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HomeMy WebLinkAboutBLDCI-17-000324-06 ti/ The Commonwealth of Massachusetts } R ,rt City\Town of 1 YARMOUTH .t 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: BASS RIVER SPORTS WORLD BLDCI-17-000324-06 Trade Name: BASS RIVER SPORTS WORLD Identify property address including street number,name,city or town and county Certificate Expiration Located at 08/13/2022 932&940 ROUTE 28 SOUTH YARMOUTH, MA 02664 i Use Group Floor Occupancy Use Group Other Classifications(s) 01st Floor 150 A-3 Amusement/Church/Gym/Library/Museum 150 PERSONS A-3 Allowable 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 p►�/�� Building Commissioner Inspection j Signature of MunicipalJa j Date of Signature of Municipal r/a g p Building Commissioner / Issuance ` t �/ Fee:$040— Y /c L) ap BLD Certoflnspection.rpt pa TOWN OF YARMOUTH rn 'CI BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 .508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION July 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: 8 Name of Premises:(13 A S5 U,t V e 2- Su) �1�5 L 0 P Tel: SOS (610 Purpose for which permit is used: i't q-(A-"b License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency R E C E I Q JUL 0 8 2021 BUILD6T nn By ���''11 Certificate to be Assued toZAS7` r(ea-Sro ar S o a-'-) Tel: �0� 3�9 - �e a Address:939 ��. ag 0 t 0 X ( ovnt 4q .m o v-r 1+1 MA- 0 4 by Owner of Reco4 of Building 1.60, 5 w e- tL E?tt_—i� uL ` l Address (t'J L cos- ►T ST JD v-n+ \Ad-12 \o �t- O'2-(v `1 Present Holder of Certificate 13A' 45 0 2Ts kAne Q.- L� L ignature of person to whom Title In n Certificate is issued or his agent (p -0 O%I II I Date Email Address: t. t1 tCk t i�-Z�l o \e CQ cum. _fkST. 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# 08/13/2021-08/132022 DATE(MMIDD/YYYY) ACG'RD® CERTIFICATE OF LIABILITY INSURANCE 07/07/2021 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 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: Teresa Brown ROGERSGRAY INC PHONE No.Extl: (508)790-4467 FAX No): E-MAIL ADDRESS: tbrown@rogersgray.com 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURERA: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: BASS RIVER SPORTS WORLD INC INSURER C: INSURER D: _ PO BOX 183 INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 672601 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE D $ CLAIMS-MADE OCCUR PREMISESO(EaENTE occu occurrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT I _ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) — UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y I N X STATUTE EERH A OFFICER M MBEREXCLUDED ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 N/A WA NIA 6562UB1 K68658921 01/01/2021 01/01/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. 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. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.CroWiey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD