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HomeMy WebLinkAboutBCOI-23-1690 2026 The Commonwealth of Massachusetts ', Town of ,ost 'VA-- ki YARMOUTH ;� �_: o', y,, ,� N*McYJUI' „f' A / ``�c�RPORATEU�,,/ 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: 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, 2026 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 Commissioner Mark Grylls Date of Inspection p ii,21 — Signature of Municipal Fire Signature of Municipal Building Chief Commissioner Date of Issuance 0/ir -- r_„„. TOWN OF YARMOUTH - _: . _ � Office of the Building Commissioner t - T r 1146 Route 28, South Yarmouth, MA 02664 a1 y` 508-398-2231 ext. 1260 Fax 508-398-0836 aMATTACHEESt / ,'C0RP0RATE�3p ` - APPLICATION FOR CERTIFICATE OF INSPECTION April 01, 2025 PAYABLE UPON RECEIPT (X) Fee Required$50.00 ( ) 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: t Street and Number: I fj VV't 28 50 v Ale c`P 0 rh v // �1 h i 11 A 0 6 u Name of Premises: 4 Lte L c d u 4 T "fik t \-L q 4,, Tel: J 0 t-- Sc\ 8-/.z9 8 J Purpose for which permit is used: h V rc k (S e ckJa on a o cl , License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to 5 k--. ?i S X V rt h Tel: 509-- 3 cj V ,r 2 2'f ' Address: 5 Saw boys, 6� . j,1 Qvni0 v '� h A e z (Au 1 Owner of Record of Building Of . ?Tv s x CA. \ti-C. L, Address 10 sty CIA.'4( 2$1) % '2 t-t c.- e f 1 M A u`2 E C E I V E D Present Holder of Certificate �.4, . Ps'v-c K 4 u, ck (.; / •r MAY 27 2025 Signatu of pers n whom Title Certificate is issued or his agent l/ /y��D,?,{"' BUILDING DEPARTMENT ! /a`ty 1� r D e Email Address: 3 i p ;vs X 0 1 C Q' co Mrl c as 6t. h t t 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#BCOI-23-1690 05/21/2025-05/21/2026 DATE(MM/DD/YYYY) ACRE) CERTIFICATE OF LIABILITY INSURANCE 05/20/2025 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): Massachusetts Catholic Self Insurance Group ADDRIESS: 66 Brooks Drive INSURER(S)AFFORDING COVERAGE NAIC# Braintree MA 02184 INSURER A: Massachusetts Catholic Self Insurance Group INSURED INSURER B Diocese of Fall River,MA INSURER C: Our Lady of the Highway Chapel 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE RENTED $ CLAIMS-MADE OCCUR PREMISESO(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 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 03/31/25 03/31/26 X PER STATUTE EORH AND EMPLOYERS'LIABILITY Y/N Commonwealth of ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N/A Massachusetts (Mandatory in NH) 3000001012025 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/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance for building inspection • CERTIFICATE HOLDER CANCELLATION Town of Yarmouth 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