HomeMy WebLinkAboutBLDCI-23-004987 T commonwealth of Massachusetts
City\Town of
; l
.,w,Mt ! 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: Days Inn Hotel BLDCI-23-004987
Trade Name: Days Inn
Identify property address including street number,name,city or town and county Certificate Expiration
Located at
69 ROUTE 28 4/23/2024
WEST YARMOUTH, MA 02673
Use Group Floor Occupancy Use Group Other
Classifications(s)
R-1 01st Floor 20 R-1 Hotel/Motel/Boarding House/Transient 20 units
Allowable 01st Floor 59 R-1 Hotel/Motel/Boarding House/Transient 59 units
Lounge Room
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 ispection
Signature of Municipal Signature of Municipal 'ate of
Building Commissioner w /) �' Issuance L�4A,
!�� / Fee:;307.00
BLD_Certoflnspection.rpt
TOWN OF YARMOUTH
Io:t ; � 1 BUILDING DEPARTME
MATTAGr1 S[!��
1146 Route 28, South Yarmouth, MA 02664 508-398 2R3 Fei. E D
MAR 08 2023 .
APPLICATION FOR CERTIFICATE OF INSPECTION J
BUILDING DEPARTMENT
March 1, 2023 PAYABLE UPON RECEIP I By.
(X) Fee Required$307.00
( ) 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: 6(-1 -- 2� '✓esf V� r i co ,1✓A 4 c2�t3
�
Name of Premises: $ 4' Ho I-P� Tel: Soq- 7 7s - 2
Purpose for which permit is used:
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
I
Certificate to be issued to b Of9[S T N A) Tel: 50 S - 7 7 S -- 2 3 T
Address: C7 ` AO 1"c - 1 S' 1A1i.0 VC( 41C1 a d1.1 fri e26 3
Owner of Record of Building Pot ,- De cs n ro li o r'a
Address (g— /Lo �' 2 ye,rvr0 vkL-► 44/9 ct261- 3
Present Holder of Certificate Doty rS lti N
Signature o person to whom Title
Certificate is issued or his agent 0 3/CJ 4/2' 2
Date
Email Address: doll S i CGt pf co d el
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#
04/23/2023-04/23/2024
Hf
,e . .
t: y
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLI-
Y
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NOD NO 4 _.
POLICY NO. WCC 5C0-5C -_
......................
PRIOR NC. NEW
ITEM
1. The Insured: Pari Devang Corp
DBA:
Mailing address: 69 Main Street FEIN:"-`"0836
West Yarmouth, MA 02673
Legal Entity Type: Corporation
Other workplaces not shown above:
2. The policy period is from 06/09/2022 to 06/09/2023 12:01 a.m.standard time at the insurea's ma/:ng 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 accidert
Bodily Injury by Disease $ 500,000 policy i mt
Bodily Injury by Disease $ 500,000 each emp'cyee
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 PIars
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 000048617
INTER SEE CLASS CODE SCHEDULE
Minimum Premium $276 Total Estimated Annual Premium $75_,
GOV GOV Deposit Premium 5193
STATE CLASS
MA 9052 State Assessments/Surcharges
$441.00 x 4.1800% $1 g
This policy,includingall endorsements, is herebycountersigned bye ---
P Y 9 -- ------..------ 0508i2022
Authorized Signature Date
Service Office: Dowling and 0 Neil Ins Agcy
54 Third Avenue 973 iyannough Road
Burlington MA 01803 Hyannis, MA 02601
WC 00 00 01 A(7-11)
includes copyrighted material of the National Council on Compensation Insurance;
used with its permission.
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