HomeMy WebLinkAboutBLDCI-17-000212-06 The Commonwealth of Massachusetts
City\Town of
YARMOUTH
—
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:THE INN AT CAPE COD BLDCI-17-000212-06
Trade Name:THE INN AT CAPE COD
Identify property address including street number,name,city or town and county Certificate Expiration
Located at
4 SUMMER ST 07/12/2023
YARMOUTH PORT, MA 02675
Use Group Floor Occupancy Use Group Other
Classifications(s)
R-1 01st Floor 4 R-1 Hotel/Motel/Boarding House/Transient 4 ROOMS#1,2,3,4
Allowable 02nd Floor 5 R-1 Hotel/Motel/Boarding House/Transient 5 ROOMS#5,6,7,8,9,10
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 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 Gryll Date of
Building Commissioner Inspection c/rcJ
Signature of Municipal Signature of Municipal Date of
Building Commissioner Issuance f O/S-/Z2
Fee: $124.00
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BLD_Certofl nspection.rpt
°V Y TOWN OF YARMOUTH
(gileArtiti53
BUILDING DEPARTMENT
e " Z t.sy� 1146 Route 28, South Yarmouth, MA 02664 508-398-22_ • 260
' . ` RED
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APPLICATION FOR CERTIFICATE OF INSPECTION
S � LU22
June 1, 2022 PAYABLE UPON RECEIPT BUILUIN AL�AQ-�-n""
(X) Fe -- - r1124:0VENT
( ) No Fee Require.---------
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: 't -St4v\M(-L' S+-
-ThName of Premises: 1 r w Al- Cap. .__
ç __Tel: 508 3 75 d s1') CPurpose for which permit is used: 9, .1_ B 'r--0 I/1 f1
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to i ),k e 01- H eJ en Ccl SS e)S Tel: t o $ 3 7--- C-CI-0
Address: ck s o v e
Owner of Record of Building
Address ) '"
Present Holder of Certificate c "
Fi • 0� _7 Co - 0 w n�f
Signature of person to whom Title 9I
Certificate is issued or his agent
Tlate
Email Address: S 6::::y ea I n n cxt csAcpe co c), cope)
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#
07/12/2022-07/12/2023
••
-4.r
WORKERS COMPENSATION AND EMPLOYERS' LIABILTY
INSURANCE POLICY----INFORMATION PAGE
INSURER: POLICY NO: WE084424A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET ENDORSEMENT EFF 12/01/2021
DEDHAM, MA 02026 NCCI Company No: 21059
{ Account No: 862009099
FEIN: 00-0910999
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
THE INN AT CAPE COD, LLC ROGERSGRAY SOUTH DENNIS
PO BOX 371 OFFICE
YARMOUTHPORT, MA 02675 434 ROUTE 134
SOUTH DENNIS, MA 02660
AGENT NO.;_ 20577
LEGAL ENTITY: LIMITED LIABILITY COMPANY (LLC)
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD: From: 12/01/2021 To: 12/01/2022
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits
of liability under Part Two are:
Bodily Injury by Accident: $ 500,000 each accident
Bodily Injury by Disease: $ 500,000 policy limit
Bodily Injury by Disease: $ 500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 226 Annual Premium: $ 853
Audit Period: ANNu , Additional/Return Premium: $ 558 ADDITIONAL
Comments : CHANGE PAYROLL PER AUDIT
Issued At:
Date: 12/2 8/2 021 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY
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