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Home My WebLink AboutBLDCI-16-004719-05 The Commonwealth of Massachusetts • City\Town of YARMOUTH i 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: RAVENSWOOD BLDCI-16-004719-05 Trade Name: RAVENSWOOD-CLUB HOUSE AT POOL SIDE Identify property address including street number,name,city or town and county Certificate Expiration Located at 345 CAMP ST 03/10/2023 WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) A-3 01 st Floor 54 A-3 Amusement/Church/Gym/Library/Museum 54 Persons-Hall, Kitchen,Office&2 Restrooms 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 .�'� Building Commissioner Inspection Signature of Municipal Signature of Municipal I/ Date of Building Commissioner �' Issuance 3 1, q z `fir Fee:$100.00 BLD Certoflnspection.rpt 1 TOWN OF YARMOUTH ; c BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 RECEIVED APPLICATION FOR CERTIFICATE OF INSPECTION FEB 17 ; r 2022 February 14, 2022 PAYABLE UPON REC IPtuI�-,pp (X) Fee Requi e�ylUU. � DEPARTMENT • ( )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 L 57-- Name of Premises: G% QI/Y/1 S „C (--;;I)467 S' Tel: IfsW/Ye( Purpose for which permit is used: gi.74kets '� License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to 2 7T Tel: n/ Address: 33 a Coj`/4, /Jo do /I,A Da II Owner of Record of Building Address Present Holder of Certificate Signature of person to whom Title/ Certificate is issued or his agent r 1 f/7 /a - Date Email Address: C/e'i, E'eav L-�c0/v/C'G0-7 We-7— 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# 3/10/2022-3/10/2023 The Commonwealth of Massachusetts 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 BLDCI 16 004719-04 Business Name: RAVENSWOOD Trade Name: RAVENSWOOD-CLUB HOUSE AT POOL SIDE Identify property address including street number, name, city or town and county Certificate Expiration Located at 345 CAMP ST 03/10/2022 WEST YARMOUTH, MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) A-3 01 st Floor 54 A-3 Amusement/Church/Gym/Library/Museum 54 Persons-Hall, Kitchen,Office&2 Restrooms 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 Building Commissioner Inspection Signature of Municipal Signature of Municipal Date of Building Commissioner Issuance N 7- ^ CC), Fee:$100.00 B LD_Certofl nspection.rpt F'YgR TOWN OF YARMOUTH yoJ.ft, .; i BUILDING DEPARTMENT ` " MATT C11 LSy�� q. aO 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION February 14, 2022 PAYABLE UPON RECEIPT (X) Fee Required 100.00 ( )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: 3 � 1 k. } Name of Premises: -)S7-477G2 Te1:S�8 / 5-- Purpose for which permit is used: C/GeZhi'ac---e--- License(s) or Permit(s)required for the premises by other governmental agencies: RECEIVED License or Permit Agency FEB 2 5 2022 rirrtp, Certificate to be issued to �'' /�f7/ /yam Tel: 6/ ') '?/, Address: 'Jt' (l ' i i MA 'L c)// Owner of Record of Building Address Present Holder of Certificate Signature of person to hom /Title j Certificate is issued or his agent 3. c /D--Th_ Date Email Address: .e--"A^ C�e1c--.7 ® C,ne° C "2eT 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# 3/10/2021-3/10/2022 �` I \) The Commonwealth of Massachusetts Y:= Department of Industrial Accidents ,p -1-... —e Office of Investigations r i' 1 Congress Street, Suite 100 � Boston, MA 0211 4-2017 www.mass.gov/dia 1 Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: el d iI€244. Address: 3 c- ,C),/, c< City/State/Zip:1. V4/z /7//9 0,2623 Phone #: 'O g- _F , / 9 ', — Are yoy.an employer?Check the appropriate box: Business Type(required): 1. I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] °. i] Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ 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•❑ Health Car with no employees. [No workers' comp. insurance req.] 12.0 Other /iV: 7'/1"2 ;r;e *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. 1 am an employer that is providing rakers'co ensa 'o ' surance for my employ s. Below is the policy information. Insurance Company Name: / " L�d/'f �/1'00/te c ' � // Insurer's Address: �% 7 L.� 7,4) `S City/State/Zip: t'i 2r '/7 5/P / ' 4 t , (F"Z. Policy#or Self-ins. Lic. # ! Me c), Expiration Date: /AD / c7 Attach a copy of the workers' compensation policy declaration page(showing the policy number and ex iration 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 fin,- 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 ce tify,under the pains and pen lties of perjury that the information provided above is true and correct. Signature: ►Vf1 - (117-Z-470 ...g.1Date: c //6/ - Phone#: 50 ? ,5 '7 /4/21: 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.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia '6'�� \� ‹c: 1 �� f