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HomeMy WebLinkAboutBCOI-23-1720- v a) c 5 .. WI �a vpo v U Z N Ziqhyr 7 A N a of V CO CV .o O C (0 ' 4 �: = +a+ N a to 0 52 0 as a) 0 e- e c N V m t o 8 o .a o t c� L —� a) c ,a o cca V Yea a Ls R rn— mv m m O 0 3 . N c as ITN a) ✓ CO Z (nr- MICO CD �j Naai c a 7 8 _ a) v o 0 V CD CO CO cc •� C. 7 = s r N (� c y CO O rn i.. V) : p Z Z r ' •y Iktik4%C w • :.:. ,a" t9 d 0) a 11 Ifi v rxca � m ns v Il tl) nl N t Cl) c .�+ d Q 51 Q W If AI �1 11411 \ u c mu) = a) o 40 µ. E 06 — cc RI N ` C w E7 W O y c otS i o N c I C c c m < m as co i �+ w c N � N � \ p 0 = v W E a e F- 1— s co t RI 3 � r m = = 1- & 2 L � 3 1� Q R Zzc�v e °' � Ya1°i � CLa 0 �' w � Z = a � � 4 v m' E d p 'p C R C i v V -c m a E re , DH �y OI(� `r � � L. a o 'p c m v � y0 c, 3...3 CC 0 IP a) ca y a) ~ Z �v a) c _ - m o 2)o Uo o0. N � ZU u)U CQ) O. >. L cm c = ' -0 2 m d u 'c0) N co U 'a co O O O > N j co Cil IL L.. Li_ L L U) O co y y � h w E. r a) it O O O t N >, co L 7 N 7 c as co c A 0 c) . O O z+ as sa 0. a) ++ C 2 ..c y -a . ' lL .L_ m •r; • V cu_ U a 3 y al v 0 m s a) W p Q. d ,� as .2 7 co O G p 7 ✓ L N 1-6N • Q 1— E C -CCD 07 (T c Z ii)U f s i EPA T ENT a°" ,� 1146 Route 28, South Yarmouth, MA 02664 508-398-223I ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION May 1, 2023 PAYABLE UPON RECEIPT (X) Fee Required $478.00 ( ) 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: �g Min \ /1.1 O�.IC. �� }�'��m ^� j 1i, Name of Premises:►� 1 p1Dn o nn I-SWif S Tel: 1 L1- D i —LI ILI° Purpose for which permit is used: \-0 I y License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency R E `i!a A:,eu. LiCiU04_LiCMie [ JUN 08 2023 \ 1 BRIG—; Certificate to be issued to 1?Q/O n1 fl t i o Tel: Address: �� O n S ue"i' % Owner of Record of Building Feb I .1211C -t CS; Address 1 CS f l 1 I -1v`e 4. �e 1, tve h.Oflt yn i4 0.0-ri I slo Present Holder of Certificate Ho ynpiThel Tnn et SUJ.-M eC9pro CO G'- ' , '. ...*\***...... . 7.e.A441041.11:189 Cgn. Signature of person to whom Title( ? Certificate is issued or his agent (PI 1)Q, Date j Email Address: b�trrn� Do)CIGV ►I n ho+e) s. orn 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# 6 j..r.,2 ,-170 06/29/2023-06/29/2024 Department of Industrial Accidents __ _ Office of Investigations 1 Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information ��,AA Please Print Legibly Business/Organization Name:F D ►-'(C opeole4 Il-IrA rri n Suite) Address: hoc 6 I I ri ii. `e.. • . City/State/Zip: J . A 0.911 Phone#: Are y 1 , an employer?Check the appropriate box: Business Type(required): 1. if I am a employer with ')O employees (full and/ 5. ❑Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. o workers'co ins ance re uired 8. ❑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]* 11.❑ Health Ca e 4.❑ We are a non-profit organization, staffed by volunteers, � � ' with no employees. [No workers' comp. insurance req.] 12. ` Other 'Any 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 )rganization should check box#1. l am an employer that is providing yworkers'compensation insurance for my em loyee��es. lwico elow is the polic info a on. Insurance Company Name: 0 )�± Nor t t,1 C(.mil 1'1 L�0 Insurer's Address: q O ) )O 7� t11►�I City/State/Zip: CAW, I Ci J Ic1 1 0 IT 1-11- )D I._l 1 -/ Policy#or Self-ins. Lic. # W C;S Li LI&IP I J Expiration Date: ,3 131 I Di— 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 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 certify, un the pa' s an enalti s of pedury that the information provided above is true and correct. Signature: Date: 4)1 i/e)�j� /1 Phone#: 11 Li " l t/ 1—� '`j l v 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): 11jBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.1:Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia AGENCY CUSTOMER ID: DARLDEV-01 LBROWN LOC#: 1 ACORD ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED FBinSure, LLC FED Hotel Properties LLC 99 Main St POLICY NUMBER West Yarmouth,MA 02673 SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Additional Coverage Information Cyber Liability-Claims Made Form,Retro Date-Full Prior Acts Carrier: Beazley Insurance Company(NAIC#: 37540) Policy#:W23B6E230601 Effective:3/31/23 to 3/31/24 Coverage -Policy Aggregate-$1,000,000 -Information Privacy Liability-Limit: $1,000,000 with$15,000 Retention -Data and Network Liability-Limit: $1,000,000 with$15,000 Retention -Regulatory and Defense Penalty-Limit: $1,000,000 with$15,000 Retention -Media Liability-Limit: $1,000,000 with$15,000 Retention ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD '''.... DARLDEV-01 LBROWN "4�---- CERTIFICATE OF LIABILITY INSURANCE DATE(MMI°°/YYYY) 6/5/2023 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 Loretta Brown FBinsure,LLC PHONE FAX 128 Dean Street (A/C,No,Eat):(508)824-8666 (A/C,No):(508)880-0142 Taunton,MA 02780 n iris,loretta@fbinsure.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Arbella Protection Ins Co 41360 INSURED INSURER B:Wesco Insurance Company 25011 FED Hotel Properties LLC INSURER c:Travelers Property Casualty Company of America 25674 99 Main St INSURER D West Yarmouth,MA 02673 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!i __--- POLICY EFF POLICY EXP - _ LIMITS LTR INSD.WVD POLICY NUMBER IMM/DDIYYYYI IMMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 8500068374 3/31/2023 3/31/2024 PRAMAGE EM SES TO oc5u ante) $ 250,000 MED EXP(Any one person) $ 10,000 --- - PERSONAL 8 AOV INJURY $ 1,000+000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- X LOC : S PRODUCT -COMP/OPAGG $ 2,000,000 JECT OTHER: ,Liquor Liab $ 1,000,000 A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) _._... $ X ANY AUTO 1020096475 3/31/2023 3/31/2024 BODILY INJURY(Per person) $ OWNED SCHEDULED - - -- AUTOS ONLY ,AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY ', (Per accident) $ EACH OCCURRENCE $ 10,000,000 A X UMBRELLA EXCESS AB AB X CCCUR 1 CLAIMS-MADE 4620092990 3/31/2023 3/31/2024 AGGREGATE $ 10,000,000 DED X RETENTION$ 10,000' '.. --- B WORKERS COMPENSATION X STATUTEPER ER $ AND EMPLOYERS'LIABILITY N I A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WWC3648613 3/31/2023 3/31/2024 1,000,000 OFFICER/MEMBER EXCLUDED? Y E.L.EACH ACCIDENT $- 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under ' 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Excess Liability 'EX-6W463206-23-NF ' 3/31/2023 3/31/2024 Per Occurrence 10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES ACORD 101,Additional Remarks Schedule,may be attached if more space is re uired Umbrella Liabilityand Excess LiabilityP a ) policies/limits extend over the General Liability,Liquor Liability,Automobile Liability,and Workers Compensation policies.See"Additional Remarks for Cyber Liability coverage. Regarding:Hampton Inn&Suites,99 Main St(Route 28),West Yarmouth MA 02673. 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 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 — AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD