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HomeMy WebLinkAboutCI-23-005197 The Commonwealth of Massachusetts _ c—_ City\Town of W YARMOUTH • At all .. K IN=al M �`! 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 BLDCI-23-005197 Business Name: RJ Resorts Green Harbor Village Resort Ownner LLC Trade Name: Green Harbor Village Resort Identify property address including street number, name,city or town and county Certificate Expiration Located at 4/1/2024 182 BAXTER AVE WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) Bld 1-19 Units 01st Floor 9 R-1 Hotel/Motel/Boarding House/Transient R-1 02nd Floor 9 R-1 Hotel/Motel/Boarding House/Transient Bid 1-9 Units Allowable Occupant Load 01st Floor 28 R-1 Hotel/Motel/Boarding House/Transient Bld 2-28 units 02nd Floor 5 R-1 Hotel/Motel/Boarding House/Transient Bld 3-5 units 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 off.Building Commissioner Issuance 3�/5/2� ee: $223.00 BLD Certoflnspection.rpt I�G C E1 VED BUILDING DEPARTMENT I E�C Route .8, South Yarmouth, 1T: 02fC4 rt '-398-22 xt APPLICATION FOR CERTIFICATE OF INSPECTION [MAR 16 2023 March 13, 2023 PAYABLE UPON RECE1P B :BUILDING DEPARTMENT (X) Fee Required 22 . ( )No Fee Required in accordance with the provisions of the Massachusetts State Building Cade, Section 110.7, t hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: rip., '10,x4rtt kvt W '/a.crAot. A 2ci '3 Name of Premises: ig3 Etar ioc tstATel: 4 'O$ ? II t Purpose for which permit is used: I.icense(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency • Certificate to be issued to &rim, 'r196r- ct 3 •k" Tel: Address: t$a aX&f t o^ /`'1R9_0 . Owner of Record of Building rec.. Address IS 13.-aver 4 i. &,15 /M da4Gy Present Holder of Certificate ret.x 044r4 - ' mature of person to whom Title Certificate is issued or his agent in*„.., Date i :�rril Acidres�.: _cofr. `„.., {,13,: ,L ce_soees •CC.<'1 Instructions: Make check payable to: Town of Yarmouth 1 146 Route 28, South Yarmouth, MA 02664 Return this application to: Building Inspector's Office Please note: Application form with accompanying fee must he 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 T111S APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection # =#W1:571 --441+s,4310914-- 182 Baxter Road /raj 41f,> e uic/- _3- 6 6,57?-7 DATE(MM/DO/WYY) ACCOREP CERTIFICATE OF LIABILITY INSURANCE ozroz/zoz3 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 -IOLDER. 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 Marsh USA,Inc. NAME - FAX 1166 Avenue of the Americas PHONE (A/C No): New York NY 10036MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN133703919-GL-22-23 INSURER A:Everest Premier Insurance Company 16045 INSUREDEOS Investors,LLC INSURER B:Everest Denali Insurance Company - 16044 444 Madison Avenue,Floor 14 INSURERC:N/A N/A New York,NY 10022 INSURER D:Everest National Insurance Co INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-011552064-01 REVISION NUMBER: 0 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 C:ONDITION 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 T POLICY EXP LTR TYPE OF INSURANCE INSD I VINO POLICY NUMBER (MWDD/YYYY) (MMIDD/YYYY) LIMBS A X COMMERCIAL GENERAL LIABILITY CC1GL00029-221 0911212022 09112/2023 EACH OCCURRENCE $ 2,000,000 DAMAGE RENED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 1,000.000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECTPRO- X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 I OTHER $ B AUTOMOBILE LIABILITY CC1CA00027-221 (AOS) 09/12/2022 09/12/2023 COMBINED SINGLE LIMIT $ 2,000,000 (Ea accident) I) X ANY AUTO CC1CA00056-221(MA) 09/1212022 09/12/2023 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 Garage Keepers Garage Keepers $ 1,000,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1 EXCESS LIAB CLAIMS-MADE AGGREGATE $ __ DED RETENTION$ $ A WORKERS COMPENSATION CC5WC00075-231 01/01/2023 01/01/2024 x PER OTH- AND EMPLOYERS LIABILITY I STATUTE I R _ ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 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 RJ Resorts Green Harbor Village Resort SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Owner,LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EOS Investors LLC ACCORDANCE WITH THE POLICY PROVISIONS. 444 Madison Ave New York,NY 10022 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN133703919 LOC#: New York ACoRL ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA,Inc- EOS Investors,LLC 444 Madison Avenue,Fkxx 14 POLICY NUMBER New York,NY 10022 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 Garage keepers Legal I iability Comprehensive $1,000,000 L imit $500 Deductible for Each Customer's Auto Loss $2,500 Maximum Deductible for L oss Caused by Theft or Mischief or Vandalism Collision $1,000,000 Limit $500 Deductible for Each Customer's Auto Loss Excess Liability: Insurer:Markel American Insurance Company Effective Dates:September 12,2022-September 12,2023 Policy#DPHX002022 Limit$15,000,000 excess of$10,000,000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD