HomeMy WebLinkAboutBLDCI-22-006032 The Commonwealth of Massachusetts
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_ l!+= 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:Yarmouth Country Cabins BLDCI-22-006032
Trade Name:Yarmouth Country Cabins
Identify property address including street number,name,city or town and county Certificate Expiration
Located at 864&878.ROUTE 28 4/19/2023
SOUTH YARMOUTH, MA 02664
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Use Group Floor Occupancy Use Group Other
Classifications(s) Cri
R-1 Hotel/Motel/Boarding House/Transient 17 Cabins
R-1 01st Floor 17
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 �yZ
Building Commissioner Inspection �_!7 0 .
Signature of Municipal (2•4
Signature of Municipal , c
Date ofIssuance2,
Building Commissioner 2
Fee:$121.00
BLD Certoflnspection.rpt
_- ,_!a TOWN OF YARMOUTH
q�t ci BUILDING DEPARTMENT
` x. 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
RECEIVED
APPLICATION FOR CERTIFICATE OF INSPECTION APR 13 2022-
March 1, 2022 PAYABLE UPON RECEIPT
(X) Fee I71eQjtfIMENT
( ) NU-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: 9 7 le 1C- -
Name of Premises: yfrit At 0 vt-t L (btu N �L �I4J Tel: �l 1"T- g 3 -08o L o't- re,!c 1 lsl4.64
Purpose for which permit is used: ('S 4 e,, /Ce.,/ty¢ (A
License(s) or Permit(s) required for the prems by other governmental agencies:
License or Permit Agency
444.64air,j -R k WOO I yik4 vtto u --Gt i°P4(1(
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Certificate to be issued to f edw i ,Lk4/J Tel: (pj 7 P 8 U0�
Address: 6 � �� �I�, ►.�' (/��'• C�1-��
Owner of Record of Buildingr--t°.2�4 ,o AA-A,`
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Address �p /3A' erz S-j-. i ( k�-(' t (/414' C?,)V7i
Pr ent Holder of Certificate 6...e 2 i ;0-i c vA-^-
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Signature of p rson to whom Title
Certificate is issued or his agent /71/4(P-1--
Date
Email Address: &144 014444, 00uAA, 6)/40t'Cc
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#
04/19/2022-04/19/2023
•
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The,Commonwealth of Massachusetts
. •W----�----- Department of Industrial Accidents •
w* Office of Investigations
xini 41 Congress Street,Suite 100
:., Boston, MA 02114-2017
www.mass.gov/dia i.
Workers' Compensation Insurance Affidavit: General Businesses
Applicant information Please Print Legibly
Business/Organization Name: 'Vi61,t (j( 04(6,,' 1
Address: 8 /2,-,
City/State/Zip: 6/C 0 d) 6Y7.. Phone #: 17 )(��
Are you an employer? Check the appropriate box: ! Business Type(required):
I.0 1 am a employer with employees(full and/ 15. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bart 'acing Establishment
2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Saks(incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• ❑ Non-profit
3.fo 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, 11.p Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
•
City/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date: •
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 tify,under ain an ,renalties of perjury that the information provided above is true and correct.
Signature: A---,. Date: r7/10/
Phone#: Co 1—r 5t .--O 0 6 A.
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. Citylfown Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
ww w.mass.gov/dia