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HomeMy WebLinkAboutBLDCI-23-004464 The Commonwealth of Massachusetts =,711 City\Town of YARMOUTH .ram New and Renewal Certificate of Inspection In accordance with 780 CMR,Chapter 1 (The Eighth Edition of the Massachusetts State Building Code)and Chapter 304 of the Acts of 2004(an Act to further enhance fire and life safety),this certificate of inspection is issued to the premise or structure or part thereof as herein identified. Identify Name of Establishment Certificate No. Issued to Business Name: Blue Rock Club, Inc. BLDCI-23-004464 Trade Name: Blue Rock Club Identify property address including street number,name,city or town and county Certificate Expiration Located at 48 TODD RD 11/30/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-2 01st Floor 49 A-2 Nightclub/Restaurant/Bar/Banquet Hall Club house 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 R Name of Municipal Mark Grylls Date of ^��� Fire Chief n!S 5c,w ) ,, Building Commissioner Inspection Signature of Municipal Signature of Municipal 1 =� Date of Fire Chief Building Commissioner Issuance J ij//l/ZF Fee:$150.00 BLD_Ce rtofl nspection.rpt BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 LICENSE INSPECTION APPROVAL LOG - 2023 NAME: Blue Rock Golf Course ADDRESS: 48 Todd Road This log is to be signed by the appropriate inspectors upon a satisfactory inspection of your building/premises. When all signatures are obtained, this log shall be presented to the License & Permits office and/or the Health Department in order to obtain your license. Licenses will be withheld until all inspectors have signed. Building Commissioner Re Date Comments Approved for 3— /7'2- Lissual No Fire Department Rep. Date Comments Approved for License Issuance L. Gfi6f- �- / -23 e LI No Board of Health Rep. Date Comments Approved for License Issuance [I Yes HI No Plumbing/Gas Inspector Date 3 /4/2_,3 Comments Approved for License Issuance I I Yes I I No Electrical Inspector Date Comments Approved for License Issuance I I Yes I_i No Taxes Paid Yes No Rev.Sept.2003 °` !----' , TOWN OF ARM. UT . ,Yb , r,r 4. }t yry y��p ��f�WDEPARTMENT a gp �5{y qp yp�� N�� Ag 7.� Y ' I _e'+ BUILDING I L D I '1'4J D E P AR TM.E 1 `#T 1, ,,,t 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 RECEIVED APPLICATION FOR CERTIFICATE OF INSPECTION February 1, 2023 PAYABLE UPON REC IP FEB 10 2023 (X) Fee e dS1,5oiNu'D0PARTMENT ( ) No F equired___ 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: LI k (Co 5t3 -31 -329/ Name of Premises: ISLA_IA C1 .(o Tel: S( -'Si 8 -%Lir Purpose for which permit is used: S.to►10,1 A(i McoLat,.. lie.m. ..y.s License(s) or Permit(s) required for the premises by other governmental agencies: C_ A License or Permit Agency Certificate to be issued to %1b Iec(G eu, T,nc. Tel: calf,-3S(p-4.t`r Address: L1 w T�1 20..� s.,,.1rt. N-, t�1% 0)4,6 4 Owner of Record of Building t, (� j.++si- Address }tiO fJo,r}}.'"tt.:.. Sire4.lr 5.1..1- / Yv,"s,,.µ„, O.G64 Present Holder of Certificate IL,k C(.1,,, t,,,c, .1(614. t. Za. coo 13.6.Wv4.✓ Signature of person to whom Title Certificate is issued or his agent 2 /d 21 Da Email Address: C je%MA„ ay CI },{,,,t, ,r}eg i iS.Cam. 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# /--d3-OO'c/ 04/01/2023-11/30/2023 `�/ v 7+v € i s 4 i?' yq • --i L'I-.' °1,Y 1-L a$', . Y-* ± :', ZR4 y .. - .. -x 2 . DAVEREA-01 OKAY AC'ORO" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDMYY) 2/16/2022 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 C NTACT N ME: Valley Forge Captive Advisors PHONE FAX 630 Freedom Business Center Drive (A/C,No,Ext):(610)458-3659 (A/C,No):(484)965-9627 Suite 203 E-MAILSS: King Of Prussia,PA 19406 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Zurich American Insurance Company 16535 INSURED INSURER B: Blue Rock Club Inc INSURER C: 0 '0cJd d INSURER D: S.Yarmouth,MA 02664 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. INSR TYPE OF INSURANCE ADDL SUBR W POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR IN SD VD IMM/DD/YYYYI IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR GL08196255 3/1/2022 3/1/2023 PREMI ES l RENTED 1,000,000 DAMAG ET occurrence) $ MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO BAP8196256 3/1/2022 3/1/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION Xy PER I STATUTE I I 0TH R AND EMPLOYERS'LIABILITY YIN WC8196035 3/1/2022 3/1/2023 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBERtory in NH)EXCLUDED? N/A(Mand 1,000,000 E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 47/10 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD