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Home My WebLink AboutBldci-16-003712-04 The Commonwealth of Massachusetts ert City\Town of YARMOUTH j New and Renewal Certificate of Inspection In accordance with the Massachusetts State Building Code, Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name: ROBERT F. KENNEDY CHILDREN'S ACTION CORPS BLDCI-16-003712-04 Trade Name: RFK CHILDREN'S ACTION CORPS Identify property address including street number,name,city or town and county Certificate Expiration Located at 01/09/2021 137 RUN POND RD SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) R-3 01st Floor 18 R-3 Single Family/Duplex Residence/Child Care 5 or Less/Congregate Living'13-Children 5-Staff 7 Bedrooms Allowable TOTAL OCCUPANCY- Occupant Load 18 Persons 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 life safety features. This certificate shall be framed behind glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to pose or tampering with the contents of the certificate is strictly prohibited. - Name of Municipal Name of Municipal Mark Grylls of Building Commissioner Ins' /'on ge7 Signature of Municipal Signature of Municipal ` D e of Building Commissioner - iF ssuance /- 71.20 `�i ' _rs'Fee:;100.00 B LD_Certofl nspection.rpt YaR •• TOWN OF YARMOUTH oN -y: BUILDING DEPARTMENT • ,�" MATTA 4� • �� 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION December 10,2019 PAYABLE UPON RECEIPT (X) Fee Required 100.00 ( ) 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: 13 / e, I r i l�r' Sou )411"wrav . Name of Premises:61"-f F eenne)f CL'/) 'e ,s 4J70 . ( 'j Tel: sd 740-6-ilk/ Purpose for which permit is used: ��' H „r-/ G�,,,,o �rij /e. 't License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency OCcO 4/2 Cite— Certificate to be issued to RF/'Ca,v t. ( rho. Tel: Soso- Zc-sr--f Address: 13') Rv.1 610.) .co.J`t, y'9✓ M4- cacer Owner of Record of Building Ro6.4- F. At o, Address �( ��gca�-, S .�,'{� k.,tD ,a2S47,1 /►'14 6,2/09 Present Holder of Certificate R4,./t Signature of person to whom Title Certificate is issued or his agent /Z/Z z3/r�' Date Email Address: C l,>;S b.•v,,e,r e diy 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# 73LDd 41- Qj),37/y- Oct 1/9/2020- 1/9/2021 41. NOTICE 11111111W41111111.11111111_ NOTICE 1Wmissrms TO O _,s - �, 7,1=r.EMPLOYEES c ..�' EMPLOYEES ^rYlrp The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21,22 & 30,this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Liberty Mutual Fire Insurance Company NAME OF INSURANCE COMPANY 175 Berkeley Street, Boston, MA 02116 ADDRESS OF INSURANCE COMPANY WC2-31S381849-029• 07/02/2019-07/02/2020 POLICY NUMBER EFFECTIVE DATES Marketing Associates Insurance Agency, Inc. 30 Southwest Park,Westwood, MA 02090 866-506-9028 NAME OF INSURANCE AGENT ADDRESS PHONE# Robert F Kennedy Childrens Action Corps. 137 Run Pond Road, South Yarmouth, MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 1 ne wrrineuriweuurr uj letuy.•ucnuseut• I- Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Al&' Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information - Please Print Le ibl Business/Organization Name: / r Address: _ City/State/Zip: Se,e `) L. . L. Phone#: .re you employer?Check the app opriate box: Business Type(required): am a employer with employees (full and/ 5. 0 Retail or part-time).* 0 I am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eating Establishment 7• 0 Office a d/or Sales(incl.real estate, auto,etc.) employees working for me in any capacity. 0 [No workers' comp. insurance required] 8. n-profit We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have no employees. [No workers' comp. insurance required]* 10'�Manufacturing 0 We are a non-profit organization,staffed by volunteers, 11 ❑Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an nization should check box#1. 7 an employer that is providing workers'compensation insurance for my employees Below is the policy information. sane Company Name: Li �v ,E Y r rer's Address: I l c) 'State/Zip: :y#or Self-ins. Lic.# — ch a copy of the workers' compensation policy declaration page(s owing the policy,.; CD Expirationnumber an expiration dal ). re to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a a tp to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the tigations of the DIA for insurance coverage verification. Office of ereby certify, under the pains d penalties f p9jury that the information provided above is true and correct `.-'" Gam-_ Date: #: icial use only. Do not write in this area,to be completed by city or town official (or Town: Permit/License# ing Authority(circle one): oard of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office ther tact Person: