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DEAL INC DEPA TMENT
"qs-)HNTT:7_,, 114 i - out 28, South Ya ° outh, A. 02t 18-398-22 ext. 1260
�1 5�09 SC�..:�y
APPLICATION FOR CERTIFICATE OF INSPECTION 1 1
JUL 2023
July 1, 2023 PAYABLE UPON RECEIP
BUILDING DEPARTMENT
(X) F .e•'aired-$I5O-AO--
( ) 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: y ?-f 7 Wei Ya/ 0af i, - 6 24 73
441‘47/
/h`if' A>/ -c
Name of Premises:�A/f6ufy Tel:
Purpose for which permit is used: / jef,( 4t V/t J s, 4 .4i esz.--'
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
(1eLicA ce.. h r- (84,ttra, eA /1Z, , /n/f/
Oe c,c/fi et it e f e cil,,.i r d).✓ki o Y�/hr/✓/2_ ��
° �-ll )4?rl llof` u— Tel: /-77�`-V70;� 4V
Certificate tp/b sued to ' ,k
Address: 1119Cf
Owner of Rgcprd of Building in a fe Ur '-9
Address IVV-X%t (-T -
Present Holder of Certificate /Lc‘ith) c4 / "c/t /7/77(
q; Aie ye- 13re-e'. C46c/J
Signature of person to whom Title
Certificate is issued or his agent �� � 3
Date ���3 7S-S�
Email Address: 41 I'A; le-44}06d SI OM
Ltti`3`t
Instructions: Make check payable to: Town of Yarmouth
1146 Route 28, South Yarmouth, MA 02664 ?)3\6
Return this application to: Building Inspector's Office (b2
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 1R
Certificate of Inspection#
08/21/2023-08/21/2024 6Co% 2..3 l7_3,
NOTICE NOTICE
TO it TO
EMPLOYEES EMPLOYEES
{.0
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111
(617) 727-4900 — www.mass.gov/dia
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:
MEMIC Indemnity Company
NAME OF INSURANCE COMPANY
PO Box 3606 Portland, ME 04104
ADDRESS OF INSURANCE COMPANY
3102804908 2023-06-01 2024-06-01
POLICY NUMBER EFFECTIVE DATES
MARSH USA INC- CHICAGO 540 W MADISON ST STE 100 CHICAGO,IL 60661 3126276000
NAME OF INSURANCE AGENT ADDRESS PHONE#
MAPLEWOOD MILL POND LLC 164 RIB 28 WEST YARMOUTH, MA 02673
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 ser-
vices 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
TO BE POSTED BY EMPLOYER k
AVISO PARR -=1i AVISO PARA
EMPLEADOS rt EMPLEADOS
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750
(617) 727-4900 - www.mass.gov/dia
De acuerdo con lo dispuesto por los articulos 21, 22 y 30 del capitulo 152 de las Leyes
Generales de Massachussets, por el presente notificamos que hemos previsto el pago a
nuestros empleados lesionados, conforme al capitulo antes mencionado, mediante un
seguro con:
MEMIC Indemnity Company
NOMBRE DE LA COMPANIA DE SEGURO
PO Box 3606 Portland,ME 04104
DOMICILIO DE LA COMPANIA DE SEGURO
3102804908 2023-06-01 2024-06-01
NUMERO DE POLIZA FECHAS DE VIGENCIA
MARSH USA INC- CHICAGO 540 W MADISON ST STE 1(X1 CHICAGO,IL 60661 3126276000
NOMBRE DEL AGENTE DE SEGUROS DOMICILIO J TELEFONO
MAPLEWOOD MILL POND LLC 164 RTE 28 WEST YARMOUTH, MA 02673
EMPLEADOR DOMICILIO
FUNCIONARIO DEL EMPLEADOR PARA ACCIDENTES DE TRABAJO(SI HUBIERA) FECHA
TRATAMIENTO MEDICO
En caso de lesiones personales ocurridas a raiz del trabajo o durante el trabajo, la
aseguradora cuyo nombre aparece arriba debe prestar servicios medicos y hospitalarios
adecuados razonables de acuerdo con lo dispuesto por la Ley de Accidentes de Trabajo.
El empleado lesionado debe recibir una copia del Primer Informe de Lesion. El empleado
puede elegir su propio medico. El costo razonable de los servicios prestados por el
medico que asista en el caso sera abonado por la aseguradora, siempre que el tratamiento
sea necesario y este razonablemente relacionado con la lesion ocupacional. En caso de
que se necesite atencion hospitalaria, por la presente se notifica a los empleados que la
aseguradora ha dispuesto que esa atencion sea prestada en:
NOMBRE DEL HOSPITAL DOMICILIO
ANUNCIO PUBLICADO POR EL EMPLEADOR