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HomeMy WebLinkAboutCI-23-005365 r O O pppp 0 i Q a z A' o fi cc Qd1\ N '2- in m c N U + mO xLLIO V N w Inas A— L D IL N C� v o. V` v l o m V m m cd m .6' N a> o v E to F1, °I G UI r tL 2 v Q ,a H _G 0 J 6 O '8 O C m a) to ' 00N CO N O C 0 y w col .5 a 'O CD a ccq .2 C� C o• m v I a G V y / C O Iii! ejj ` ' C 0 O a a�i v�i w c0 7C (_/ w E n 2 it c x _ x o ti 0 ;; ma I . CI W ' O ~ S m 1 G V N ti L G 2 m •�1 o ci m x o 0 0to w a� CCI• � � 'S wC: U E O w � 781 , y O El � Z Z m co � } 8 x x x .s wo 00 � � o 0 El b m Nm c O = th • Q is � � c O v_ m E •w m o b V 3 ' b § c zm inm I a� ou T 1 'F„.: ',AA V CD a a U a w U = o mi o O ao v C t cm 'O p C ...T.0 . ya! E CO 13 a) d rii N 0 t0 g 0w 0 w U 04 co 00 as -to 2 to to au TO a I co 5 g �: w I 0 0 _ I J a I 3 iu 0 0 t c a4IJ ' Ij1i1pj , g Q, J o M ?�pCyIN� # O O N i�IIIIUII t, o m a�x�.i.0,' to E rn z to 7 n„, "' " ; ''k '° nt g " uNl �, , �.rr1, � - - } IL ING DEPARTMENT 1146 Route 28,South Yarmouth,MA 0266402664S08-398-2231 ext. 1260 APPLICATION FORCERTIFICATE OF INSPECTION March•-1,2023 PAYABLE UPON RECEIPT (X)Pee Required 148.00 ( No Fee Required In accordance with the provisions of the Massachusetts State Building Code,Section 110.7,1 hereby apply for a Certificate Of Inspection for the below-named premises iotated at the following address: Street and Number: „s :$L' Y "` ' Nameof f < ,� Pulliam for which{ is, used , � ; License(s)arPrrmrn� i .s required for the premises fby other governmental agencies: License or P : it Agency Certificate to be issued to ` 't. .. 7 : Tel: ` 't . '- "...-4=' iPi , ca �y+� fi r ` ./ „ " +i'"',+", ' f z."-.. Owner of Adores Building Record ofz 1 t : �` 4 Address , Cert;x" ► = Gf Present,Holder of Certificate ;0 Ste .fits : ', 4.44 II, Ate Signat of n mom T .5' ,e itle Certificate is issued or his agent :1 �'+0/2,.,3 Irate Ening Address: A: iteitie,pgetix:xieveelveave ez;1000.7 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 ta be certifed. Application+ttion 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 OP YOUR WORKER'S COMPEN AIION INSURANCE FORM WITH THIS APPLICATION OR we CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate'ofInspection 04/15/2023—a4/I 512024 743 ,.Sias Stile A�Rom"® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/28/2022 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 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 NAMEACT PHILIP GINEXI JR. GENATT V PHONE 3333 NEW HYDE PARK RD (A/C.No.Ext):516-387-3069 FAX E-MAIL (A/C,No): SUITE 400 ADDREss: pginexi©genattspeciaity.com NEW HYDE PARK NY 11042 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Zurich North America INSURED NEWPHOTE Newport Hotel Group LLC, ETAL INSURER B 28 Jacome Way INSURER C: Don McCall INSURER D: Middletown RI 02842 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2114059569 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 IMM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS A WORKERS COMPENSATION $ W AND EMPLOYERS'LIABILITY C014008008 11/15/2022 11/15/2023 Y/N STATUTE X ERH ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory In NH) If yes,descr be under E.L.DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space is required) LOCATIONS: 1. 1 WAVE STREET,MIDDLETOWN,RI 02842 2.213 OCEAN STREET,HYANNIS,MA 02601 3. 178-180 THAMES STREET,NEWPORT,RI 02840 4. 13-15 KILBURN CT.,NEWPORT,RI 02840 5.82 MT.HOPE STREET,N.ATTLEBORO,MA 02760 6.SETTLERS GREEN,RTE. 16,NORTH CONWAY,NH 03860 7.40 NORTH MAIN STREET,FALMOUTH,MA 02540 See Attached... 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. EVIDENCE OF INSURANCE AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD 25(2014/01) The ACORD name and logo are registered marks o f ACORD ACORD CORPORATION. All rights reserved. AGENCY CUSTOMER ID: NEWPHOTE LOC#: AW RD ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED GENATT V Newport Hotel Group LLC,ETAL 28 Jacome Way POLICY NUMBER Don McCall Middletown RI 02842 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE 8.28 JACOMB WAY,MIDDLETOWN,RI 02842 9.20 WAVE AVENUE,MIDDLETOWN,RI 02842 10.97 SOUTH SHORE RD.,BLDG#1,SOUTH YARMOUTH,MA 02664 11.97 SOUTH SHORE RD.,BLDG#2,SOUTH YARMOUTH,MA 02664 12.7710 GRANITE LOOP RD,TETON VILLAGE,WY 83025 13.7710 GRANITE LOOP RD,TETON VILLAGE,WY 83025 14.73 SOUTH SHORE RD,BLDG#1,BLDG#2 BLDG#3,SOUTH YARMOUTH,MA 02664 15.38 PURGATORY RD.,BLDG#1,BLDG#2,MIDDLETOWN,RI 02842 16.368 OLD POST RD.,NORTH ATTLEBORO,MA 02760 17.259,251,267 THAMES STREET,1 STATE STREET,BRISTOL,RI 02809 18.157 HOLLY RIDGE RD.,CONWAY NH 03818 19.235 OCEAN STREET,HYANNIS,MA 02601 20. 120 PALMER AVENUE,FALMOUTH,MA 02540 21. 107-108 ATLANTRIC RD.,BLDG#1,BLDG#2,BLDG#3,GLOUCESTER,MA 01930 22.43&45 HULL SHORE DRIVE,HULL MA 02045 23.131 OCEAN STREET,HYANNIS,MA 02601 24.149 OCEAN STREET,HYANNIS,MA 02601 25. 390 N.GLENWOOD STREET,JACKSON,WY 83001 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD