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Home My WebLink AboutBLDCI-22-006522 The Corn o twealth of Massachusetts y =`= pity\Town of wfir= �- ARMOUTH A u.I. ' 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: Parker Beach Lodge BLDCI-22-006522 Trade Name: Parker Beach Lodge Identify property address including street number, name,city or town and county Certificate Expiration Located at 192 SOUTH SHORE DR UNIT 10 6/1/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) R-1 01st Floor 25 R-1 Hotel/Motel/Boarding House/Transient 24 Rooms 1 Office 02nd Floor 26 R-1 HoteUMotel/Boarding House/Transient 26 Rooms 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 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 Date of // Building Commissioner % =-Inspection Signature of Municipal Signature of Municipal44—'2. Date of Building Commissioner / Issuance (, 7 z., zz F :;220.00 BLD_Certoflnspection.rpt Image (28).jpg 5/6/22,2:07 PM "6F•Aitt TOWN OF YARMOUTH of ,; V 1y BUILDING DEPARTMENT � " '"" .`-. s 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION May 1,2022 PAYABLE UPON RECEIPT R E �' �° ' . n (X)Fee Required $2 0.CF- ( ) No Fee Requir MAY 092022 In accordance with the provisions of the Massachusetts State Building Code,Section 110.7,I hereby appl fogs ____ Certificate of Inspection for the below-named premises located at the following address: BU I_ By Street and Number: 19 2- Sc'4 Sh n<e Ir. Name of Premises: p ke,' Rtach Lod J(, Tel: 5"0s- 4'Pi- '7 bRT Purpose for which permit is used: Lo delqiO C 1 License(s)or Pennit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to ei di t loop,/ Tel: fQ("7 - 312 - D4")8- Address: 4 U?n 1 I 1 mi o r d S S-• nil Ai bit h-e o, d , CY-A 0 1 c1'1 5- Owner of Record of Buildin Address a5� etctcr- c S f25)7, ►'W1 Present Holder of Certificate Z-if 4er.4�1C / 1 -1- ni1r Si nature of p n to whom Title Certificate is issued or his agent c /, ' 20'IL- Date Email Address: Eat ii C Lar k h Das, cab-) 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# 06/01/2022-06/01/2023 84-'6C I-22--0 D&Sam • https://mail.google.com/mail/u/0/ Page 1 of 1 CHEMICAL PERMIT 2.jpg 5/6/22,2:06 Plv The Commonwealth of Massachusetts Department of Industrial Accidents Eeiltl=, 1 Congress Street,Suite 100 ?'Ir Boston,MA 02114-2017 4,7 .4Lia. www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: HbY ( Z.Lfyl Ern yai t Address: 112 U Own City/State/Zip: f/Lt f hl y�{Y inf l.L t m Ph Phone#024 �q 5(,�• (e q e� . 7(0 g9 Are yo an employer?Check the appropriate boa: Business Type(required): I.Q It am a employer with employees(full and/ 5. ❑Retail 2.0 or part-time).* 6. ❑Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no 7Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c.152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]•" 4.❑ We are a non-profit organization,staffed by volunteers, I I.❑Health Care with no employees.[No workers'comp.insurance req.] I2.111'Other 'Any applicant that checks box#1 must also fill out the section below showing their workers compensation poll inf. on •'If the corporate officers have exempted themselves.but the corporation has other employees.a workers'compensation police is required and such an organization should check box 41 I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Nv([(,t/Ac li (k//jam(, 6 . Insurer's Address: 3 / Pal)/1 ,S LLaKKt City/State/Zip: CO (II«S - { //e ( A j g 7 0 3 t�,� t Policy#or Self-ins.Lic.# IT L>(.t )(i.Z 1p(a 0 9 t) Expiration Date: -7 I.. 27j Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct Sienature: tpJ Date: .5 /G /2-0 L?� Phone#: 1p/7 _7 J// 7'3/1ry i Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: wwxv massgov/dia https://mail.google.com/mail/u/0/ Page 1 of 1