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O N ca m c..) d _ L ca co c = Q f— C a t0 w — a) E c m C) N 0)L Z u)U Of.1r/ TOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION November 21, 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: '/-4' 20t Z9, lAk `✓k2h©t n?, 0z�, 3 Name of Premises: ���,, bY � Tel: Soe-��r3-!sW Purpose for which permit is used: RA-fin/JailI -e' f sine, License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency f vp ( ,I7—mil--(,3 Certificate to be issued to 4/61 !y 44 ,� Tel: .Dg /S Z Address: yet, 120de ��, t,/�,� Y✓ rntl o z.c,773 Owner of Record of Building /ll rt PGr( S E{o i e t l'cvma L C �, Address ito / H�,r�vv� five Lexint�n nu Oa 4a-1 Present Holder of Certificate / P�,s; L DQGr��3 Si -ti �tume"" natu V� o g person to whom Title Certific. is issued or his agent r.,iz,(z3 RECEIVED Date Email Address: Gmi u,rcien yOv„?o ,u,,,� ����2'11013 Instructions: Make check payable to: Town of Yarmo r�►�on�o t��f»�ti,LN7 eY uth — - —_ Return this application to: 1146 Route 28, South Yarmouth, MA 02664 Building Inspectors 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 # &Cp/_Q3-/7 7 1279112023"TO i 27'31 l2024 '`......iip JAMSHOT-01 FQUISPE 'ACC:P/GUIX /DDlYYYY) DATE DA (MM �..._ CERTIFICATE OF LIABILITY INSURANCE 1EMM/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 1921,44EACT Francis Quispe Boyd&Boufford Insurance Agency,LLC PHONE ... . 167 S River Road Unit 10 (A/C,No Ext): FAX (603)673-7228 (A/C,No):(603)673-7290 •Bedford,NH 03110 E-MAIL ADDRESS..._Francls@Bouffordins.com INSURERS)AFFORDING COVERAGE NAIC# INSURERA Technology Insurance Company.... 42376 INSURED INSURER B: S&H Hotel Yarmouth LLC INSURER c Jamsan Hotel Management Inc. 110 Hartwell Ave Suite 300 ..,I,NSURERo.__... exington,MA 02421 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 .. .......... .. ..... ........ .........._..... POLICY EFF ; POLICY EXP LTR 3 TYPE OF INSURANCE INSD'WVD I POLICY NUMBER (MMlDOlYYYY)'(MM/DDtYYYY)I LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S .._ . ..... ......._ ......._ '""""". CLAIMS-MADE I OCCUR i j DAMAGE TO RENTED PREMISES(Ea occurrence} I$ MED EXP(Anyone cerson) i$ j ---- I I ! PERSONAL&ADVINJURY I S GEN'L AGGREGATE LIMIT APPLIES PER: ; ; GENERAL AGGREGATE $ • POLICY PE LOC ' PRODUCTS-COMP/OP AGG I S OTHER: j AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _LEa_accident) _ i $ ANY AUTO • OWNED SCHEDULED BODILY INJURY jeer person) I$ AUTOS ONLY I I AUTOS BODILY INJURY(Per accident). $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _AUTOS ONLY (Per accident' • UMBRELLA LIAB I OCCUR $ • EACH OCCURRENCE EXCESS LIABCLAIMS-MADE ... 1 , AGGREGATE.........._.._ ;$ DED I RETENTIONS ; A I WORKERS COMPENSATION j I , PER OTH AND EMPLOYERS'LIABILITY ; X •;STATUTE,�,.._.... ER „ ANY PROPRIETOR/PARTNER/EXECUTIVE Y/-N. TWC4307998 8/1/2023 8/1/2024 • ,OFFICE ry in NH)EXCLUDED? Y f{N!A ( E L EACH ACCIDENT $ 1,000,000 (Mandatory If yes,describe under E L DISEASE EA EMPLOYEES 1 000,000 I DESCRIPTION OF OPERATIONS below -- - -• --- j E.L.DISEASE-POLICY LIMIT I $ 1,000,000 I I I • i DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) reference location:476 MA-28 West Yarmouth,MA 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) The ACORD name and logo are registered marks of ACORDCORD CORPORATION. All rights reserved. No.: 04916-HT-1518 LICENSE ALCOHOLIC BEVERAGES THE LICENSING BOARD, TOWN OF YARMOUTH, MASSACHUSETTS GRANTS A SETTS Annual Innholder All Alcoholic License to Expose, Keep for Sales, and to Sell All Kinds of Alcoholic Beverages To Be Drunk On The Premises ' To: S&H HOTEL YARMOUTH,LLC DBA:THE CAPE POINT Date: 1/1/2023 476 ROUTE 28 Ref: LICA-20-0003-04 WEST YARMOUTH,MA 02673 Fee(s): 2,350.00 License Duration Type: Annual Manager:NILESH PATEL License Conditions Premises is a 116 unit year round hotel which includes a cafe,kitchen,bar,indoor and outdoor pools, seasonal cabana at the outdoor pool,meeting rooms,storage rooms,office,exercise facility,game room(arcade) laundry room. and Occupancy:Hotel guest room occupancy 470,bar&restaurant occupancy 40,4 conference per conference room). rooms(196)(49 On the following described premises: 476 ROUTE 28,WEST YARMOUTH,MA 02673 This license is granted and accepted upon the express condition that the licensee shall in all respects,conform to all the provisions of the Liquor Control Act,Chapter 138 of the General Laws,as amended,and any rules or regulations made expires December 31,2023,unless earlier suspended,cancelled or revoked. IN TESTIMONY WHEREOF,the undersigned have thereunto affixed their official signatures. The Hours during which Alcoholic Beverages may be sold are From: LICENSE 8:00AM- I:OOAM Weekdays&Saturdays granted by: 10:00AM- 1:00AM Sundays Outdoor Service to cease at 9:OOPM Mon.-S and at. '�m"r.�/,��� � r 8:00PM on Sundays LICENSING AUTHORITIES This License Shall be Displayed on the Premises in a conspicuous position where it can be easil read