HomeMy WebLinkAboutBLDCI-16-005966-05 The Co m wealth of Massachusetts
} !' City\Town of
a ARMOUTH
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: BOY SCOUTS OF AMERICA BLDCI-16-005966-05
Trade Name: CAMP GREENOUGH
Identify property address including street number, name, city or town and county Certificate Expiration
Located at
GREENOUGHS POND 04/24/2023
YARMOUTH PORT, MA 02675
Use Group Floor Occupancy Use Group Other
Classifications(s)
A-3 01 st Floor 241 A-3 Amusement/Church/Gym/Library/Museum Health Lodge-4
Admin Building-13
Maushop Lodge-19
Allowable Conference Rm-60
Occupant Load Dining Hall-tables&
chairs- 112
Bunkhouse/sleeping-
32
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 3
Building Commissioner Inspection
Signature of Municipal Signature of Municipal Date of
Building Commissioner Issuance ,V.OZ
Fee: $0.00
BLD_Ce rtotl ns pection.rpt
.°� �aR TOWN OF YARMOUTH
(� ./;y BUILDING DEPARTMENT
A.,\,, TT .;, !S[/4.
‘442
�� :t 1146 Route 28, South Yarmouth, MA 02664 508-398-2 -t. 1260
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APPLICATION FOR CERTIFICATE OF INSPECTION MAR 0 7 2012
March 1, 2022 PAYABLE UPON RECEIPT BUILDING DEPgRrMENT
( ) Fe •'
(X) 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 t the following address:
Street and Number: ? FAQ 1'1) VIP /t)
Name of Premises: (2-,, 6-JeQ r)1A L Tel: -'i Ol 3o - Y-
Purpose for which permit is used: ,� f(1 f (--,
£'"�
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
i .7 J4,0.14),
Certificate to be issued to Lam, .(..(®�i- O Co 1 , .l`t`� Tel: fe)i 7 ii it 1,--+--
Address: D20 /J,))e�✓ ��C-4 AriKei J. A t-li 045 2J`~
Owner of Record of Building A
Address ;/
Present Holder of Certificate fii,,,t___,
K/ficr47
Signature of person to wh' Title '
Certificate is issued or his agent 2/////
Date
Email Address: L '/--1 , r�i �. pc��lr` felt d r_5'
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# LC,l)C/-l(o-d 059&pip--Q.S
04/24/2022-04/24/2023
Print Form
NOTICE / NOTICE
TO TO
EMPLOYEESr, EMPLOYEES
d t y ilr sv e
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http:/,/www.state.ma.us/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:
A. I. M. Mutual Insurance Company
NAME OF INSURANCE COMPANY
54 3rd Ave Burlington MA 01803
ADDRESS OF INSURANCE COMPANY
V WC-100-6014316-2021 A 03/31/2021-03/31/2022
POLICY NUMBER EFFECTIVE DATES
NAME OF INSURANCE AGENT ADDRESS PHONE#
Cape Cod & Islands Council, Inc. #224 BSA 247 Willow St Yarmouth Port MA 02675 508-362-4322
EMPLOYER ADDRESS
03/06/2021
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 ser-
vices 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
Cape Cod Hospital 16 Park St Hyannis MA 02601
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
BOY SCOUTS OF AMERICA
''` '� CAPE COD AND ISLANDS COUNCIL
March 4, 2022
Town of Yarmouth
Building Department
1146 Route 28
South Yarmouth MA 02664
Re: Application for Certificate of Inspection
Enclosed are our Application for Certificate of Inspection and Workers Compensation Cerfti-
cate.
We are happy to schedule the inspection at a mutually agreeable time. Please contact our office
at 508-362-4322 to make arrangements.
Thank you.
7"td"•"- Ag• 04?‹:a4;
Michael R. Riley
Scout Executive
247 Willow Street
Yarmouth Port MA 02675-1744
Phone(508)362-4322
Fax (508)362-4323
www.scoutscapecod.org Prepared.For Life"
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