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HomeMy WebLinkAboutBCOI-23-1733- dCMN Z •a N IS0 C�1 N w C ca. -a., N p ,c„ .., . R . c N V coQ z a 'C `�� co C) t `m a a)a) to `Ea) � U la y as a) c = .a 7 a) Ut C o aO1a�i NNE•EL m m C) •C T2 z a3 c �' c. 0 Its O 8 c y C4 al o N h O O 'D N c a) C C ui co.w2-, E,.-0 • N y roo 1 , d ci O N 0 . ce. �N.lr 0 0 8 j co of O a"'= �r L. U LN _a„ a.D m '0 'd � � crL$s �‘-'d P' H e o ai = Q63m iP0 = m N ` + 40aec4a iii e 1& 14,Q O_ O re ``0 li 2 E 6 8 } )4 O C c r of = M = c) •' a) 'C co v o '- 0 c Nz - = a _ v m GI p 'p O 'Op C O 0 O 0N.) . +•f m a E a/ _ -. F Ea 14 0I tc O -0 o 7a Ti /o c m ~ y 'CI -N ) v 0 V = O c 3 co `� co 0 r... O O O U �O N O m Cl.H a)I— Z v a� c _ z E Eo c E o O O. Nr � zU tn0 C) a ..c N a C . 0 C .O a) a) '0- v c c}a O A,N c cr) 0LL .0 _c co C ZN 1—ui a) LL O .c a) .Q m o cc?c w w O J 0 .,- co a a) o tr. 0:1 I I a '- a) ii 'O w O O c vN _: R c 0 C.) O O 0. m w w 4111) C J 3 A2 'C N aso o O 1a a) a= o d o s a) co 112 N (0 o- Q ~ N E cal co rnt d) C z 6)U °o--, a4 TOWN OF YA ', MOUTH 11 3(:) ,.a,li 1 M BUILDING L f ;"AT ", •`' 1146 Route 28, South Yarmouth, NI 02664 5()8-3 -2231 et. 1260 RECEIVED D APPLICATION FOR CERTIFICATE OF INSPECTION JUL 0 7 2023 July 1, 2023 PAYABLE UPON REChIP ,q'ti/qAlri (X) quirecil 1oU.6EI T G22 tD ( ) 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-namedbe premises located at the following address: Street and Number: 13 4 .\'t.0 YTS ' Name of Premises: s 5 lv E 4— S(7o dL I s to 042Lb Tel: '5 o g`'j ci Q- (c.O'r/a Purpose for which permit is used: `2 C°4 b t 11 License(s) or Permit(s)required for the premises by other governmental agencies: 0 4 License or Permit Agency `J /� 6 1 IT / '/t,,- 1°111)/ Certificate to be issued to-gos5��VEQS,po,2-rs tZoJ2s- Tel:;(3g-3`k2- (,01 b \ Address: 9,24 72 a g i (70 -soy. k 63 1 5o u-r ff ��� lh o tt i rl•-(i� O 2.L ,c( Owner of Rec of Building Ass R V2\I E - ' A& r kA t t c— ,v 0/Address I{3 t_ � �-�Q5 r Si. 50 , " ✓L� L3�H- ��- or1..(c!o � � S.4 o ``\\ Pres nt Hol f Certificate 3Ass \Z \V E(L S po,2T s tA- o IL i_l i :1-_-, c_ • A-5 v-sL 612— /.. — ignature o erson to whom Title Certificate is issued or his agent J Lv) cl 1).O 2 3 Date Email Address: t• 11 i ck io e l I o j r e, co cos4-. v., e.,-1— 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(10/- - ._/733 08/13/2023-08/13/2024 AC RL® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `►'� 7/7/2023 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 RogersGray,A Baldwin Risk Partner PHONE FAX 410 University Ave (A/C.No.Extt:800-553-1801 (A/C,No):877-816-2156 Westwood MA 02090 E-MAIL maii@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# License#:PC-514062 INSURER A:HDI Global Specialty SE INSURED BASSRIV-05 INSURER B: Bass River Sports World, Inc. ,&Bass River Realty, LLC P. O. Box 183 INSURER C: South Yarmouth MA 02664 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1307742826 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 (MM/DD/YYYY) (MM/DD/YYYY) UMITS A X COMMERCIAL GENERAL LIABIUTY 18LB5540 6/1/2023 6/1/2024 EACH OCCURRENCE $1,000,000 CLAIMS MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $EXCLUDED PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO 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 UAB X OCCUR 18EX3537 6/1/2023 6/1/2024 EACH OCCURRENCE $1,000,000 X EXCESS UAB CLAIMS-MADE AGGREGATE $ DED X RETENTION$in nnn $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER n ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 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) Family Sports Facility Worker's Compensation certificate will be issued directly by insurance company. 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. Town of Yarmouth 1146 MA-28 South Yarmouth MA 02664 AO it PRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD r. DATE '`� CERTIFICATE OF LIABILITY INSURANCE 07/07/2023 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 NAME: Kelley Goodrich BALDWIN KRYSTYN SHERMAN PARTNERS LLC PHONE No.Ext(: (508)760-4604 FAX No): E-MAIL ADDRESS: kgoodrich@rogersgray.com 4211 West Boy Scout Blvd Suite 800 INSURER(S)AFFORDING COVERAGE NAIC# Tampa FL 33607 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: BASS RIVER SPORTS WORLD INC INSURERC: INSURER D: PO BOX 183 INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 909609 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 POLICY EFF POLICY EXP LTRINSD WVD POLICY NUMBER -(MM/DD/YYYYL(MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(My one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION Nw, PER X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6S62UB1K68658923 01/01/2023 01/01/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 C Daniel M.Crojey,CPCU,Vice President—Residual Market—WCRIBMA 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD