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HomeMy WebLinkAboutBCOI-23-1714- The Commonwealth of Massachusetts Town of YARMOUTH New and Renewal Certification of Inspection In accordance with the Massachusetts State Building Code,Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name:Blue Bird Hospitality Corp BCOI-23-1714 Trade Name:Cape Shore Inn Identify property address including street number,name,city or town,and county Certificate Expiration Located at 793 ROUTE 28 April 1,2025 SOUTH YARMOUTH,MA 02664 Floor Occupancy_ Use Group Other Use Group Classification(s) 01st Floor 8 R-1 Hotels,motels,boarding houses, 8 Units etc. Managers Apt Allowable Occupant Load 02nd Floor 10 R-1 Hotels,motels,boarding houses, Lobby-10 Units etc. 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 line safety features.This certificate shall be framed behind clear glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned.Failure to post or tampering with the contents of the certificate is strictly prohibited. Name of Municipal Building / /r f J� Name of Municipal Chief � fVlar G ate of Inspection y Commissioner Signature of Municipal Fire Signature of Municipal Building Date of Issuance Chief Commissioner Z� Z� TOWN OF YARMOUTH 4.o 1�'' - y BUILDING DEPARTMENT '_Y4 MATT00RATt AG 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 '���'�O,oOJ. G APPLICATION FOR CERTIFICATE OF INSPECTION March 1 , 2024 PAYABLE UPO CEIP (X) Fee Require $157.00 ( ) No Fee Requ In accordance with the provisions of the Massachusetts State Building Code, Section 1 10.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 1 a rel Nf\ ! RECEIVED Name of Premises: 'Ca, c.S l 1rt j ✓� Tel: LMAR 112024 f Purpose for which permit is used: ce,r + of- 14 S p-e c H' D 17\ BUILDING DEPARTMENT License(s) or Permit(s) required for the premises by other governmental agencies: CAL License or Permit Agency Cie vis3pea-Coyi CCL VIv r-e Tel: (PCD 9�` Cp / -a�.3 /Certificate to be issued to � cs Address: TB deco Sk 3o tilt., ti c{: r t) t`^ t 1 02.6 E4 Owner of Record of Building u ?at- i Address 7c3 Maio S4 So)- , Y►-trrw th HA 02L6k1 Present Holder of Certificate I 4L,( ( '71 r,e_G" Signature of person to whom Title ` I Certificate is issued or his agent 3 -- l Z Date Email Address: Cc c k(j 1'Yn a:_ 6. 3L,� c 0 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 # `' CD1 3 —t-i f 04/01/2024-04/01/2025 a) c � 0 • 't e v. aa)) a w .Q 0 v Cftca `` it N c y vI 0 v� .V` N v' — c to t O v 'c c w a) C) co a.� "a "c CD < cam _C I • 4) o . D as -:1,= i 62-In c�= a) ao2J N W y d.a a y C 7 3 2gt Z' 0 0 3 cc o,c _c ae ° 8 0 t�1 m C �N, aa) m C o N ta Is co o 0 0 c w vs a cif C h 5 O C. 0 a) w-0 .y fi �.. as 0 1E E o •� cc w en c c 2a) 0 aat Nv . ' x° 0 -C3 CD 0 V 0 O gp t C V a►" Da` mlim � _yw h.kik44 C a' c cc r) co "` e To U 2 �+ x .0 y a gc1 0en A as o E _ 2 4, p � = v W Q � HH Eca 1\ O co F. y. m w > > Q as , 1 a� it 0 E m E ca y M5 y rn3 1-- Q 2 Ez cr. } I La co . co !ci c c CD c c u' � O= ' c E m E o _ .c 0 a :°4. m a N h p co o 0 .0 0 n c a� ai i m 13 cE0°, ' = � E s 3 0 fa v' co O o ° F— Z t CO c . ID mE mE _ _ E E c E U c° 1D zU in U c oca)a) v 4 .- a ,ib .0ccac m a) .y cu $ y 00 c ;•y = co oo y c E H t u. o o � ��a m a C co y o CO '� as J a) 0 .,, 0a,m a) O 0 F R CO J to 4)o C.) O 4r) C3 O O o o N QF-CU 0)a) E cco a) TOWN OF YARMOUTH rt _,:fi ft h BUILDING DEPARTMENT `— 1146 Route 28, South Yarmouth, MA 02664 508-39 - ,T APPLICATION FOR CERTIFICATE OF INSPECTION 2 2023 MAY 5 � March 1, 2023 PAYABLE UPON RECEIP aulLoir,G DEPARTMENT ( ) 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: 1 cr) IA A --lc SA, Y. ov lL NA-- 0 -cc Name of Premises:Blur_ [3,'rl / 41 , (b/p , Tel: SDI'-01 - it C. 'e S1,o - i,111() ` Purpose for which permit is used: .� License(s) or Permit(s)required for the premises by other governmental agencies: Q` License or Permit Agency Certificate to be issued to 1 n`1• i.- Je l Tel: CO3 - 71f-Z31y Address: 1(V! 11A_- , sod4& YD.,rr.oj , /1A- 02 41 Owner of Record of Buildmg ti.�,, . la 11 Address 1°t3 N Z$,S 1(�-Ir-ev+i, Mt n-2_4"69 Present Holder of Certificate f ,n,` V,`. ei Signature of person to whom Title Certificate is issued or his agent OS 1 11 kip 2-3 Date Email Address: C6Te-SVoce 1rn � R O y-v��, Lain 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# 131.. 3_ 04/01/2023-04/01/2024 ��/ AC D CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) L.,..--- 05/24/2023 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 AJAY THAKKAR NAME: THAKKAR INSURANCE AGENCY LLC PHONE 7812620800 FAX (A/C.No,Exth (A/C,No): 7819967570 134 CAMBRIDGE ST,2ND FLOOR EMAIL ADDRESS: AJAY@THAKKARINSRUANCE.COM BURLINGTON,MA 01803 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Atlantic Casualty Insurance Company INSURED INSURERS: THE TRAVELERS INDEMNITY COMPANY BLUE BIRD HOSPITALITY CORP INSURER C: Underwriters at Lloyd's,London 793 ROUTE 28 INSURER D: SOUTH 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 ADDL SUBR POLICY EFF 1 POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A 5793424A 05/09/2023 05/09/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOG PRODUCTS-COMP/OP AGG $ Included OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 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$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N STATUTE ERH B OFFIC RPMEMBEREXC UDED?ECUTIVE N/A E.L. ACCIDENT $ 1,000,000 (Mandatory in NH) UB-8W420411 05/18/2023 05/18/2024 EACH If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C Property Building/RC $ 950,000 AA1122000 05/04/2023 05/04/2024 BPP/RC $ 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Loc 1:793 ROUTE 28,SOUTH YARMOUTH MA 02664 Building and BPP cover at Replacement Cost. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth,MA ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rte 28, South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE AJAY THAKKAR I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD