HomeMy WebLinkAboutBLDCI-16-006830-06 T ommonwealth of Massachusetts
}p 't City\Town of
—13'Tt- 1 YARMOUTH
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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:AMBASSADOR INN&SUITES BLDCI-16-006830-06
Trade Name:AMBASSADOR INN&SUITES
Identify property address including street number,name,city or town and county Certificate Expiration
Located at
1314 ROUTE 28 06/12/2023
SOUTH YARMOUTH, MA 02664
Use Group Floor Occupancy Use Group Other
Classifications(s)
R-1 01st Floor 36 R-1 Hotel/Motel/Boarding House/Transient 36 UNITS&LOBBY
Allowable 02nd Floor 52 R-1 HoteUMotel/Boarding House/Transient 52 UNITS
MANAGER'S APT.
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 grass 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 p�4�
Signature of Municipal Signature of Municipal (21- Date of
Building Commissioner O Issuance 7_ G -zZ
Fee:;337.00
BLD_Certofl ns pection.rpt
n�rrn�-ay.:
• �F�YgR TOWN OF YARMOUTH
Nivo +. ' . 1 BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
May 1, 2022 PAYABLE UPON RECEIPT
(X) Fee Required $337.00
( ) 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: 131 Li (4.-e 2-9" Co- ( 1 f 1 P— v
Name of Premises: 741 {;' - 1 l,,b Tel: CS--00cly
Purpose for which permit is used: 2 et)0,04 l3 Lti '�� 244
License(s) or Permit(s) required for the premises by oth governmentancies:
License or Permit Agency RECEIVED
MAY 09 2022
- BUIL4441/444,1E-N-r
By
Certificate to be issued toA-1111 eh Tel: ITO 9
Address: j j 14) 1?4- 25/ so,JCavyw. .. ./ nem-02&6 4
Owner of Record of Building 1 Al*
Address -- SCI,YY1 e�J 521-11 e ► ,
Present Holder f Certificate h�', �' IrY1 f S LC 7-
erktu'e of person to whom itle
i ate is issued or his agent
Date
Email Address:
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# B u-)C-/-I(o-OD30 -eyl -Dio
06/12/2022-06/12/2023
r
Technology Insurance Company, Inc.
A Stock Insurance Company
WORKERS COMPENSATION WC 99 00 01 B
AND EMPLOYERS LIABILITY 1 of 5
INSURANCE POLICY INFORMATION PAGE
Ncci Code: 39071
1. Insured: Policy Number: TWC4072618
Gayatri"Krupa Corporation
DBA:Ambassador Inn&Suites
1314 Route 28 Individual _Partnership
South Yarmouth,MA 02664 X,Corporation
Other workplaces not shown above:
None Federal Tax ID: 200550066
Producer: Risk Id:
AmTrust North America,Inc. Renewal of: TWC3951858
c/o Baldwin Krystyn Sherman Partners,LLC
434 Route 134 Ste.Fl
South Dennis,MA 02660
2. The policy period is from 3/9/2022 to 3/9/2023 12:01 a.m. at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of
the states listed here:Massachusetts
B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$500,000 each accident $500,000 policy limit $500,000 each employee
C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here:
All states except ND,OH,WA,WY and State(s)Designated in Item 3A.
D. This policy includes these endorsements and schedules: See Extension of Information Page
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating
Plans.All information required below is subject to verification and change by audit.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM 1,993
STATE ASSESSMENT 68
TOTAL ESTIMATED COST 2,061
Minimum Premium 405
Deposit Premium / y� / 2,061
Issue Date: 1/28/2022 Countersigned by:
thorized Representative
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