HomeMy WebLinkAboutBLDCI-16-003718-04 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
Business Name: CHARLAMAS NIKOLAIDIS BLDCI-16-003718-04
Trade Name: SEASIDE INN
Identify property address including street number, name,city or town and county Certificate Expiration
Located at
812 ROUTE 28 12/21/2022
SOUTH YARMOUTH, MA 02664
Use Group Floor Occupancy Use Group Other
Classifications(s)
R-1 01st Floor 2 R-1 Hotel/Motel/Boarding House/Transient 1 -Rental Unit
1-Owner's Unit
Allowable 02nd Floor 4 R-1 Hotel/Motel/Boarding House/Transient 4-Rental 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 /s—"R
Building Commissioner � 7Inspection
Signature of Municipal Signature of Municipal Date of
Building Commissioner _14/ Issuance J/3 n 2
Fee: $100.00
ai n resh,.n„c.,,,,.+;..., ..�
, 81.•Y4R
4o TOWN OF YARMOUTH
• o D BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
DEC 0 3 2021
IC FOR CERTIFICATE OF INSPECTION
LGENPPLATION
UIEDIN DEPARI M
Nv , 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: I(a A
Name of Premises: Uv ffitt (0,4 CJt.4 / ' it Tel: 17# )(DC' (` (s,
Purpose for which permit is used:
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to Sea s i e., I , ,,, Tel: 7 7'/ ?(09 J/be/
Address: (2,f- 5_ a
Owner of Record of Building
Address
Present Holder of Certific
ouiki
S' re pe o whom Title
Certifi e i s ed or his agent ///z 7 f Z(
Date
Email Address:
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# .B(IX'/—/(p
12/21/2021-12/21/2022
The Commonwealth of Massachusetts
Department of Industrial Accidents
y ,� t1.�— Office of Investigations •
r.fir- IY�.�,� dl �
j• � 1 Congress Street, Suite 100
"y Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Sfa t In t,v
Address: I '(LA" Z
City/State/Zip: c ck 1/tM (,�� Phone #: - 3 31 C
Are you 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.N 1 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] 8. ❑ Noi-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, 11.0 Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other r✓ A-
*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: (]/J till #414
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 ofa STOP WORKORDER penalties TC vRuar`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 certify,under the pains and pen ies of p jury that the information provided above is true and correct.
Si nature: Date: ///2 c7 Zu 2
Phone#:
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