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HomeMy WebLinkAboutBldci-16-004161-04 (: ,.,,.._„„_,0 The Commonwealth of Massachusetts i et City\Town of ►= =��— 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: HOLLY TREE CONDOMINIUM TRUST BLDCI-16-004160-04 Trade Name: HOLLY TREE MOTEL Identify property address including street number,name,city or town and county Certificate Expiration Located at 02/16/2023 412 ROUTE 28 WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) 01st Floor 8 R-1 Hotel/Motel/Boarding House/Transient 8 UNITS 160-167 R-1 76 UNITS MAIN BLDF. 02nd Floor 76 R-1 Hotel/Motel/Boarding House/Transient 76 UNITS MAIN BLDG. Allowable Occupant Load 01st Floor 46 R-1 Hotel/Motel/Boarding House/Transient MNGRS.OFFICE& LOBBY SWIMMING POOL SQUASH COURT -10 BREAKFAST ROOM-36 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 .3--3-�f-, Building Commissioner Inspection /�� Signature of Municipal Signature of Municipal Date of Building Commissioner Issuance 7/1/ 2 Fee:;325.00 BLD Certoflnspection.rpt rr,_ -„AXI. 11'�) BUILDING DEPARTMENT: ====T� 1146 or to 28, South Yarmouth, MA 02664 508 398 22 i T:ct i o!.-,._.__._._y FEB 08 2022 APPLICATION FOR CERTIFICATE OF INSPECTION BUILDING DEPARTMENT 3Y January 1, 2022 PAYABLE UPON ' - ' (X)Fee Required$325.00 ( ) 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: - 1 2 Iii\k \I� N I Name of Premises: l-t \ Tel: J Ue'/) V CO-'CO(C ( / Purpose for which permit is used: ` 1ir-5-1- \___ License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to Tel: , D J 7 Address: 7- V\f"-�`� �j�---. _ \ v\A 1if --- 0 -2--(0±3 Owner of Record of Building Address `� �� Pr older of Certificate c___,____ IM . Signature of person to w om g Title � � �I � Z Certificate is issued or his agent Date Email Address: . 6e r 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# )C l— l (o--DOL-//Go p --6 !".1 _ • ——a——a s • AC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 3 04/28/2021 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 Diane Carmain NAME: The Armstrong Company Insurance Consultants lalcNr o,Ext): (310)530-0099 (FAX No): (310)530-0098 2780 Skypark Dr,Ste 440 E-MAIL dcarmain@armstronginsco.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Torrance CA 90505 INSURER A: Ohio Security Insurance Company 24082 INSURED INSURER B: Holly Tree Condominium Trust INSURER C: 412 Main Street,Route 28 INSURER D: INSURER E West Yarmouth MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 21/22 WC Only REVISION NUMBER: I 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE RENTED $ CLAIMS-MADE OCCUR PREMISESO(Ea occurrence) $ MED EXP(Any 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 $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE OTH- ER YIN 1,000,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A XWS57855775 04/01/2021 04/01/2022 E.L.EACH ACCIDENT $ OFFICER MEMBER EXCLUDED? 1000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ , If yes,describe under 1000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Health Department-Hazmat Ren AUTHORIZED REPRESENTATIVE 1146 Route 28 South Yarmouth MA 02664 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD