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HomeMy WebLinkAboutBLDCI-22-005374 0 c ww,, G v C r ° •V .- o o Z Lo - N `„„ Vl a) o x a o +. .d 1a W N y40 vii N m O a) m .cU o 6 ° ° .0• o a? c. N O �. CO V U Ca V1 N Q Pr E3 1011 o c i o 0 O.) 0 = 4 o a •O U vo w N V a) -O C O O •w Z O C ..,?..i co V ` -,;11„, r M.ett O 7 2 =coo CA p 'c M L To -c15 LU O U \\v a 3 O Erg N N = U U C NO COO �1 �i O 'C o c . C tt / rna W y o E in F=- ' E o ° N m 45 11 c L.O �.. O ++ Q }. s C a O II'C � = p m a.' d O o 5 .N 'E :�y L CO MCI m U m y 00 Q' a. _ 'co X a 5 m E �0 mob/ N O co co Gj pl N a 2 rn c� c i�l g 0 !. cocr) N 'C = a� N b • U O U O C a) Z V 0 Q . •. O CD co O et 7 E - N N O O .ti �N 7 _m 7 r ` 8 y m I- m a� 0 Z 00 (n o0 v L no a C O O M C O • cn CO y O. to ,0 �o C f r a U ^V co 4: co C C C L U 'Q 0 0 V bA 0 .NNIS L o- _ w M I- a o 92 p LL o TA G W .a „, ,.. . LL L .• ,.... V) Ell 2 ^ 0 O o CO 0 16 _O. 0 w 0 u c _ a •1v . " y o :Ill.'" ' N r+ Z' U 1y s 3 a) 0 I 3 R V 0 a 000 allitimillm co vs v d c_ < O a C g c c y J y Q t� g. bA O O i�IIIIIIIII� l+� 8 cu U 46 U 0 U C a) giciltiLao c a> Z ii cn II "Ro TOWN OF YARMOUTH o ,' y BUILDING DEPARTMENT o.,op' 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION March 22, 2022 PAYABLE UPON RECEIPT (X)Fee Required 100.00 ( )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: 48 Todd Road Name of Premises: Blue Rock Golf Course Tel: 508-314-3291 Purpose for which permit is used: All alcohol beverages License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Seasonal - Alcoholic Beverages ABCC RECEIVED Certificate to be issued to Blue Rock Club Inc. Tel: 508-314-3291 MAR 2 4 2022 Address: 48 Todd Road, South Yarmouth MA 02664 Owner of Record of Building Davenport Realty Trust ti— Address 20 N Main Street, South Yarmouth MA 02664 B Present Holder of Certificate Blue Rock Club Inc. Vn Signature of person to whom Title Certificate is issued or his agent `3 eZ 3 a oa). Date Email Address: cdavenport@thedavenportcompanies.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 CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# Loci-aa 4/1//2 022-11/3 0/2 0 2 3 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ko`"''--- 6/1/2022 3/1/2022 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 Lockton Companies CONTACT NAME1185 Avenue of the Americas,Suite 2010 PHONE FAX New York NY 10036 (A/C,No.Ext): (A/C,No): E-MAIL 646-572-7300 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Mount Vernon Fire Insurance Company 26522 INSURED Blue Rock Club Inc. INSURER B: 1498770 48 Todd Road INSURER C South Yarmouth MA 02664 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 18315470 REVISION NUMBER: XXXXXXX 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 INSD WVD POLICY NUMBER POLICY EFF POLICY EXP (MM/DDIYYYYI (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX DAMAGE RENTED CLAIMS-MADE OCCUR PREMISESO(Ea occurrence) $ XXXXXXX MED EXP(Any one person) $ XXXXXXX PERSONAL&ADV INJURY $ XXXXXXX GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ XXXXXXX PRO- POLICY ` JECT LOC PRODUCTS-COMP/OP AGG $ XXXXXXX OTHER: $ AUTOMOBILE LIABILITY NOT APPLICABLE COMBINEDSINGLE LIMIT (Ea accident)SI $ XXXXXXX ANY AUTO BODILY INJURY(Per person) $ XXXXXXX OWNED SCHEDULED XXXXXXX AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) XXXXXXX $ XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAB CLAIMS-MADE AGGREGATE $ XXXXXXX DED RETENTION$ $ XXXXXXX WORKERS COMPENSATION NOT APPLICABLE PER i AND EMPLOYERS'LIABILITY Y I N STATUTE OERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ XXXXXXX OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ XXXXXXX If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ XXXXXXX A MA Liquor Liability N N LQ2004312 6/1/2021 6/1/2022 Per Person Limit:$1M Per Accident Limit:$1M Aggregate Limit:$2M DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Blue Rock Club Inc.,48 Todd Road,S.Yarmouth,MA. CERTIFICATE HOLDER CANCELLATION 18315470 183 Ce of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRI?'Cni Aj1VE I I''- {'°. ( j ~ div„, ,. ©1988-2015 ACORD CORPORATION. I rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD