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HomeMy WebLinkAboutBldc-17-002397-06 .,._j , The Comm ,n 'vealth of Massachusetts 1 T. ',C .ty\Town of ._=whiff YARMOUTH WIWI 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:St. Pius Tenth School BLDCI-17-002397-06 Trade Name: St.Pius Tenth School-Assembly Identify property address including street number,name,city or town and county Certificate Expiration Located at . 32,/ p/bo D RP 07/01/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-3 01st Floor 703 A-3 Amusement/Church/Gym/Library/Museum Cafeteria-130 Chapel-27 Administration-16 Allowable - Gym-530 Occupant Load 02nd Floor 166 A-3 Amusement/Church/Gym/Library/Museum Library-80 Art/Music-44 Multi Purpose Rm-42 Resource Rm-15 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 ry`A9_ Building Commissionerspection T Signature of Municipal Signature of Municipal (a' � ' Date of Building Commissioner_ _ Issuance �/L9 L 2- Fee: $0.00 BLD Certoflnsoection.rot The Commonwealth of Massachusetts et 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:St. Pius Tenth School BLDCI-17-002397-06 Trade Name: St. Pius Tenth School-Assembly Identify property address including street number,name,city or town and county Certificate Expiration Located at 3L/ WbC D Rp 07/01/2023 SOUTH YARMOUTH,MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-3 oist floor 703 A-3 Amusemenu nurcniGymiLibrary/Museum Cafeteria-130 Chapel-27 Administration-16 Allowable Gym-530 Occupant Load 02nd Floor 166 A-3 Amusement/Church/Gym/Library/Museum Library-80 Art/Music-44 Multi Purpose Rm-42 Resource Rm-15 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:$0.00 `° a4 TOWN OF YARMOUTH fri _� �� BUILDING DEPARTMENT ,st „„TT . <'' J S[.; 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION June 1, 2022 PAYABLE UPON RECEIPT ( )Fee Required (X) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 3 2 1 YVOt 2 i S • (ai ox, y� n Name of Premises: S4-" 1 'L'S K SIJh^4J` Tel: �� ��b 6<<Z Purpose for which permit is used: J1 CO O+- ►MS c. `' License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to St. 1 t x Sri t Tel: 3" 6((L Address: 32( OWL 12-1 %. 'tRY+n,.,0 wit, Owner of Record of Building Qpw►. t-4' (►c- 13►ckop -« k-;" Address 3 Z( 14004_ 12c1 S gcz✓vt.�4,k-- Present Holder of Certificate -)f, ?w N KC V_JACX71 MONO Vt,Obk cf ' 1)u k(14.A s /kQgeV Signature Of person to whom Title Certificate is issued or his agent G- Lam, en Date Email Address: --)V.95 ecici @ sex SGNQ2I- . O c G- Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth, MA 02664 Return this application to: Building Inspector's Office Please note: Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified. Application must be received before the certificate will be issued. The building official shall be notified within ten (10) days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection#$L�C:� - /'1- 00 ,./ .9-'7 -64 07/01/2022-07/01/2023 • C CERTIFICATE OF LIABILITY INSURANCE DATE(MM`DD"YYY) 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). PRODUCER CONTACT NAME: Ratio Risk Services PHONE FAX IA1C,NO.ExU: (A/C,No): 66 Brooks Drive ADDRESS: Certificates@Ratiorisk.com INSURER(S)AFFORDING COVERAGE NAIC# Braintree MA 02184 INSURER A: Massachusetts Catholic Self Insurance Group INSURED INSURER B: INSURER C: St Pius X School INSURER D 321 Wood Road INSURER E South Yarmouth MA 02664 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 (MM/POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER DDIYYYY) (MM/DDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DGE TO RENTED CLAIMS-MADE L I OCCUR PREMISES SES 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: $ 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 RETENTION$ $ A WORKERS COMPENSATION Certificate of Approval 03/31/22 03/31/23 x STATUTE ERµ AND EMPLOYERS'LIABILfY Y/N Commonwealth of ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? NIA Massachusetts (Mandatory in NH) 3000001012022 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If YYes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 nvscRlpLON OF OPERATION$bgLow _ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Evidence of Workers Compensation Insurance for St.Pius X School for Town of Yarmouth 2022 Food License Permit Application. CERTIFICATE HOLDER CANCELLATION St. Pius X School SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 321 Wood Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE Amanda Taillon 4r — Iw • .� . ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD