HomeMy WebLinkAboutBLDCI-16-005188-05 The Commonwealth of Massachusetts
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1} City\Town of
ui = 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:TIDEWATER INN BLDCI 16 005188-05
Certificate Expiration
Trade Name:TIDEWATER INN
Identify property address including street number, name, city or town and county
Located at 135 ROUTE 28 05/20/2023
WEST YARMOUTH, MA 02673
Use Group Floor Occupancy Use Group
Other
"—
Classifications(s) R-1 Hotel/Motel/Boarding HousefTransient Bld. 1 -12 units,Bld.-
01 st Floor 49 R-1 10 units, Bld.4-24
units,Bld.3-3 units,
r managers apart.,lobby
Allowable &game room
Occupant Load Bld. 1 -12 units,BId.2-
02nd Floor 54 R-1 Hotel/Motel/Boarding HouselTransient
10 units,Bld.3-6 units,
Bld.4-24 units
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 r G
Building Commissioner „ Inspection (�
/ if Date of
Signature of Municipal
Signature of Municipal Issuance
Building Commissioner
IL26, ,,--": - .7/. , ,r/z....
roP ee:$373.00
BLD Certoflnspection.rpt
�;��, TOWN OF YARMOUTH
41, ::,c1 a', .ja BUILDING DEPARTMENT
r\MATTAC fi Vti: �'
, .:tom 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
RECEIVED
APPLICATION FOR CERTIFICATE OF INSPECTION
A 20222022 j '
PAYABLE UPON RECEIPT
X Fee Required-_ TMENT
Bilil li-VG uEPiAR ( ) qu ed $373.00
BY - - - ( ) 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`j R . .K'
Name of Premises:' ;okc toque' n y\ . Tel: 508*'' ?5•-L3.Q�
Purpose for which permit is used: O(„, nC
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
11 '' � A T 'de
f' c n n *
Certificate to be issued to �'[qhj �by)p 1 �� ►Nt� Tel: �j oX- 77�43- 2 .
Address: (3 9 RT: -23; Lt.), Vow u- ,t i MA__ 02 >73
Owner of Record of Building Ai"�rh •
Address
Present Hold f Certificater-I"(,, 9e.„-1 e�
6/ .)-4 -
Signature o person to whom Title
Certificate is issued or his agent ' / L9 2 2 .
Date
i `
Email Address: qY''�'V� ( Haf�l,viy fe .67,4A--
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#
05/20/2022-05/20/2023
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 AK8XPJ 03/12/22 -03/12/23
POLICY NUMBER
EFFECTIVE DATES
PO BOX 9011
CORCORAN & HAVLIN INSURANCE GROUP WELLESLEY MA 02482 (800)-304-8242
NAME OF INSURANCE AGENT ADDRESS PHONE
Hari Hospitality Inc 135 ROUTE 28 WEST YARMOUTH MA 02673-4653
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 services 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
Form WC 88 20 01 E Printed in U.S.A.