HomeMy WebLinkAboutBLDCI-22-007287 The Commoxwe ilth of Massachusetts
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New and Rene ' '�Certificate of Inspection
In accordance with the Massachusetts State Building Code, Section 110.7
Identify Name of Establishment Certificate No.
Issued to
Business Name: Maplewood Mayflower Place SNF LLC BLDCI-22-007287
Trade Name: Maplewood-Mayflower Place Nursing Home
Identify property address including street number, name,city or town and county Certificate Expiration
Located at
579 BUCK ISLAND RD 7/11/2023
WEST YARMOUTH, MA 02673
Use Group Floor Occupancy Use Group Other
Classifications(s)
-2 01st Floor 72 1-2 Institutional Hospital/Nursing Home 72 Beds
1Allowable ,-'
-
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 mate of
Building Commissioner (21-
� Inspection 7—/. / a
Signature of Municipal Signature of Municipal Date of
Building Commissioner II Issuance , s/0Z
Fee:$100.00
BLD_Certoflnspection.rpt
NOTICE _ NOTICE
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The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111
(617) 727-4900 — www.mass.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:
MEMIC Indemnity Company
NAME OF INSURANCE COMPANY
PO Box 3606 Portland, ME 04104
ADDRESS OF INSURANCE COMPANY
3102804908 2022-06-01 2023-06-01
POLICY NUMBER EFFECTIVE DATES
M&T INSURANCE AGENCY, INC. 285 DELAWARE AVE BUFFALO,NY 14202 7168537960
\TAME OF INSURANCE AGENT ADDRESS PHONE#
MAPLEWOOD MAYFLOWER PLACE ALF LLC 579 BUCK ISLAND RD 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
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 '
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RECEIVED
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'TOWN OF YARMOUTI•
JUN 16 2022
BUILDING DEPARTME it T T
�.�.1C4Vii0 1146 Route 28, South Yarmouth,MA 02664 508-398-2131 ext.
APPLICATION_FOR CERTIFICATE OF INSPECTION
June 1,2022 PAYABLE UPON RECEIPT
(X) Fee Req i ed$100.00
(- ) No Fee Req
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: s' 'n
Street and Number: 5-1 I &k L��,� /e �_d � 7�/ 7 1-
Name of Premises: f ,e,141 f Tel: �0 d-q5 7 7a17
Purpose for which permit is used: ( .1.(.," �a�y� a y —h V1 �i ,Rd-' tb
License(s)or Permit(s)required for the premi.e by other governmental agencies:
License or Permit Agency
lio
Certificate to be issued to E 75e. U�� Ow"—eon
Address: 3-7q i&u 14-,t {'�G1-fit p 7
Owner of Record Building 6G�t ���/� 4Ja�Z 1.�1 ��
Ad. ess ay (�iv�,l ��� �1�2 J _l�,
• • es:A H.,. .f Certificate y!Z(p lfjlr i f-e4L{ac.e1 !LE' cs'/f 1 F �lJ
is'��.. re of person to whom Title
� '`' ' cate is issued or his agent C' /3- i L?—
Date
Email Address: (3'- Q Gt..Jilk,i171� (liaiati pa /• 0.4)11
S r4 mIaS-I-rcv--iv
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 CERI' hICATE OF INSPECTION.
Certificate of Inspection# 8(,U�" - -1�>7� -7
07/11/2022-07/11/2023