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HomeMy WebLinkAboutBCOI-24-18- .\ The Commonwealth of Massachusetts gi Town of YARMOUTH New and Renewal Certification of Inspection In accordance with the Massachusetts State Building Code,Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name:277 South Shore Drive,LLC Trade Name:Surf&Sand Beach Motel BCOI-24-18 Identify property address including street number,name,city or town,and county Certificate Expiration Located at 277 SOUTH SHORE DR SOUTH YARMOUTH,MA 02664 February 15,2025 Floor Occupancy_ Use Group Other Use Group Classifications) 01st Floor 18 R-1 Hotels,motels,boarding houses, 17 Units etc. Managers Apt&Lobby Allowable Occupant Load 02nd Floor 18 R-1 Hotels,motels,boarding houses, etc. This certificate of inspection is hereby issued by the undersigned to certify that the premise,structure,or portion thereof as herein specified has been inspected for general fire and line safety features.This certificate shall be framed behind clear glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned.Failure to post or tampering with the contents of the certificate is strictly prohibited. Name of Municipal Chief Name of Municipal Building Mark s Date of Inspection 7)3/� Commissioner NNNN Signaturei of Municipal Fire Signaturemm of Municipal Building Chief Commissioner Date of Issuance 1:g�do TOWN OF YARMOUTH ;41•,,,t . y BUILDING DEPARTMENT �V:'--- '' e1 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION January 1, 2024 PAYABLE UPON RECEIPT (X) Fee Required $181.00 ( ) 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: J 17 �SQu i' S`?Qie Pf l Ilro Name of Premises:S U(+t 411G( &PQC.-V\ 01 d It I Tel: gI) 3 7(r f0V y/ Purpose for which permit is used: j i C l License(s) or Permit(s) required for the premises by other governmental agencies: ► RECEIVED License or Permit Agency — --- ir/Fiti212024 �\ BUILDING DEPA4 / IP By Certificate to be issued to &ctt t-S ly' $et,ch , k I Tel:SO b-.�5/cf;�3�/� Address: den Shart Dr ur/v.(.i1v\ MA a 4-4,0,'1 Owner of Record of Building a B� :d�-� 56a Dr,vt , t L. C i Address �'U (3 (1 310 S -(p•y►Aop_44''1 M A C 1 Cc Co" Present Holder of Certificate So wy a 5 c tJ'rry-t ScSignature of person to whom Title Certificate is issued or his agent /-//)c, .2 L/ Date Email Address: S n 5 010 kl to Q 01 , C ovn 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 # 6C 0/ _2y --J 02/17/2024-02/17/2025 A�C3PR•b (DATE(MMIDD(YYYY) 1 CERTIFICATE OF LIABILITY INSURANCE 05/01/2023 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 be endorsed. If SUBROGATIONIS 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: THE OCEANSIDE INSURANCE GROUP PHONE (508)771-1660 Fax 08084400 (A/C,No): PO BOX 38 (AlC,No,Ext): WEST DENNIS MA 02670 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Hartford Accident and Indemnity Company 22357 INSURED INSURER B: SKP1M,LLC.,731 MAIN STREET LLC,277 S.SHORE INSURER C: DRIVE LLC DBA SKIPPY'S PIER 1 PO BOX 370 INSURER D SOUTH YARMOUTH MA 02664-0370 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LW INSR WVD (MMIDDIYYYYI (MMIDD/Y YYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY GEN'L AGGREGATEGA LIMIT APPLIES PER: GENERAL AGGREGATE POLICY I I JECT PRO' ri LOC PRODUCTS-COMP/OP AGG OTHER: AUTOMOBILE LIABILITY COMEINED SINGLE LIMIT (Ea accident) _ ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS —HIRED —^NON-OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) _ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS- AGGREGATE MADE DED RETENTION WORKERS COMPENSATION x PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY YIN E.L.EACH ACCIDENT $1,000,000 A PROPRIETOR/PARTNER/EXECUTIVE --- N/A 08 WEC AD1A4A 05/30/2023 05/30/2024 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION 277 South Shore Drive,LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Surf and Sand Motel BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED Sandra M DiGiovanni IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 370 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 �'ee.„6- c:234.7 C tt&.u�2-, ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD rr�I pt DATE(MMIDDIYYTV) Ac�Q� �- CERTIFICATE OF LIABILITY INSURANCE 05/01/2023 E HE HOI DER.THISACERTIF CERTIFICATED DOES NOTTAFF RMATIVELYA ORNNEGATIVELY AMENDS EXTEND OR ATERT CERTIFICATE ONLY CONFER NO RIGHTS UN THE COVERAGE CONSTITUTE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDERCONTRACT BETWEEN THE es)must be orsed.tf su bject to N helt the certificate holder is an erms and conditions of the policy,certain erta nONAL l policies Dmay requ,the ire endorsement.A statementBonO this certificateGATIONISldos not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: THE OCEANSIDE INSURANCE GROUP PHONE (508)771-1660 FAX (AID So): 08084400 INC,No,Est): PO BOX 38 E-MAIL ADDRESS: WEST DENNIS MA 02670 INSURER(S)AFFORDING COVERAGE NAICR INSURER A: Hartford Accident and Indemnity Company 22357 INSURED INSURER B: SKP1M,LLC.,731 MAIN STREET LLC,277 S.SHORE INSURER C: DRIVE LLC DBA SKIPPY'S PIER 1 INSURER o: PO BOX 370 INSURER S. SOUTH YARMOUTH MA 02664-0370 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 MAYS HAVE BEEN REDDULCCEDY EBY PAID CLAIMS. LIMITS INSR XP TYPE OF INSURANCE ADOL SUER POLICY NUMBER JMMIDDIYVYYI IMMIDDIY YYYI LTR INSR WVD EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CCLAIM&MADE❑OCCUR PREMISES lEa occurrence) MED FXP(Any one person) PERSONAL SADV INJURY GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG POLICY❑PRo- IIILOC — JECT OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY COMBINED mzidantl — BODILY INJURY(Per person) ANY AUTO —ALL OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS PROPERTY DAMAGE --AIRED _AUNAWNEO (Per accident) AUTOS _AUTOS EACH OCCURRENCE OCCUR UMBRELLA UAB _CLAIMS- AGGREGATE E%CESS LIAR MADE OEDI 'RETENTION$ X (PERSTATUTE I IOFRTH- WORKERSCOMPENSATION AND EMPLOYERS'LIABILITY E.L.EACH ACCIDENT 51,000,000 ANY YIN A OFFICERTORIPAR ECUTIVE r NIA Og WEC ADIA4A 05130/2023 05/30/2024 E.L.DISEASE-EA EMPLOYEE $1,000,000 OFFICER/MEMBER EXCLUDED? L (Mandatory In NH)DE E.L.DISEASE-POLICY LIMIT $1,000,000 R under DESCRIPTION TI OF OPERATIONS below , DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION 277 South Shore Drive,LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Surf and Sand Motel BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Sandra M DiGiovanni AUTHORIZED REPRESENTATIVE PO Box 370 South Yarmouth MA 02664 _Ferean of Cade ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ,