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Home My WebLink AboutBLDCI-22-004182 C,"" The Commonwealth of Massachusetts j = 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:Go Dutch Colving LLC BLDCI-22-004182 Trade Name: The Escape Inn Identify property address including street number,name,city or town and county Certificate Expiration Located at 1237 ROUTE 28 2/17/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) R-1 01st Floor 6 R-1 Hotel/Motel/Boarding House/Transient 6 UNITS&OFFICE Allowable 02nd Floor 7 R-1 HoteVMotel/Boarding House/Transient 7 UNITS 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 Signature of Municipal Signature of Municipal i' ,Date of Building Commissioner7(/ Issuance 3 . '�, 2 2 Fee:$130.00 BLD Certoflnsoection.rot 5 cof' pool) -rv`Mfg : 2.3 /4,�ivN 'I. a-3 Pe- v it( ,..' TOWN OF YARMOUTH otbuto 'i.v``,4; BUILDING DEPARTMENT ED on 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 tlo� BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF INSPECTION BY _------- December29, 2021 PAYABLE UPON RECEIPT (X)Fee Required 130.00 ( )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: R E C E V E D Street and Number: 1237 Route 28—South Yarmouth, MA 02664 �—] Name of Premises:_The Escape Inn _Tel:_401 855 5095 JAN 2 4 2022 1 Purpose for which permit is used: Operating Hotel_ License(s)or Permit(s)required for the premises by other governmental agencies: By BUI.- I TVIFNT ` License or Permit Agency _Health Inspection City of Yarmouth _Business License City of Yarmouth Certificate to be issued to Isidro Beccar Varela Tel: 401 855 5095 Address: 23 Mann Avenue—Unit 3,Newport, RI 02840 Owner of Record of Building Go Dutch Coliving, LLC Address 23 Mann Avenue—Unit 3,Newport, RI 02840 Present Holder of Certificate Isidro Beccar Varela Go Dutch Coliving LLC (Isidro Beccar Varela, Manager)_ Signs a of person to whom Title Certificate is issued or his agent 1/24/22 Date Iammail .-\Jdres : _isidro.beccar@gmail.com Instructions: Make check payable to: Town of Yarmouth 1146 RVulc 28, 3uuL11 \dimuutII, 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 CAAINOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# f�' Q 2_4 1 I(7 2/17/22-2/17/2023 1• `�` ` t;,; WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800)876-2765 NCCI NO 40959 POLICY NO. WCC-500-5023306-2021A PRIOR NO. WCC-500-5023306-2020A ITEM 1. The Insured: Go Dutch Coliving LLC DBA: The Escape Inn Mailing address: 23 Mann Ave Unit 3 FEIN:*****1171 Newport, RI 02840 Legal Entity Type: Limited Liability Company Other workplaces not shown above: See Location 2. The policy period is from 10/19/2021 to 10/19/2022 12:01 a.m.standard time 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: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ - 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 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. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. _;otal Annual Of Annual Remuneration Remuneration Premium INTRA 001186515 INTER 111111111 SE CLASS CODE SCHEDULE Minimum Premium $276 Total Estimated Annual Premium $586 GOV GOV Deposit Premium $598 ;STATE CLASS MA 9052 State Assessments/Surcharges $280.00 x 4.1800% $12 This policy,including all endorsements,is hereby countersigned Dy '! ` �— 09/24/2021 Authorized Signature Date Service Office: Starkweather&Shepley Ins Brkg Inc 54 Third Avenue PO Box 549 Burlington MA 01803 Providence,RI 02901 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. `��r�� ' w ^ ^ � ` ^ , ' � _~��__ _,~___' - _ -- __ __' _---� '__-- ��---__- --___--_-_- __- __ - _--_-_ - ---_- _ - ,- � '`� ' = ` ' � _` __ --___ _____ ' _ _ __ _