HomeMy WebLinkAboutBLDCI-23-003242 The Common wea o`Massachusetts
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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: Mill View Suites BLDCI-23-003242
Trade Name: Mill View Suites
Identify property address including street number,name,city or town and county Certificate Expiration
Located at
85 ROUTE 28 I 1/12/2024
WEST YARMOUTH, MA 02673
Use Group Floor Occupancy Use Group Other
Classifications(s)
R-1 01st Floor 7 R-1 Hotel/Motel/Boarding House/Transient 7 Bedrooms
Allowable 02nd Floor 8 R-1 Hotel/Motel/Boarding House/Transient 8 Bedrooms
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 _�Q
Building Commissioner Inspection av�'
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Signature of Municipal Signature of Municipal Date of
Building Commissioner Issuance ///0/25
Fee:$115.00
• BLD_Certoflnspection.rpt
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TOWN OF YARMOUTH
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,H BUILDING DEPARTMENTRR
"„T,:1 � 1146 Route 28, South Yarmouth, MA 02664 508-398-2 r - !Y_E
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DEC 08 2022
APPLICATION FOR CERTIFICATE OF INSPECTION
BUILDING DEPARTMENT
By._ —
December 1, 2022 PAYABLE UPON RECrirI -
(X) Fee Required$115.00
( ) 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: Cbt) a U
Name of Premises: t \\ \i N 701)C5 Tel: S 09 3 1 4 4 A.4 6
Purpose for which permit is used: LC r; i T l tot pc \ 5 it e)\0 n
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to \-off 1,.)40')00 t,7 Tel: al AGO 4-`) VI--
Address: a 1.,,AnxN \M 0 ooNC\ I H o,An,5 Mlk rya60 l
Owner of Record of Building R AA,;) (30i ne,,,y
Address a t-pxvm Cavrk, 14Tith,y 11,1- pto bo)
Present Holder of Certificate on<,leA/ ec ui Ut 5
Signature of person to whom Title \ \
Certificate is issued or his ag ra 1 5 )-a
Date
Email Address: '4 1 \ 6c455Y;Nrit,r ,file r\\e' . Cop
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#
01/12/2023-01/12/2024
11
_
NOTICE _ NOTICE
TO _ _�►� TO
EMPLOYEES == = EMPLOYEES
144 - so.
IND
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111
(617) 727-4900 — www.mass.govldia
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:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 4614
BUFFALO, NY 14240-4614
ADDRESS OF INSURANCE COMPANY
UB-8N646839-22-42-G 08-15-22 TO 08-15-23
POLICY NUMBER EFFECTIVE DATES
PAYCHEX INS AGENCY INC 150 SAWGRASS DR
ROCHESTER, NY 14620
"' NAME OF INSURANCE AGENT ADDRESS PHONE #
o� BASS RIVER PROPERTIES 2 LYNXHOLM COURT, 2ND FLOOR
MANAGEMENT CORP HYANNIS
0
MA 02601
EMPLOYER ADDRESS
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 services
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
NAME OF HOSPITAL ADDRESS
000545 W20P1G15 TO BE POSTED BY EMPLOYER