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HomeMy WebLinkAboutBldci-16-006080-06 1 The Comm nVealth of Massachusetts ii.,,,, i. t €ity\Town of ' YARMOUTH 4 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 BLDCI-16-006080-06 Business Name: MAYFLOWER INN Trade Name: MAYFLOWER INN Identify property address including street number,name,city or town and county Certificate Expiration Located at 504 ROUTE 28 04/21/2023 WEST YARMOUTH, MA 02673 r Use Group Floor Occupancy Use Group Other Classifications(s) R-1 01st Floor 20 R-1 Hotel/Motel/Boarding House/Transient BLDG. 1 -16 UNITS BLDG. 2-4 UNITS 02nd Floor 5 R-1 Hotel/Motel/Boarding House/Transient BLDG. 1 -MANGRS. Allowable APT.&OFFICE Occupant Load BLDG.2-5 UNITS 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 /!/O . Building Commissioner Inspection Signature of Municipal Signature of Municipal Date of Building Commissioner Issuance v.:2 Fee:$145.00 BLD Certoflnspection.rpt • TOWN OF YARMOUTH 6. (F.- .7. 4--,�a(�.�J BUILDING DEPARTMENT a�,�MATTA vt/4 ...,, . 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION March 1, 2022 PAYABLE UPON RECEIPT (X) Fee Required $145.00 ( ) 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: C6 1 Clvv S \ .fi a Lk) -es ). q R O MA V 7 3 Name of Premises: a f\o Tel: 9 7 37 S S Cj'C Purpose for which permit is used: k-6 c _ RECEIVED License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency MAR 0 7 2022 BU I l � N T Certificate to be issued to C a,G vv,IS Tel: in n 3 7 S S Ito',_ Address: S6 VW\c h S T .J S(t. w‘c, )14,, M- 6 0 73 Owner of Record of Building . �[', L (4 i 1 ` , S 5 h o� A y Vh G 1' Address S o Li Vn.0 'o rl. , AA A- 7 3 Present Holder of Certificate 5 Pr on e Il-S /vc O tv v�NC • natu of person to whom Title /� / Certificate is issued or his agent 3 l nn Date Email Address: Qe. t► ►Gj ��G1(Y� (� �}� q 1 L 1 C� \fi\, 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 CERTI ICATE OF INSPECTION. Certificate of Inspection#FLOC/-6/(pOtY_ D- R&6—D(1 04/21/2022-04/21/2023 ABC-' ©. DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/01/21 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). ON PRODUCER NAME:CT Brian Allain PHONE 44853 FAX No): 978-345-1007 Choice Insurance Agency (A/C,No,Eat): 978_33- 376 Summer Street E-MAIL ADDRESS: ballain@choice-insurance.Com Fitchburg,MA 01420 INSURER(S)AFFORDING COVERAGE NAIC II INSURER A: AmGuard Insurance Company INSURED INSURER B: Sandbar Management Inc INSURER C: Cape Cod Inflatable Park INSURER D: P.O.Box 481 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. ADDLBUBR POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE INSD WVD POLICY NJMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED i CLAIMS-MADE OCCUR PREMISES(Ea occurrence) ,$ • MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY I I PRO- JECT LOC PRODUCTS-COMP/OP AGG $ $ - OTHER: AUTOMOBILE LIABILITY COa aBINEDtl SINGLE LIMIT $ (EcANY 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 STATUTE PER X OTRH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? NIA SAWC283178 10/01/21 12/01/22 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY 1,000,000 LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Operations of Insured 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. Sandbar Management,Inc. P.O.Box 481 West Yarmouth,MA 02673 AUTHORIZED REPRESENTATIVE I ?)Mj ? \©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD