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HomeMy WebLinkAboutBCOI-23-1789- ID a) o ° u. N O \ N a) -0 00 mn A - a) ' k '— a) co c%) W `. en 0 � N ON—' v p C a '1_ R a) 0 a) E E C)co ai a) rC V m U o o .-U a) p mO ct_ mots °o mn c ^ 0 -' Y co N a C .0 \ k\ :23s. w U �,p 8 w m c m � a•0) cE a) 0 m ZU) r- W g c.N C 7 0 0 'Q 0 0 0 0 =0 c 'Z _o .0 it o U O 7 7 7 co C , a) N o v. lo U U U_ w 0 . 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Qnl1�e 2 � .._._..,.�_.�...�.__..._ m SW J T OCT 30 2023 Name of Premises: �(ji n ton 6 Purpose for which permit is used: 1+04-C --Bu� � u ' License(s) or Permit(s) required for the premises by other governmental agencies: BY License or Permit Agency Certificate to be issued to� js c r!1 ►hIC6I Tel: "CSl.P2AUIO Address: GI GI &f V-D iL i Z� Owner of Record of Building Address 110c- FGI 1 I t U 1L 1T1'T S-e 7' LUI'\I& m V 02"r1 Present Holder of Certificate op'n p n _Th na. 3i,U tt'J Cape CCd- Signature of person to whom Title Certificate is issued or his agent I 01 Date Email Address: j ,C O►I n' 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 be:ore the certificate will be issued. The building official shall be notified within ten (10) days of any change in the abcve information. PLEASE SEND US A COPY OF YOUR ORKER ''S TCOMPENSATION OF INSPECTION.CE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE Certificate of Inspection# 6 C0/-d.3/?cy 12/31/2023-12/31/2024 , DARLDEV-01 LBROWN '4c CM'o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/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 endorsem_ent(s). _ T PRODUCER CONTACT Loretta Brown NAME: FBinsure,LLC PHONE 128 Dean Street (A/C,No,Ext):(508)824-8666 (A/C,No):(508)880-0142 Taunton,MA 02780 E-MAILDSS:Ioretta@fbinsure.com INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A: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 0: 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 W POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD VD (MM/DD/YYYYI (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 8500068374 3/31/2023 3/31/2024 DAMAGE TO RENTED 250,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO X LOG JECT PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Liquor Liab $ 1,000,000 COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY (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) $ A X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 10,000,000 EXCESS LIAB CLAIMS-MADE 4620092990 3/31/2023 3/31/2024 AGGREGATE $ 10,000,000 DED X RETENTION$ 10,000 $ B WORKERS COMPENSATION " PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y WWC3648613 3/31/2023 3/31/2024 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE s, N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 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/VEHICLES ACORD 101,Additional Remarks Schedule,may he attached if more space is required) Umbrella Liability and Excess Liability 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE� i, // .X. Vim,. ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: DARLDEV-01 LBROWN LOC#: 1 ACORN' ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED FBinsure, LLC IFED Hotel Properties LLC 99 Main St POLICY NUMBER West Yarmouth,MA 02673 SEE PAGE 1 CARRIER - --_- --L.--_- . NAIC CODE I 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