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Home My WebLink AboutBLDCI-22-004182-01 Ni 40 o Q o ('�( M o .r :. `� M xax � `N. v e P.. O W N 0 W y `�m �j F. N a. n LL ) •.0 \ C t"� N a ayO� ` w od OJO V CO CO O U Y COh .a o 0 m J es co co 41 5 m o. O+ U Ti co) cd w WI a. w O Cil ° s c • o tD 4 .• . at o 0 C c co N �1 O O V b O O V Q OD .11 C CO .5 a 4m4 Ell .0 M G4 0 at to 0 t w I— I" T T 6. ° ovi c a = r3 •�„y p o H O o o ¢' w y O 0 z E z a 4- ,- 0 i Io 0 0 a z v H b C m U L" "b Ce °' o rn .am 0 U O • ti " co 7 °_> I� m am O.0N C z m 'cn m 4U co o a b )' g .Ph a cn a 5 U c O cc n Ut S O+co L L O N y co 0 8 .2 'S LL La a O y oc O 4" .O Law IL O O L.)• y (1S Q 0 N co — O ,tz ,`. t .o CL 7 c fill • 4 1 mitErvivi m Lo§ca P. a .x w �to� uir <EL Q on0 •5c ocom Z in o- BUILDING DEPART' TENT `\ "` t 1 146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 II APPLICATION FOR CERTIFICATE OF INSPECTION r 28 2023 March 13, 2023 PAYABLE UPON RECEI Ti (X) Fee Required 3�1®�DIN DEFJAI?2ENT ( )No Fee Requir Y — 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: 1237 MA 28, South Yamouth, MA 02664 Name of Premises: The Escape Inn Tel: 508 264 0650 Purpose for which permit is used: Operating a Hotel License(s)or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to Go Dutch Coliving LLC (Isidro Be¢rpr Varela, manager) Address: 23 Mann Ave Unit 3. Newport, RI 20840 Owner of Record of Building Go Hutch Coliving LI C Address 23 Mann Ave Unit 3, Newport, RI 20840 Present Holder of Certificate r. ,i Manager Signature of person to whom Title 3/24/2023 Certificate is issued or his agent Date Email Address: isidro.beccar@gmail.com 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# /3t1X/-Z2-0644OOa _04 �l 02/17/2023 —02/17/2024 '9 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 • POLICY NO. WCC-500-5023306-2022A PRIOR NO. WCC-500-5023306-2021A ITEM 1. The Insured: Go Dutch Coliving LLC DBA: The Escape Inn Mailing address: 23 Mann Ave Unit 3 FEIN:**-'**1171 Newport,RI 02840 Legal Entity Type: Limited Liability Company • Other workplaces not shown above: See Location 2. The policy period is from 10/19/2022 to 10/19/2023 12:01 a.m.standard time at the insured's mailing 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 accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee 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 Plans. 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 001186515 INTER 111111111 SEE CLASS CODE SCHEDU-E I I I Minimum Premium $273 Total Estimated Annual Premium $471 GOV GOV Deposit Premium $478 STATE CLASS MA 9052 State Assessments/Surcharges $167.00 x 4.1800% $7 This policy,including all endorsements,is hereby countersigned by 09/14/2022 Authorized ignature Date Service Office: Starkweather&Shepley Ins Brkg Inc 54 Third Avenue PO Box 549 Burlington MA 01803 Providence,RI 02901 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission.