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HomeMy WebLinkAboutBCOI-23-1722 2024 ) 2 cy 2 c 2 # 2e II B q la) t / 2 co c a) riS a) n\kliki k m z 'E cu c .a 3 --(Ab )f § $co/ e I° ( 2 zo - o , O - © _ a 0.-ti co = f 0 b 0 2q % k £ k -- a � 8 . _ a m 0 « c C a . Q / \ P g 2 § k e ■ 2 C a E 3 / a -c / . U o co # c -I0 1. � � 2 / � � 0 e = e f o $ -Jo a2 § 2 § 00_# .c a kf ' ) C\J 77 � 0 a ■ C , � £ £ e CO 2 � � k li E � = <2 </ /7f } ■ 0 � ta. CQK /30 , -� $ I c •U) m / # 2 k oE2 � 220 k z O k_ W 2 § j = E 2 § 02 / � �m km - 0 O V E k ‹ ƒ oea < > f@c c 2 c I § % $ _ § �2 $ c n ■ c a . "C 1 ck6 kk , kk / / 0. o E « 020 2 3 @ / ck J kk ° — k \ O 2 » ■ . ■ .w oo$ 2 m = 0 ® E 2 22@ _ J 2 2 c U k 2 E o ® c _ 2 a) E .2E o k. a24 • occo c ƒ gL z0n0 a) �$ ƒ b k . ' CO k � o $ CO 0 § 2 o : § //�a o c cD0 22 . 2 c ) /k R es -1 ep a M ■ ƒ il J ) . \ = § t $ E % # 2 ° = lb- ()4 aall* @ o Q o t2 p c © 2 / � Ti \ o / k \� 2 co % $ ° ° ■ f k k ƒ I� . . % E &2 Z O6 p �•+r� o � ` � TOWN OF YARMOUTH R D t V '� D ro.f ` -��� BUILDING DEPARTMENJUN 12 2023 1146 Route 28, South Yarmouth, MA 02664 508 398-2 31 ext. 1260 BUILDING LiEPARTMENT APPLICATION FOR CERTIFICATE OF INSPECTION June 1, 2023 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) 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: 579 Buck Island Road,West Yarmouth,MA 02673 Name of Premises: Maplewood at Mayflower Place Tel: (508)790-0200 Purpose for which permit is used: EOEA license to operate assisted living units License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency EOEA Certificate to be issued to Maplewood Mayflower Place ALF,LLC Tel: (508)790-0200 Address: 579 Buck Island Road,West Yarmouth,MA 02673 Owner of Record of Building West Yarmouth Property I,LLC Address 303 International Circle,Suite 200,Hunt Valley,MD 21030 Present Holder of Certificate Maplewood Mayflower Place ALF,LLC /41r General Counsel Signa of person to whom Title Certificate is issued or his agent 6/7/23 Date Email Address: amiller@maplewoodsl.com 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 C T ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# DLbi 07 3—/7 _ .- 07/11/2023-0 7/11/2024 AC RD® CERTIFICATE OF LIABILITYDATE(MM/DD/YYYY) ilk.......—.-- INSURANCE os/o7/zaz3 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 MARSH USA LLC. NAME: Marsh U.S.Operations PHONE FAX 212-948-0770 540 W.MADISON (NC.No.E:n: (866)966-4664 CHICAGO,IL 60661 (A/c,No): E-MAIL Chica o CertRe nest marsh.com ADDRESS: 9 q INSURER(S)AFFORDING COVERAGE NAIC# CN137888845--GAWXP-23-24 INSURER A:National Fire&Marine Insurance Co 20079 INSURED p INSURER B:Federal Insurance Company 20281 Maplewood Mayflower Place ALF,LLC 1 Gorham Island INSURER C:MEMIC Indemnity Company 11030 Wesport,CT 06880 INSURER D:N/A N/A INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CHI-010380867-02 REVISION NUMBER: 4 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 LTR TYPE OF INSURANCE POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 42-PSC-328861-01 06/01/2023 06/01/2024 EACH OCCURRENCE $ 1,000,000 X CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY PRO X LOC JECT PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ B AUTOMOBILE LIABILITY 7359-40-41 06/01/2023 06/01/2024 COMBINED SINGLE LIMIT $ 1,000,000 X 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) $ A UMBRELLA LIAB _ OCCUR 42-USC-328867-01 06/01/2023 06/01/2024 EACH OCCURRENCE $ 10,000,000 X EXCESS LIAB X CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$ C WORKERS COMPENSATION $ 3102804908 06/01/2023 06/01/2024 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N N/A (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 A Professional Liability 42-PSC-328861-01 06/01/2023 06/01/2024 Each Claim 1,000,000 Claims Made/Ded.$50,000 Aggregate 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Maplewood at Mayflower Place-ALF,566-579 Buck Island,West Yarmouth,MA 02673 CERTIFICATE HOLDER CANCELLATION Town of Yarmouth 1146 Route 28 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE South Yarmouth,MA 02664 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I Wireve. c "7-e.S�f�e' ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD