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HomeMy WebLinkAboutBLDCI-23-006144 c 0 `� rt 8 z �; wocit N a e m p M N I. ,ty ` m p 10 J) W N I- W 0 01 N al M Z fn to .b 0 O LL m VJ t t0 D x D m ypU, v� (� ^\ C 00 V 7 0 N N 5 0 \ H ,\ •OC N N N '`Jl cp 1:4la. VI t m 2 m m CD y w 0 �.. U 0J O O C m ch tH 0000 .b m 0 CA e 2 � 1 9. C o r� a Co) O. . . , y u� N `+�- C 1.4 N O O U� o v t ob C.)iilliii « N U ai I I y g oa t x U c co O 00 v, .O 1 co o w at Will Q C I-- {— CO m 1 0 8 m m •� C 0 M c m O o o 4 'w C .r uoi 7To p 0 E Qj coco ciI N Q O . 5 A k* U E E Gu Z c�6 C N t7 2 2co\\_ -5 I io. e VI'v I c. N U .p bA coL8 41 p a) N L co g H 0 i N 4r .O m it O O 0 0 C y N la 4. .... L O 'b 0 To i rQ C10 73 U 4 Ititlifili II�O ' .00 h wJ w al QF v m LoO f0 ALIIELit-Liii, C CO 0) Z fn (0.YRR4o TOWN OF YARMOUTH - y BUILDING DEPARTMENT �M�Mep Ctl b�l 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION May 5 2023 PAYABLE UPON RECEIPT (X)Fee Required 241.00 ( )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: 00a 4,UTE y6 r 5/�n.4rov /AK9 e' 7? Name of Premises: 51/4✓,#//2.0 virta- eor•Ak Epd Tel: 603 E3/-P6 _ Purpose for which permit is used: `AOi C/ 9 pv—e-e-#®'eVc.), License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit R E C E I V C D Agency MAY 05 2023 BUILDING DEPARTMENT By: Certificate to be issued to,5-0A4/.e0 oft y edhee corms' Tel: ja '383/94f'Z Address: 226 ger/r4 ?.6 racer #.0414,ant /YI4 62673 Owner of Record of Building t 4/4 L4C Address /redo&q694/ S,-, j3 el", ,*.4 4002 y Present Holder of Certificate Signature of erson t whom Title Certificate is issued or his agent �/03/012::1-Z3 �,,�J Date Email Address: Gla �lJifeotAt4e . LGN�I 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# 436,i3C 3_09W V n� 6/3/2023—6/3/2024 ON co The Commonwealth of Massachusetts Department of Industrial Accidents ff Office of Investigations Lafayette City Center fl 2Avenue de Lafayette, Boston,MA 02111-1750 • www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:Wagner Hospitality Management LLC Address:272 Huntington Ave City/State/Zip: Boston, MA 02115 Phone#: (603)831-9642 Are you an employer?Check the appropriate box: Business Type(required): 1.LU I am a employer with 32 employees (full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 70 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. 0 Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp.insurance required]** 4.0 We are a non-profit organization, staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp. insurance req.] 1211 Other Hotel *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: RogersGray Inc Insurer's Address: 410 University Ave. City/State/Zip: Westwood, MA 02090 Policy#or Self-ins. Lic.# WCC-500-5027070-2022A Expiration Date:05//16/2023 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of a fme up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi , der th in and p allies of perjury that the information provided above is true and correct. Signatur 8/12/2022 Date: Phone#: (6 831-9642 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): 1.OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.DLicensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia A /20/2022 �`�`® MM/ CERTIFICATE OF LIABILITY INSURANCE DATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO 7ATE LDER. 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(les)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 Rogers Gray NAME: 410 University Ave PHONE FAX (ac.No.Ext):800-553-1801 I(ac,No):877-816-2156 Westwood MA 02090 E-MAIL mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Associated Employers Insurance Company 11104 INSURED WAGNHOS-01 Wagner Hospitality Management, LLC INSURER B 1249 Beacon St INSURER C: Suite 1 Brookline MA 02446 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:163927232 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: POLICY PRO- JECT LOC GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) $ UMBRELLALIAB OCCUR EXCESS LIAR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED 1 I RETENTION$ A WORKERS COMPENSATION WCC 500 5027070 2022A 5/16/2022 5/16/2023 $ AND EMPLOYERS'LIABILITY I STATUTE I I ERH ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICER/MEMBEREXCLUDED? N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory in NH) If es,describe 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 if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Intercontinental Hotel Group ACCORDANCE WITH THE POLICY PROVISIONS. 3 Ravinia Drive Atlanta GA 30343 ( ,:tedoA DREPRESENTATIVE ACORDitee344‘...„..................._ ©1988-2015 CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered ma ks of ACORD AC Rom® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 7/20/2022 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 CONTACT Rogers Gray NAME: 410 UniversityAve PHONE 800-553-1801 Westwood M 02090 E MAIL'E"f t' I FAX No):877-816 2156 ADDREss: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Associated Employers Insurance Company 11104 INSURED WAGNHOS-01 Wagner Hospitality Management, LLC INSURERB: 1249 Beacon St INSURER C: Suite 1 Brookline MA 02446 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:163927232 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INK) WVD POLICY NUMBER (MM!DD/YYYY),(MM!DD!YYYY► LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(My one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ OWNED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS SCHEDULED HIRED NON-OWNEDBODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) $ UMBRELLA LIAB OCCUR EXCESS LIAR EACH OCCURRENCE $ CLAIMS MADE AGGREGATE $ DED I I RETENTION$ A WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY WCC-500 5027070.2022A 5/16/2022 5/16/2023 ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N I MUTE I I ERH OFFICER/MEMBEREXCLUDED? N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory In NH) If yes,describe 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 if more space is required) 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. InterContinental Hotel Group 3 Ravinia Drive Atlanta GA 30343 A DREPRESENTATIVE 7 o"egeom.%A.o„..................... ACORD 25(2016/03) The ACORD name and logo are registered ma $8-2015 of ACORDORD CORPORATION. All rights reserved. s The Commonwealth of Massachusetts Department of Industrial Accidents 13 Office of Investigations Lafayette City Center r 2Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:Wagner Hospitality Management LLC Address:272 Huntington Ave City/State/Zip: Boston, MA 02115 Phone#: (603)831-9642 Are you an employer?Check the appropriate box: Business Type(required): 1.11 I am a employer with 32 employees (full and/ 5• 0 Retail or part-time).* 2.0 I am a sole proprietor or partnership and have no 6. Restaurant/Bar/Eating Establishment 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp.insurance req.] 12.0 Other Hotel *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: RogersGray Inc Insurer's Address: 410 University Ave. City/State/Zip: Westwood, MA 02090 Policy#or Self-ins.Lic.# WCC-500-5027070-2022A Expiration te: 23 Attach a copy of the workers' compensation policy declaration page(showing the policy nu ber and expiration date). Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certi , er the p ofperjury that the information provided above is true and correct. Si afore: 8/12/2022 Phone#: (603) 1-964 Date: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): 1.DBoard of Health 2.0 Building Department 3.[]City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.[]Other Contact Person: Phone#: www.mass.gov/dia