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HomeMy WebLinkAboutBCOI-24-19 The Commonwealth of Massachusetts 9.) 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:Holiday Vacation Condo Assoc,Inc BCOI-24-19 Trade Name:Holiday Vacation Condominum Identify property address including street number,name,city or town,and county Certificate Expiration Located at 488 ROUTE 28 March 9,2025 WEST YARMOUTH,MA 02673 Floor Occupancy_ Use Group Other Other 11 R-1 Hotels,motels,boarding houses, Bid 1(11Units) etc. Use Group Classification(s) Other 14 R c1 Hotels,motels,boarding houses, BLD 2(14 Units) et Allowable Occupant Load Other 10 . Ft-11 Hotels,motels,boarding houses, BLD(10 Units) etc. Other 7 R-1 Hotels,motels,boarding houses, BLD 4(Units) etc. 1 Story Storage Building/Former 2 car garage 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. c— Name of Municipal Chief Name iof s Municipal Building Mark ryl D e of Inspection J?I as Commissioner Signature of Municipal Fire Signature of Municipal Building Date of Issuance ��/,%Y Chief Commissioner •YaR _ o TOWN OF YARMOUTH c. o . . y BUILDING DEPARTMENT ';N MATTA ScJ '. 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION February 1, 2024 PAYABLE UPON RECEIPT 4); (X) Fee Required $196.00 ,( ,in ( ) No Fee Required �� JJ1 r.7(fr•' In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a 4O Certificate of Inspection for the below-named premises located at the following address: Street and Number: "7'48A 1 o U Ie. Z CJ /LLc '1 S.1-, 1 Name of Premises: 140I i dal V C th o/1 r ' fOmin;,,,Tel: 775-- 64 IL( 77 9 3b$-Z)o�s Purpose for which permit is used: t License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency _ -, l p C E 1 V F. D i 9 FEB 2 2 2024 t. J Certificate to be issued to Tel: 3u"� � n�Erv7 Address: 4 ea P- ok_ Zg Irka:4, n Sk Owner of Record of Building !-lbkdoi V&teaSrim Ceyvicry,iniJO Tn,gf Address Li S$ IZoc Zib ► 10 i Present Holder of Certificate Nb I .4O-1 Va..c _hOr'n C [o/Ili/1i un-7 77- s 4- Aja4-J ?C .� n.( Signature o person to whom Title Certificate is issued or his agent Z'j21 241 Date Email Address:Qitt..eictsDOCZ hCc Vat. ever) 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 CANN T ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# 0 _a y.. ( G 03/09/2024-03/09/2025 VDAC I-1 E3 E".3° TY POLICY EMPLOYERS LIABILI WORKERS C AND POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (686208-4494P90-0-24) RENEWAL OF (6562UB-4494100-0-231 INSURER: ACE AMERIC).N INSURANCE COMPANY A STOCK COMPANY NCCI CO CODE: 12165 1. INSURED: PRODUCER: HOLIDAY VACATION CONDOMINIUMS BROWN & BROWN OF MASS LL 488 ROUTE 28 500 VICTORY RD WEST YARMOUTH MA 02673 MARINA BAY NORTH QUINCY MA 02171 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s)attached, 2. The policy period is from 03-02-24 to 03-02-25 12:01 AM.at the insured's mailing address, 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s)listed here: MA memo. =MEM B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item IA. The knits of our liability under Part Two are: Bodily Injury by Accident: $ 500000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit 0— Bodily Injury by Disease: $ 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 068 :=Z D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications. Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 01-23-24 WC ST ASSIGN: MA OFFICE: RMD CHUBB 24M PRODUCER: BROWN & BROWN OF MASS LL 7 7W2C 000257 VDAC C1-11-110 Ea' WORKERS COMPENSATION AND ,7h r<, EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01( A) POLICY NUMBER. (69620z-4494990-0-20 CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER$100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S SIC-CODE: 7011 NAICS: 721199 STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 2978 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 338 TERRORISM 77 TOTAL ESTIMATED PREMIUM 3393 TAXES AND SURCHARGES 141 DEPOSIT AMOUNT DUE 3534MP A/R (WCIP) # Minimum Premium: $488 EMPLOYERS LIABILITY MINIMUM: $50 ST ASSIGN: MA DATE OF ISSUE: 01-23-24 WC OFFICE: RND CHUBB 24M PRODUCER: BROWN & BROWN OF MASS LL 77W2C CHUB B. WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 I A) POLICY NUMBER: (6S62U8-4494P90-0-24) INSURER: ACE AMERICAN INSURANCE COMPANY 12165-MA INSURED'S NAME: HOLIDAY VACATION CONDOMINIUMS RATE BUREAU ID: 000364081 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN 043048146 ENTITY CD 001 HOLIDAY VACATION CONDOMINIUMS 488 MAIN ST, RTE 28 WEST YARMOUTH, MA 02673 SIC CODE; 7011 NAICS: 721199 CARPENTRY - CONSTRUCTION OF RESIDENTIAL DWELLINGS NOT EXCEEDING THREE STORIES IN -= HEIGHT 5645 IF ANY 5.37 CLERICAL OFFICE EMPLOYEES HOC 8810 IF ANY .04 HOTEL: ALL OTHER EMPLOYEES & SALESPERSONS, DRIVERS 9052 257045 1.20 3085 c o c Ca I� ©ATE OF ISSUE:01-23-24 WC ST ASSIGN: MA SCHEDULE NO: 1 OF MORE 000258