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Home My WebLink AboutBCOI-23-1717 2024 a) 0 � � d � 2 \ VI a 1- k k CO § k a c f ) Q ® c c E k m t k f % NI 0 H "0 I kNib . k 0.-6 2 c § I 7qf k § -c k t k v mc � e s c 7 (a _k k ® - . ■ � � % % £ — a e ■ o § 2 $ R R a2 © IA § o § cr. 0 0. CO 0 f, 0 ' ok aka) �� 0 co ( >,/ § � � � f \ 0 N , el CO CA % oa c . 2 � f �� e c ' E ® « . � 2 � . 0 70zEco \ � § p 0 = § W3 � 2 � � $ e2 ��. % $ f BRA a2 « 0 © 2 0 a k @• O ea < T � Ea).5. kdf § c ■ E % q .)2 a 2 5 �■ e ■ � a f v � m E § \ -o2 ■ / i B $ / 7 E§ 73 f � J § q 220 \ k _ V # � � CO kE � � o00 t 3 2 V 2 J Co 72 ■ § Za CD a $ E o = q k k\ i\ Q A f O U. 0) 5 �Ik § k 't 2 t ° ° k • O u_ .0fa 2 0m 2 ® f § G 2 0 >. = a § � Co ■ c co — mu) 0 0 k 2a k § /0. k ■ _ 0 ® 00c 7 - eg ® a 1 8a � d k @ § U o � 2 2 c co 0 0 0 9 § CO 2 as8 = k \ ) 2 / 2 \ t £ k ( k/ z in A \ �u. I UT y431 i ► UM INC DEPART 1146 Route 28, South Yarmouth, MA 02664 50 -3 ' x ECEJVFD APPLICATION FOR CERTIFICATE OF INSPECTIO JUN 02 2023 May 1, 2023 PAYABLE UPON RECEI) rEU;LDING DEPARTME T 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 at the following address: Street and Number: ( 5 t RoLtL cp s Name of Premises: No �) d.� iJu Q I Tel: cJ a- 3(�2 / �, Purpose for which permit is used: ( pi„Ch 0 0 l License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency �2,1L L Af Certificate to be issued to O r� 61 de., I Xr iA y� `-'` Tel: 'DO ZS- -01, 7��(V Address: ( 'No 5 cuy-1 Owner of Record of Building t J Address 1' AI Cat v i Present Holder of Certificate M / y y ©43 / evneri Si:nature of person to whom Title Certificate is issued or his agent c j',A L," D to Email Address:lab 1 c S'.0Le 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# f3C J-2 3-I -117 06/02/2023-06/02/2024 F/'� Documents i The Hartford 10/13/22,4:52 PM 0 3/2022 Workers' Compensation Posting Notices 08WECCK5823 Account setttnys • THE"` Policies Billing Audit Documents Claims Resources X HAiggvIng trouble viewing the document? , , Download Now D` The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER,2 AVENUE DE LAFAYETTE, BOSTON, MA 02111 (617)72T-4900—http l/www ma.govidia 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: Twin City Fire Insurance Company NAME OF INSURANCE COMPANY One Park Place,300 South State St,7th Floor Syracuse NY 13202 ADDRESS OF INSURANCE COMPANY 08 WEC CK5823 09/01/22 -09/01/23 POLICY NUMBER EFFECTIVE DATES 88 FALMOUTH ROAD BRYDEN&SULLIVAN INS AGCY INC/PHS HYANNIS MA 02601 (508)-775-6060 NAME OF INSURANCE AGENT ADDRESS PHONE NORTH SIDE NURSERY SCHOOL INC 165 MAIN ST YARMOUTH PORT MA 02675 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 iniurv_ In cases renuirina hoanital attention_ emnlovaas are hereby notified that the insurer ha_c arranged far https://business.thehartford.com/documents?fiiter_policy Page 1 of 1