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HomeMy WebLinkAboutBLDCI-17-005460-06 The o monwealth of Massachusetts 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: DAYS INN BLDCI-17-005460-06 Trade Name: DAYS INN Identify property address including street number,name,city or town and county Certificate Expiration Located at 69 ROUTE 28 04/23/2023 WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) R-1 01st Floor 20 R-1 Hotel/Motel/Boarding House/Transient 20 Units Allowable 02nd Floor 59 R-1 Hotel/Motel/Boarding House/Transient 59 Units Occupant Load Lounge Room 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 3 -tAy Signature of Municipal Signature of Municipal Date of Building Commissioneraff Issuance vq.Fee: $0.00 RI n Cmrtnflncnartinn mt .-/��--" PARIDEV-01 HWILLIS A4/^+CRDV DATE(MM/DD/YYYY) `„_,,, CERTIFICATE OF LIABILITY INSURANCE 611 512 0 21 I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 1 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: AP Intego Insurance Group,LLC PHONE FAX 1601 Trapelo Rd Suite 280 (A/CA CA Lo,Ext): (A/C,No): E-MWaltham,MA 02451 ADDRESS:support@apintego.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Markel Insurance Company 38970F INSURED INSURER B: Pari Devang Corp INSURER C: 69 Main Street Route 28 INSURER D: West Yarmouth,MA 02673 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR7 TYPE OF INSURANCE ADDL'SUBR' POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYYI IMM/DD/YYYYI ICOMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _—.._$ I.. i_ ' -i ' DAMAGE TO RENTED PRES Ea occurrence) $ L I CLAIMS-MADE OCCUR — �, MJEEMED EXP(Any one person) $ [ l _ PERSONAL&ADV INJURY_-_ !$ ! POLICY, —j jE8T ]LOC PRODUCTS-COMPOPAGG $ Ir 1 GEN'L AGGREGATE LIMIT APPLIES PER: $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident)_ $ ANY AUTO BODILY INJURY(Per person) ,$ OWNED SCHEDULED AUTOS ONLY AUTOSWNEp BODILY INJURY(Per accident) $ HIREDTO ONLY AUUTO ONLY ��Perr accident DAMAGE $ $ UMBRELLA UAB OCCUR ! EACH OCCURRENCE .$ EXCESS LIAB CLAIMS-MADE1E AGGREGATE $ DEC RETENTION$ 1 $ A WORKERS COMPENSATION X PER EORH AND EMPLOYERS'LIABILITY YIN WCO216183-01 6/9/2021 6/9/2022 - 100,000 OFFICER/MEMBER EXCLUDED? N 1 A E.L.EACH ACCIDENT S ANY PROPRIETOR/PARTNER/EXECUTIVE __ (Mandatoryin NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT ;$ DESCRIPTION OF OPERATIONS I 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 Proof of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD (c) Facing charges for any offence in any country? No DECLARATION j /Cc 6i) r� Iet n Ysincerely 1. (Name of the applicant) .5Yd// (... -/..'?9/(4/.4olemnl and declare that foregoing particulars stated on this application are true and I make this solemn declaration consciously believing the same to be true. In case the information is found to be false at any stage, I am liable for legal action/cancellation of registration as Overseas Citizen of India cardholder/deportation/blacklisting or any other action as deemed fit by the Government of India. I have no objection to share the requested personal particulars for processing of Overseas Citizen of India card by the security agencies. i 2. I shall not use the Overseas Citizen of India card for undertaking any TABLIGH . tivities in India 3. I shall not use the Overseas Citizen of India card for undertaking any missio'ary or mountaineering activities or Research in India without prior permission from the competent a. hority designated by the Government of India 4. In the event of dissolution of marriage or marriage to another fore'. er or death of Indian spouse, I shall surrender my card to the issuing authority or mission [applic.. e to spouse based applications]. Date ..../.2.--) 1 2 12 02% Place �1 S P. 1n fi Signature of e Applicant.. 1 I )(A, • *Application) r Minor Child I am a parent/legal guardian**/ legal adoptee parent of to whome the foregoing particulars relate. I hereby apply on behalf of my/the child for his/her registration as an Overseas Citizen of India Cardholder. N Z Date m o Place Signature of the Applicant *To be filled only for minor ** In the case of legal guardian, *** In the case of legal adoptee applicant enclose proof of guardianship parent, enclose legal adoption ° documents" 45 a) i tAter 13/De,I2O21 01:57:30 AM Page 4 of 7 t .v' ,o, Ya o TOWN OF YARMOUTH o . �,. ..�y} g BUILDING DEPARTME Te MAT^AGM vt � ,t� 1146 Route 28, South Yarmouth, MA 02664 508-39;- . ec.t. 2 MAR 04 2022 APPLICATION FOR CERTIFICATE OF INSPECTIO _. _. _ - J BUI � � -Ity rNl By March 1, 2022 PAYABLE UPON RECEI 1 (X) Fee Required$307.00 ( ) 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: !Sl f_ otie- , /jves7" 9/Q'd?t2o z.* I?) • ©2 6' Name of Premises: 0,41'0'52-2V1I fa)i'77/ Tel: 5""08 - ,s'-233Z_ Purpose for which permit is used: 9 3(- `•9 gZS""b ' Cal License(s) or Permit(s) required for the premises by other governmental agencies: ,.I./.4.ccinse or Permit Agency Certificate to be issued to ,_70,09>/ 1 /i /' Tel: SG*- 7.- - 2332-- Address: a 9,- x7,7 -2 , ,/i B7 y ia-,,�!/?.r7j, f� � •—, 026 .3 Owner of Record of Building ��-7 `ie irh,9 ��j�—/,-1 ,9•Cr„7 Address -/4942ff1—2 / heJ7 a2Jae1 y. /27g_' ('l2_. x3, Present Holder of Certificate y15+ y/A/ IP 61775— Signature of r m Title Certificate is issued or his agent Date 03 D 202 7 Email Address: dz, fYS`��"� eye jtc'C 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# i3 /--OQS4/(.D 04/23/2022-04/23/2023