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HomeMy WebLinkAboutBCOI-24-33- The Commonwealth of Massachusetts 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:Blue Rock Resort Trade Name:Blue Rock Resort BCOI-24-33 Identify property address including street number,name,city or town,and county Certificate Expiration Located at 39 TODD RD SOUTH YARMOUTH,MA 02664 April 1,2025 Floor Occupancy Use Group Other 01 st Floor 22 A-1 Movie theaters or theaters for Bld 1-4 units Bld 2-5 units Use Group Classification(s) performing acts(stage and scenery) Bld 3-5 units Bld 4-4 units Bld 5-4 units Allowable Occupant Load 02nd Floor 22 R-1 Hotels,motels,boarding houses, Bld 1-4 units Bld 2-5 units etc. Bld 3-5 units Bld 4-4 units Bld 5-4 units Suite Above Pro Shop 1 Units 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 Is Date of Inspection Commissioner zc'1 �D� Signature of Municipal Fire Signature of Municipal Building J Date of Issuance /// Chief Commissioner /Z�2� 4 'ir`l o TOWN OF YARMOUTH ' - BUILDING DEPARTMENT 0µ � �ly ,:,` MATTACM ESE,,/ ' `,,,,„, ,,:co,��� 3;' 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION March 1 , 2024 PAYABLE UPON RECEIPT (X) Fee Required $205.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 1 10.7, 1 hereby apply for a Certificate of Inspection for the below-named premises located at the following address: ,1/ 9-4-3.16,4\ Street and Number: y; i0L1 . yact„ ,„ ,i M \ o 6(.v c-i Name of Premises: 11t) 1` o c...K #-"Rtc,.5ac-* Ow i1 LILTel: 5Cg 3 °I5t3 0.9(`)• n Purpose for which permit is used: License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency RECEIVED MAR 112024 BUILDING DEPARTMENT By: _ Certificate to be issued to OIL-cock)e% , ,,%. Tel: 50 T a 3 7 g ka t Address: 6 0 14 tin/k.s c ` 'I-� ,c i-ek. M 0 ' i 5 C & L) L0c Owner of Record of Buildirtgi Address Present Holder of Certificate a 0 a - iz., r gnature of person to whom Titlt- Certificate is issued or his agent _ i I . c-I Date A '� n Email Address. ('0 i I DearV ,� ► A.� c �. I. � . C'�So t•• 5 - co Instructions: Make check payable to: Town of Yarmouth 1 146 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 # gc...biL)--.33 04/01/2024-04/01/2025 73 , sio4 q��® DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 01/25/2024 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 CONTACT MARSH USA, LLC. NAME: PHONE I 1166 Avenue of the Americas (A/C.No.Ext): FAX No): New York, NY 10036 E-MAIL ADDRESS: I INSURER(S)AFFORDING COVERAGE NAIC# CN133703919-all-GAU-23-24 _ INSURER A: Everest Premier Insurance Company 16045 INSURED INSURER B : Everest Denali Insurance Company 16044 EOS Hospitality RJR MA Employee LLC 444 Madison Avenue I Floor 14 INSURER C : ACE Property and Casualty Insurance Company 20699 New York, NY 10022 INSURER D: Everest National Insurance Co INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: NYC-011880458-01 REVISION NUMBER: 0 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 SUBRI POLICY EFF 1 POLICY EXP ' LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) A l X I COMMERCIAL GENERAL LIABILITY CC4GL00011-231 09/12/2023 09/12/2024 EACH OCCURRENCE $ 2,000,000 I 1 DAMAGE TO RENTED I I CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ _1 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY I I P O X I LOC i PRODUCTS-COMP/OP AGG $ 2,000,000 i i I $ i I OTHER. B 1 AUTOMOBILE LIABILITY CC4CA00014-231 (AOS) 109/12/2023 09/12/2024 + COMBINED SINGLE LIMIT $ 2,000,000 i----1 I (Ea accident) D I X ANY AUTO CC4CA00013-231 (MA 09/12/2023 09/12/2024 I BODILY INJURY(Per person) $ I-' OWNED j SCHEDULED 1 I BODILY INJURY(Per accident) $ I AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) X Garage Keepers ', 1 ! Garage Keepers $ 1,000,000 C X UMBRELLA LIAB X OCCUR PUMB23-A-G27675578 ±09/12/2023 09/12/2024 EACH OCCURRENCE $ 10,000,000 EXCESS LIAB I CLAIMS-MADE I I I AGGREGATE i $ 10,000,000 I I i DED I i RETENTION$ ; Prod Completed I $ 10,000,000 A !WORKERS COMPENSATION CC4WC00014-231 09/12/2023 09/12/2024 x PER I I OTH- i i AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 !OFFICER/MEMBER EXCLUDED? N N/A 1 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ I If yes, describe under 1,000,000 I DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT $ A i Liquor Liability CC4GL00011-231 09/12/2023 09/12/2024 General Aggregate 2,000,000 Retained Limit-$1,000 1 Each Occurrence Limit 2,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Blue Rock Resort SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 39 Todd Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Yarmouth, MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE -Zirecz. 424 Tit s::-i .---f---"e' 1 © 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN133703919 LOC#: New York AW RD ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA,LLC, EOS Hospitality RJR MA Employee LLC 444 Madison Avenue I Floor 14 POLICY NUMBER New York,NY 10022 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Garage keepers Legal Liability Comprehensive $1,000,000 Limit $500 Deductible for Each Customer's Auto Loss $2,500 Maximum Deductible for Loss Caused by Theft or Mischief or Vandalism Collision $1,000,000 Limit $500 Deductible for Each Customer's Auto Loss Excess Liability. All excess limits fall under the same policy(PUMB23-A-G27675578) ACE Property&Casualty Insurance Company $10,000,000 Excess of primary carriers Markel American Insurance Co $15,000,000 excess of$10,000,000 Excess of primary ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD