACH EMPLOYEE FOREIGN COV DIVIDEND PLAN/SAFETY GROUP ADDITIONAL COMPANY INFORMATION SPECIFY ADDITIONAL COVERAGES/ENDORSEMENTS(Attach ACORD 101,Additional Remarks Schedule,if more space is required) TOTAL ESTIMATED ANNUAL PREMIUM -ALL STATES TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES TOTAL MINIMUM PREMIUM ALL STATES TOTAL DEPOSIT PREMIUM ALL STATES $ $ $ J CONTACT INFORMATION TYPE NAME OFFICE PHONE MOBILE PHONE E-MAIL INSPECTION Norbert Ginter ACCTNG RECORD CLAIMS INFO INDIVIDUALS INCLUDED/EXCLUDED PARTNERS,OFFICERS,RELATIVES(Must be employed by business operations)TO BE INCLUDED OR EXCLUDED(Remuneration/Payroll to be included must be part of rating information section.) Exclusions in Missouri must meet the requirements of Section 287.090 RSMo. STATE LOC# NAME DATE OF BIRTH RELATIONSHIP SHIP/TITLE/ OWNER- DUTIES INC/EXC CLASS CODE REMUNERATION/PAYROLL MA 1 Norbert Ginter LLC Manager 100 All Exc 9052 15,000 1 ACORD 130 (2013/09) Page 1 of4 ©1980-2013 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD P0904156604aftIdAc{t E 4gi'4- 1J36 53C092E - N STATE RATING SHEET -- 6. ARE SI IB_CnNTRA(STORS USED?(lf'YES".give%of work subcontracted) STATE RATING WORKSHFET -.Foativ kQRLisr1Je�..Ezl/VI,TJdDgT& T1FCH AN ADDIT ONAL PAGE 2 JF ITHIS FORMmust be included in the State Rating Worksheet on Page 2) $.1W,,Il ellMt'€IC C aT(ICRtIDOST TIEFERATION? N Lp�y�rRl,.PGlatiltATION PR�I��IES,DUTIES,CLASSIFICATIONS FULL PART DESCR #CMI'LOYEES ESTIMATEDANNUAL ESTIMATED 3. f�Y G�OUP SIC NAICS REMUNERATION/ RATE ANNUAL MANRAL TIME TIME PAYROLL PREMIUM ggDDS5�� Hn}n 101 ANY ENfPCOYEES LNDER 14 OR OVER 60 YEARS OF AGE? 2 35,000 N 11. ANY SEASONAL EMPLOYEES? N 12. IS THERE ANY VOLUNTEER OR DONATED LABOR? (If"YES",please specify) N 13. ANY EMPLOYEES WTH PHYSICAL HANDICAPS? N 14. DO EMPLOYEES TRAVEL OUT OF STATE? (If"YES",indicate state(s)of travel and 6equency` N 15. ARE ATHLETIC TEAMS SPONSORED? N 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? ACORD 130 (2013/09) Page 3 of 4 PREMIUM STATE: FACTOR FACTORED PREMIUM FACTOR FACTORED PREMIUM TOTAL N/A $ $ INCREASED LIMITS $ SCHEDULE RATING• $ DEDUCTIBLE• $ CCPAP $ STANDARD PREMIUM $ EXPERIENCE OR MERIT - MODIFICATION $ - PREMIUM DISCOUNT $ $ EXPENSE CONSTANT N/A $ ASSIGNED RISK SURCHARGE• $ _ TAXES/ASSESSMENTS• N/A $ ARAP• $ $ • N/Ain Wisconsin TOTAL ESTIMATED ANNUAL PREMIUM MINIMUM PREMIUM DEPOSIT PREMIUM $ g $ REMARKS (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) ACORD 130 (2013/09) Page 2 of 4 DocuSign Envelope ID:FD979B2B-4B44-4F4B-942A-3C04106C092E PRIOR CARRIER INFORMATION/LOSS HISTORY AGENCY CUSTOMER ID: PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS LOSS RUN ATTACHED YEAR CARRIER&POLICY NUMBER ANNUAL PREMIUM MOD #CLAIMS AMOUNT PAID RESERVE POL CO: POL# CO: POL#: CO: POL CO: POL#: NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS,OPERATIONS AND PRODUCTS:MANUFACTURING-RAW MATERIALS,PROCESSES,PRODUCT,EQUIPMENT;CONTRACTOR-TYPE OF WORK,SUB-CONTRACTS;MERCANTILE-MERCHANDISE,CUSTOMERS,DELIVERIES;SERVICE-TYPE,LOCATION;FARM-ACREAGE,ANIMALS,MACHINERY,SUB-CONTRACTS. GENERAL INFORMATION EXPLAIN ALL"YES"RESPONSES Y/N 1. DOES APPLICANT OWN,OPERATE OR LEASE AIRCRAFT/WATERCRAFT? N 2. DO/HAVE PAST,PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D)STORING,TREATING,DISCHARGING,APPLYING,DISPOSING,OR TRANSPORTING OF HAZARDOUS MATERIAL?(e.g.landfills,wastes,fuel tanks,etc) N 3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET? N 4. ANY WORK PERFORMED ON BARGES,VESSELS,DOCKS,BRIDGE OVER WATER? N 5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS? N 6. ARE SUB-CONTRACTORS USED?(If"YES",give%of work subcontracted) N 7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (If"YES",payroll for this work must be included in the State Rating Worksheet on Page 2) N 8. IS A WRITTEN SAFETY PROGRAM IN OPERATION? N 9. ANY GROUP TRANSPORTATION PROVIDED? N 10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE? N 11. ANY SEASONAL EMPLOYEES? N 12. IS THERE ANY VOLUNTEER OR DONATED LABOR? (If"YES",please specify) N 13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS? N 14. DO EMPLOYEES TRAVEL OUT OF STATE? (If"YES",indicate state(s)of travel and frequency) N 15. ARE ATHLETIC TEAMS SPONSORED? N 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? ACORD 130(2013/09) Page 3 of 4 DocuSign Envelope ID: FD979B2B-4B44-4F4B-942A-3C04106C092E GENERAL INFORMATION (continued) AGENCY CUSTOMER ID: EXPLAIN ALL"YES"RESPONSES Y/N 17. ANY OTHER INSURANCE WITH THIS INSURER? N 18. ANY PRIOR COVERAGE DECLINED/CANCELLED/NON-RENEWED IN THE LAST THREE(3)YEARS?(Missouri Applicants-Do not answer this question) N 19. ARE EMPLOYEE HEALTH PLANS PROVIDED? N 20. DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES? N 21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? N 22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If"YES",#of Employees: N 23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE(5)YEARS? (If"YES",please specify) N 24. ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES? IF YES,EXPLAIN INCLUDING ENTITY NAME(S)AND POLICY NUMBER(S). N SIGNATURE Copy of the Notice of Information Practices(Privacy)has been given to the applicant.(Not required in all states,contact your agent or broker for your state's requirements.) PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES.YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE.THESE RIGHTS MAY BE LIMITED IN SOME STATES.PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable in AZ,CA,DE,KS,MA,MN,ND,NY,OR,VA,or WV. Specific ACORD 38s are available for applicants in these states.) (Applicants Initials): Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly(or willfully)*presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.*Applies in MD Only. Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false,incomplete, or misleading information is guilty of a felony(of the third degree)*. *Applies in FL Only. Applicable in KS: Any person who,knowingly and with intent to defraud, presents,causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of,or in support of,an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,which is a crime and subjects such person to criminal and civil penalties(not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only. Applicable in ME, TN,VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties(may)*include imprisonment,fines and denial of insurance benefits.*Applies in ME Only. Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction,shall be sanctioned for each violation by a fine of not less than five thousand dollars($5,000)and not more than ten thousand dollars($10,000),or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances[be]present,the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. Applicable in UT: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. APPLICANT'S SIGNATURE(Must be Officer,Owner or Partner) DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER 12/16/2021 I ®I RM PST ftbrie(4(r>e 1 Miclsatt fvi rAseu, 'AttiRtV130(2013/09) Page cif$