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�`� ``j"�'\ 'a TOWN OF YAR.M:O U TH
1; nor la
-. � BUILDING DEPARTMENT
" v" x 1.146 Route 28 South Yarmouth, MA 02664 508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
June 1, 2023 PAYABLE UPON RECEIPT
(X) Fee Requ' ed$100.00
( ) No Fee Re ' ed
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: 5 743 & ck S/G r Dad
Name of Premises:01 ldy(,(.�( P�(o_ & g nc;v 6.646 Tel: -0.967.7047
Purpose for which permit is used: DPH license to operate SNF/skilled nursing units
License(s)or Permit(s) required for the premises by other governmental agencies: [iE C E I y
License or Permit Agency JUN 13 2023
DPH
BUIL
BY
MM,ov
Certificate to be issued to Maplewood Mayflower Place SNF,LLC Tel: (508) 957-7007
Address: 579 Buck Island Road,West Yarmouth,MA 02673
Owner of Record of Building West Yarmouth Property I,LLC
Address 303 International Circle,Suite 200,Hunt Valley,MD 21030
Present Holder of Certificate Maplewood Mayflower Place SNF.LLC
General Counself
ig ature of person to whom Title
Certificate is issued or his agent 6/12/23
Date
Email Address: amiller@maplewoodsl.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# ,/3C oZ.3-- /-79.3
07/11/2023-07/11/2024
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
• 1 Congress Street, Suite 100
" Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: trYlapie tcc1 ( 1u` 1/
G��'I
cL
n D �t�C-fl
Address: fl 7 6,tek k Ian r/ A?d1 W. [Cl/„/jZUGLI7 t
City/State/Zip: ,ua` iyA A /I,047 33 Phone #: 5 -I5-7. 760 7
Are yoy,an employer?Check the appropriate box: Business Type(required):
1. I am a employer with ga employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]**
4.❑ We are a non-profit organization,staffed by volunteers, 11. ealth Care
with no employees. [No workers' comp. insurance req.] 12.111 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: tl e pi IC_
Insurer's Address: Co 5 0 £ I in V" 4 # 01
City/State/Zip: i`fAAt.Q.,C i- / N.H• a 31 Q 1
Policy#or Self-ins. Lic. # 3/0 02 $e V II8 Expiration Date: 1 i /2L
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains d penalties of perjury that the information provided above is true and correct.
Signature: 11 vit,ist. j41 LAD N 1'S Date: b I it id-Oal.a)
Phone#: 5 a -'7<7 , OO7
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia