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TA �C .:,JA .. DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 08-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
May 1, 2023
PAYABLE UPON RECEIPT
(X) Fee Required $337.00
( ) No Fee Required
In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereb for
Certificate of Inspection for the below-named premises located at the following address: y apply a
Street and Number: 1 3 / 4
2S'
Name of Premises: �
beli -y thY) F Tel:( r}g 39
-4/090
Purpose for which permit is used: j Cafe_
License(s) or Permit(s)required for the premise y other gove ental a encies:
License or Permit .�' F
Agency
FHAY 17 2023
Bu
E3v �Aj NT
� / i �/
Certificate to be issued to fll SSGIC/eY in,n s cu j 3 Tel:( V9 -
Address: 37' S � 3 4OO
Owner of Record of Building Y►'1 026 6
Address . ‘ 2 6
Present Holder of_ ificate ha C Cam,,�A,Y 1)111 te4
ran C�`
Si r f person to whom /-vyS(
Certifi a e is issued or his agent Title 11 V
S--- G 202
Date _L
Email Address:inAgerat/WOja410Y ceo .0 --P Ta
D SSC`sk br Co ill
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
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. or structure or part
PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS
APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF
Certificate of Inspection# g� )/--a3,/7 INSPECTION.
06/12/2023-06/12/2024 ��
Technology Insurance Company, Inc.
A Stock Insurance Company
WORKERS COMPENSATION
AND EMPLOYERS LIABILITY WC 99 00 01 5B
INSURANCE POLICY 1 of 5
INFORMATION PAGE
Ncci Code:39071
1. Insured:
Gayatri Krupa Corporation
Policy Number: TWC4219545
DBA:Ambassador Inn&Suites
1314 Route 28
South Yarmouth,MA 02664 Individual_ Partnership
Other workplaces not shown above: X Corporation
None Federal Tax ID: 200550066
Producer: Risk Id:
Baldwin Krystyn Sherman Partners,LLC Renewal of: TWC4072618
410 University Ave
Westwood,MA 02090-2311
2. The policy period is from 3/9/2023 to 3/9/2024 12:01 a.m.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:Massachusetts
B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$500,000 each accident $500,000 policy limit $500,000 each employee
C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here:
All states except ND,OH,WA,WY and State(s)Designated in Item 3A.
D. This policy includes these endorsements and schedules:See Extension of Information Page
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.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM
STATE ASSESSMENT 1,967
TOTAL ESTIMATED COST 67
Minimum Premium 2,040
rt/
Deposit Premium 402
Issue Date: 1/31/2023 Countersigned by: 2,040
Au ized Representative