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HomeMy WebLinkAboutBLDCI-17-002519-03 The Commonwealth of Massachusetts ft City\Town of >_k r l= .., YARMOUTH 1- 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: PLANET FITNESS BLDCI-17-002519-03 Trade Name: PLANET FITNESS Identify property address including street number, name, city or town and county Certificate Expiration Located at 7 LONG POND DR 10/01/2021 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) 01st Floor 186 A-3 Amusement/Church/Gym/LibiaryiMuseum AEROBICS RM-49 4-3 EXERCISE AREAS-137 Allowable Other 15 A-3 Amusement/Church/Gym/Library/Museum 15-MEZZANINE 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 Signature of Municipal Date of Building Commissioner Issuance /O - s prcricyt o pi-Ertl) Fee: $100.00 A RI n CPrtnflnsnactinn rnt ,: 1i-k TOWN OF YARMOUTH Oba 0 o', ,, D V D BUILDING DEPARTMENT \nary l st .+ s`�, .,t,,, �, -- a e 28, South Yarmouth, AMA 02664 508-398-2231 ext. 1260 * J OCT 07 2021 BUILDING D>jrr��c T ON FOR CERTIFICATE OF INSPECTION By _______--------- September 1, I PAYABLE UPON RECEIPT (X) Fee Required $100.00 ( ) 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: 11 1...0r) ?&)d Drr Vr 041 Y a.c ro D)-'o 6A i Name of Premises: / lki14' 6'-r)c) Tel: 5 d g- 1760-a300 Purpose for which permit is used: i ihie.s. Ceryl-cs-' License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency 1 arwl Ihei I ovn Certificate to be issued to a( 4 &I an e` Tel: T 53J 1 s71 Address: m p Owner of Record of But. ing IA) J'/y II ' IJ Address 3 ( )6 f r-oOti 4.38!'�' S �J d rD\T. OI I7 L Present Holder of Certificate i 11 1c1an `� A e o Qr n Si'. atu i•f person to 'om Title Certificate is issued or his agent 1 / 4) .9-Q.)--1 �y 41C4C-Lf DateEmail Address• bOICt,n li d'C I i e 4 111.•t > 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# 10/01/2020-10/01/2021 --J 0 ® DATE(MMIDDIYYYY) AR o CERTIFICATE OF LIABILITY INSURANCE 6/1/2021 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 If 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 NAAMECT Jenn Garibay HAUSER PHONE FAX 5905 E.Galbraith Rd,Ste 9000 (A/c,No.Ext):513-745-9200 IA/c,No):513-745-9219 Cincinnati OH 45236 E-MAIL jgaribay@thehausergroup.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED PLANFIT-01 INSURER B:Union Insurance Company 25844 CDM Fitness Holdings,LLC 2 Hampshire Street INSURER C:Liberty Insurance Corporation 42404 Foxboro MA 02035-3171 INSURERD:Fireman"s Fund Insurance Co 21873 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:434762143 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 ADOL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR,WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY Y CPA5468537 2/3/2021 2/3/2022 EACH OCCURRENCE $1,000,000 DAMAGE TO D CLAIMS-MADE [X I OCCUR PREMISES(EaENTE occu occurrence) -$1,000,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ X POLICY JEC I I LOC PRODUCTS-COMP/OPAGG $3,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y MAA5468538 2/3/2021 2/3/2022 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ - OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE _AUTOS ONLY AUTOS ONLY (Per accident) A X UMBRELLA LIAB X OCCUR Y CUA5468539 2/3/2021 2/3/2022 EACH OCCURRENCE $5,000,000 - EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION WC5-Z91-472621-041 2/3/2021 2/3/2022 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N N/A EL.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Excess Liability Y USL002648202 10/21/2020 10/21/2021 OCCURRENCE 5,000,000 AGGREGATE 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Information Only AUTHORIZED REPRESENTATIVE 9.At LIJOA4-11 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD o%- R . 1 TOWN OF YARMOUTH it, , .rya: BUILDING DEPARTMENT �\ ;,\G ,MA?TAiM ,,,;y, '�3 % 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 d,,C) APPLICATION FOR CERTIFICATE OF INSPECTION September 1, 2021 PAYABLE UPON RECEIPT (X) Fee Required $100.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 11 Loll 9tnd Dn Vo ')�il,r D011 D�'1O 11-1 ' n Name of Premises: 'I ) Aj14 61-ric,i) Tel: 5be- '7bO'o(-3O0 Purpose for which permit is used: l'I i( Cryk" License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to&if 4 f 'I Qn er Tel: J J i 535 1 -571 Address: m O Owner of Record of Bur ing 10 i fil Address b s -0 3$a SJ Mak. 0111 L Present Holder of Certificate i'1 elan i 0i . ;. ,, - Uf D Q r trio Si-;natu is f person to le Om Title' Certificate is issued or his agent 1 / 4) k - Date ' Email Address b ar K� �� at I I1 }-1C-C olet e " '1'{f„(,,,•(-1y-` 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# 10/01/2020-10/01/2021 I ® " DATE(MM/DD/YYYY) A 0 CERTIFICATE OF LIABILITY INSURANCE 6/1/2021 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 CONTNAME: Jenn Jenn Garibay HAUSER PHONE FAX 5905 E.Galbraith Rd,Ste 9000 (A/c,No.Ext):513-745-9200 (A/c,No):513-745-9219 Cincinnati OH 45236 ADDRESS: jgaribay@thehausergroup.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED PLANFIT-o1 INSURER B:Union Insurance Company 25844 CDM Fitness Holdings,LLC INSURERC:Liberty Insurance Corporation 42404 2 Hampshire Street Foxboro MA 02035-3171 INSURERD:Fireman"s Fund Insurance Co 21873 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:434762143 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) IMMIDDIYYYY) A X COMMERCIAL GENERAL LIABILITY Y CPA5468537 2/3/2021 2/3/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X I OCCUR PREMISES(Ea occurrence) $1,000,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $3,000,000 $ OTHER: B AUTOMOBILE LIABILITY Y MAA5468538 2/3/2021 2/3/2022 COMBINED SINGLE LIMIT $1.000.000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ - OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED x NON-OWNED (PReOPP r acca DAMAGE $ AUTOS ONLY _ AUTOS ONLY ent) A )( UMBRELLA LIAB X OCCUR Y CUA5468539 2/3/2021 2/3/2022 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTIONS _ $ C WORKERS COMPENSATION WCS-Z91-472621-041 2/3/2021 2/3/2022 X STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNERIEXECUTIVE IY I NI N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Excess Liability Y USL002648202 10/21/2020 10/21/2021 OCCURRENCE 5,000,000 AGGREGATE 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Information Only AUTHORIZED REPRESENTATIVE 9.At LL),,,.._..e, I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD . , .\. TOW N OF YARMOU7 H r" ct,90 attto 2 BUILDING DEPARTMENT ^� "' y" 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION September 1,2021 PAYABLE UPON RECEIPT (X) Fee Required S100.00 ( ) 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: Q.L. Li1 Street and Number: 11 Lon bna Dr\i/c LJO W Yt Ya r er o Q 1'1 Name of Premises: l ) f1C4' n Tel: 5bif''7b0"2'" 00 Purpose for which permit is used: r' Cerrkt"- License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency 10.milhoi1- Certificateissued to 66t( / n Lr Tel: J 535 )to be i3e!Q Address: .. r, m s Z O MI._.t+ All ♦. • Owner of Record of Bu } tv Address _ ..0 ,i a '#r '.. 4 i J% • A / a) 7 f Present Holder of Certi icate L i 1 z ' t3?1 Sin a !'tu la f person to •m t Title Certificate is issued or his agent I 4) 420.14 Date i , Email Address' b an 1" ti ! 4G1 0I a "I, -�'N.,La' 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# /34W)--1 . O 579----4.1 10/01/2020-10/01/202'1 �+' AC• CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDOIYYY" 6/1/2021 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 POUCIES 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(Ees)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions Mf 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 NAME T Jenn Garibay HAUSER I FAX 5905 E.Galbraith Rd,Ste 9000 WC oNN .Exec:513-745-9200 i tAlc,No 513-745-9219 Cincinnati OH 45236 ADDeabs: jgaribay®thehausergroUp.Com I. INSURER(S)AFFORDING COVERAGE NAM I INSURER A:Acadia Insurance Company 31325 ...�___—_._..._.. PLANFIT-Ot INSURED INSURER a:Union Insurance Company 25844 COM Fitness Holdings,LLC INSURER c:Liberty Insurance Corporation i 42404 2 Hampshire Street Foxboro MA 02035-3171 INJURER D:Fireman"s Fund Insurance Co 21873 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:434762143 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 A IY 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. Y '. MOADOLSUBRIf1' POLICY EFF POUCY EXPJ TYPE OF INSURANCE 0 MD POLICY NUMBER IMMIDDIYYYY)I IMWDW' YY} LA X I COMMERCIAL GENERAL UABIU1Y Y CPA5468537 2/3/202' 2/'/2022 EACH OCCURRENCE :$1,000.000 I � DAMAGE TO RENTED` J E 1,000,000 i I CLAIMS-MACE I"' OCCUR PREMISES 15N owx-encel I i MED EXP(Any one person) S 5,000 i—i PERSONAL 8 ADV INJURY S 1,000,000 I GENT-AGGREGATE LIMIT APPLIES PER: { GENERAL AGGREGATE 5 I X POLICY—^, i 7LOC OTHER' PRODUCTS-COMP/OP AGO 3 3,000.000 E COMBINED SINGLE LIMIT B AUTOMOBILE UASILnY Y !MAA5488538 2/3/2021 2/3/2022 (Es acddonI) E 1,000,D00 BODILY INJURY(Per parson) S OWNED SCHEDULED BODILY INJURY(Per accident)r S AUTOS ONLY X AUTOS d PROPERTY DAMAGE l i HIRED NON-OWNED AUTOS ONLY X AUTOS ONLY 'Mot aodOanQ I E A X UMBRELLA UAB X $OCCUR Y { CUA5468539 2/3/2021 i 2/3/2022 !;EACH OCCURRENCE $S,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE I Q 5,000,000 DED__ RETENTIONS '$ C WORKERS COMPENSATION g I WCS•291-472521-04^: 2/3/2021 2/312022 jX TUTE , AND EMPLOYERS'UABILIrY Y 1 N I ANYPROPRIETORIPARTNERUEXECUIIVE N/A 1 E.L EACH ACCIDENT >5 1,000,000 (Mandatory U nd�MMNH'EXCtUDEO? YyFp(, EL DISEASE-EA EMPLOYEE,E 1,000,000 II describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POUCY LIMIT E 1,000,000 D Excea Liably Y I USL002648202 10/21/2020 10/21/2021 OCCURRENCE 5,000.000 AGGREGATE 5,000,000 I I DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD tat,Additional Remarks Schedule.may be s taehed If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Information Onty AUTHORIZED REPRESENTATIVE OD 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD