HomeMy WebLinkAboutBLDCI-22-007311 The Co i l I nwealth of Massachusetts
I 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:Yarmouth Resort Condo Trust BLDCI-22-007311
Trade Name:Yarmouth Resort
Identify property address including street number,name,city or town and county Certificate Expiration
Located at
343 ROUTE 28 UNIT 100 5/31/2023
WEST YARMOUTH, MA 02673
Use Group Floor Occupancy Use Group Other
Classifications(s)
R-1 01st Floor 68 R-1 Hotel/Motel/Boarding HouselTransient 68 Room&Lobby
02nd Floor 68 R-1 Hotel/Motel/Boarding House/Transient 68 Rooms
Allowable r
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 of
Signature of Municipal Signature of Municipal Date of
Building Commissioner Issuance 7 Zoe:Z 2
F $478.00
BLD Certoflnspection.rpt
o� YAR TOWN OF YARMOUTH
, � BUILDING DEPARTMENT
O .
1146 Route 28, South Yarmouth, MA 02664 508-398-22 1 aE1¢ cE I V E 0
[JUN 17 2022
APPLICATION FOR CERTIFICATE OF INSPECTION
BUILDING DEPARTMENT
June 17,2022 PAYABLE UP �'' ---�_••'T-
(X)Fee Required 478.00
( )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: 3 1 M u S"
Name of Premises: "/ AMD u L2g01 Tel: , • "
''- I' b (SOC-1402)
Purpose for which permit is used: Ce (U k_ act 1gocc �3��-1 b
License(s)or Permit(s)required for the premises by other governmen51/R02,5311.-
ncies: �
License or Permit Agency
T S,� CtMt
Certificate to be issued to 6l/la((9U f'"- 1 tcv4- I
Address:
Owner of Record of Building Mac.\ l rl
Address 3 t Et.(.9c-c . *AA.<u .
Present Holder of Certificate yit
act tt.A
Sign a of person to whom Title b ` tiZ
Cert. cate is issued or his agent
Date
Email Address: (ky Vkko u liPse-c ---- atck Cod 9_5 `^'Q '"I
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# 0073 //- #9-pp
'5/31/2022-5/31/2023
NOTICE NOTICE
TO TO
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111
(617) 727-4900 - http://www.ma.gov/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:
Hartford Casualty Insurance Company
NAME OF INSURANCE COMPANY
One Park Place, 300 South State St, 7th Floor Syracuse NY 13202
ADDRESS OF INSURANCE COMPANY
08 WEC EM1436 04/24/22 - 04/24/23
POLICY NUMBER EFFECTIVE DATES
265 ORLEANS ROAD
HUB INTERNATIONAL NEW ENGLAND LLC NORTH CHATHAM MA 02650 (508)-945-0446
NAME OF INSURANCE AGENT ADDRESS PHONE
JCS HOSPITALITY LLC 343 ROUTE 28 WEST YARMOUTH MA 02673
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 employmer
to furnish adequate and reasonable hospital and medical services in accordance with the provisions of th
Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. Th
employee may select his or her own physician. The reasonable cost of the services provided by the treatini
physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work relate(
injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged fa
such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
Form WC 88 20 01 E Printed in U.S.A.