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HomeMy WebLinkAboutBCOI-23-1690 20265 2025 .C..\ The Commonwealth of Massachusetts Town of og Y94. 114%.,) YARMOUTH o -io,y :_� r4/ New and Renewal Certification of Inspection "°°-a.,, In accordance with the Massachusetts State Building Code,Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name:St.Pius X Chuirch Trade Name:Our Lady of the Highway BCOI-23-1690 Identify property address including street number,name,city or town,and county Certificate Expiration Located at 1044 ROUTE 28 SOUTH YARMOUTH,MA 02664 May 21,2025 Use Group Classification(s) Floor Occupancy_ Use Group Other 01 st Floor 542 A-4 Arena/Spectator Seating Allowable Occupant Load 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 Q_ ,,‘,4ark Commissioner II Da-of Inspection 4/710a iSignature of Municipal Fire Signature of Municipal Building /� �/ �Chief Commissioner lF j •'-e of Issuance T L y TOWN OF YARMOUTH o0,4 ; -a BUILDING DEPARTMENT 1146 Route, 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION April 01, 2024 PAYABLE UPON RECEIPT (X) Fee Required $50.00 C'w 5O4 ( ) 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: 10 Li LI R0 it t- £ 2 5 l a cn U J AM- a a (O(o L Name of Premises: Our L.4 j 0E- E I Ow Ai Tel: 5-0S • 3 9g . CP6(.51.- Purpose for which permit is used: C t-I-U2C 0 License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to 5+ ?;u5 X ( h u,CC t-t Tel: 508 - 3 f, r l ! E D Address: 5 4�3' hR M-R,4 5-T , SQUT d ; 1- 1 An/I- ca I, Owner of Record of Building yTc `S+ uSx CHuz. H Address 10H`f 2Ot 2 e s� �l�eMv�-r� /v�.4 oa���l MAY 03 2024 Present Holder of Certificate '5-7 P i us X C ltuI-C r� __ #,E1000 4Y __��d-t" - / cJ'm n /1-` 5, f ignature of person to whom Title Certificate is issued or his agent A-82/L 3a. 7.2 y Date Email Address: 5 T p/U,S X 0 FF./CEO CUtitC.9-S 7. Alt // 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# 05/21/2024-05/21/2025 ACOR f,� @ • DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/12/2024 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 NAME: PHONE FAX (A/C,No,Ext): (A/C,No): E-MAIL Certificates Ratiorisk.com Massachusetts Catholic Self Insurance Group ADDRESS: @ 66 Brooks Drive INSURER(S)AFFORDING COVERAGE _ NAIC# Braintree MA 02184 INSURERA: Massachusetts Catholic Self Insurance Group INSURED INSURER B: Diocese of Fall River INSURER C: St. Pius X Church-Our Lady of the Highway INSURER D: 1044 Route 28 INSURER E: South Yarmouth MA 02664 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. NSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRINSD WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE RETE $ CLAIMS-MADE OCCUR PREMISESO(Ea occur ence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO-JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ _ $ A WORKERS COMPENSATION Certificate of Approval 03/31/24 03/31/25 X PER OTH- AND EMPLOYERS'LIABILITY Y/N Commonwealth of STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N/A Massachusetts (Mandatory in NH) - 3 000001 01 2024 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Workers Compensation Insurance for The Diocese of Fall River and St. Pius X Church - Our Lady of the Highway. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE Amanda Taillon ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD