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BLDCI-15-004937-06
The Com o wealth of Massachusetts r. 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:The Inn at Yarmouthport BLDCI-15-004937-06 Trade Name:The Inn at Yarmouthport Identify property address including street number, name,city or town and county Certificate Expiration Located at 04/06/2023 168 ROUTE 6A YARMOUTH PORT, MA 02675 Use Group Floor Occupancy Use Group Other Classifications(s) R-1 01st Floor 1 R-1 Hotel/Motel/Boarding House/Transient 1 BEDROOM&SITTING AREA/BATH/OFFICE 02nd Floor 4 R-1 Hotel/Motel/Boa ding House/Transient 4 BEDROOMS/BATH Allowable /OWNERS APT. 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 S L� Z Z e:$100.00 BLD Certoflnspection.rpt °i�YAR TOWN OF YARMOUTH of , , ,y BUILDING DEPARTMENT "4,..`"•�s` 1.1.46 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 a4b�uLe w.� i APPLICATION FOR CERTIFICATE OF INSPECTION March 1, 2022 PAYABLE UPON RECEIPT (X)Fee Required $100.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: /k V la v re- 6 19' Name of Premises: 77-2-e _Tn n ct t /6(r w,o utli Poext Tel: 0$ -7 - 7 5 y , Purpose for which permit is used: Se a 4 6 re,cA-k-- x s-t-- License(s) or Permit(s) required for the premises by other governmental agencies: RECEIVED License or Permit Agency — Occ,U p air t 6t MAR 18 2022 CO tnm o u IA vivt.ccA. Aleea,ter t' ,, BUIL MENT �"'i Q.2.t-J0.4-e-/-, /L, /�, e --e. By — - Certificate to be issued toTtje Snn A_4 dctrrn0Jth ii,r"t Tel: 50S-749' - 7 S(4, Address: /& ,Ss R o 0.7-e- 12.,$ Owner of Record of Building D lhv eu, d) T..rl C Address /c ,� 40 0 -e 6,A Present Holder of Certificate Dal ho a_.r-di _rive., Signature of person to whom w Title Certificate is issued or his agent 'W7/a 3) Date Email Address: '" F--Q r5 ON I ,f a n'" mo..t Q • CO 4A 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#B /—/S—O0 737_"Ly,t_.v 0 04/06/2022-04/06/2023 _ - - � - ^ ^ � � � � � . _ _- '_ __ _______ - ____- __ _ '�-_ � _ _-_- _ __ __ -- - �__ / ` ` � � ��w� � � �0�^ . ' � - _ _ � __'___-_� _ __. _ _ _ _ _ - ��_ __� � - _- _- _ _ - __' - '- � _ __� --_ _-_' ___ _ -_-__ _ �_ � -_- � � ' � � AcoRD CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YWY) 12r06/2021 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 Tina Reeves NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX (A/C,No,Ext): — (A/C,No): 973 lyannough Road E-MAIL treeves©doins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Norfolk and Dedham Mutual Fire Ins Co 23965 INSURED INSURER B Dayboard,Inc,DBA:The Inn at Yarmouth Port INSURER C: 168 Route 6A INSURER D: INSURER E: Yarmouthport MA 02675 INSURER F COVERAGES CERTIFICATE NUMBER: CL2112692411 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A R1801801A 01/12/2022 01/12/2023 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY PRO 2,000,000 JECT LOC PRODUCTS-COMP/OPAGG $ OTHER. Innkeepers Liability $ 3,000 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) $ X UMBRELLALIAB _ OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE BINDER 01/12/2022 01/12/2023 AGGREGATE $ 1,000,000 DED X RETENTION $ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER Y r N 1,000,000 A ANY CER/MEMB PROPRIETOR/PARTNER/EXECUTIVE UTiVE N N/A VVE183697A 01/12/2022 01/12/2023 E.L EACH ACCIDENT 5 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements.Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended thecoverage provided by the policy provisions. 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 e .c I - ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and log()are registered marks of ACORD i r II