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,; ° f, of 1146 oute 28, South Yarmouth, MA 02664 508-398-223 `t 3 , 1 ' = D
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APPLICATION FOR CERTIFICATE OF INSPECTION JUL 18
2023
BUILDING DEPARTMENT
Jun 29, 2023 PAYABLE UPON RECEIPT By _
(X) Fee Required $100.00
( ) 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: ( 35 O�
Name of Premises: ` - ( C'(Th Tel: 508 17 CL o,
Purpose for which permit is used:
License(s) or Permit(s) required for t e premises by other go ernmental agencies:
License or Permit Agency
tN
Certificate to be issu d to �� L� 1:) L Tel: `''7i510,g2
Address: • \, (-)
Owner of Recor of Buildin - 1 _
Address f �(11 ���lC� �\� �- E oO(O 01 13r
P.esent Holder of Certificate ,0-t x - It
na e • person to whom Titlei . 91,.E
Date - 1
Certificate is issued or his agent ,d
��
n � i 1
Email Address: `rs@lJ` < 1J1 �r( CI S d C
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# 3Co/- 3_-/73 -Pct., Poct-e_.
05/20/2023-05/20/2024
?Q.,r+ 1 c'' h a, (s h ( a-lhb-k,E 5 . c ► ig
NOTICE
NOTICE
TO
TO
� S
EMPLOYEES EMPt-DYEE
alth of Massachusetts
The Commonwealth ACCIDENTS
INDUSTRIAL
DEPARTMENT OF IN BOSTON, MA 02111
LAFAYETTE,
LAFAYETTE CITY CENTER, 49 AVENUE a.gov/dia
(617) 72
Chapter 152, Sections 21, 22, & 30, this will give
As required by Massachusetts General Law,chapterto ees under the above
you notice that I (we) have provided for
payment
by insuring
uwith:eme y
mentioned
Hartford Casualty Insurance Company
NAME OF INSURANCE COMPANY
One Park Place, 300 South State St,7th Floor Syracuse NY 13202 _
ADDRESS OF INSURANCE COMPANY
03112l23 -03112/24 =—
08 ICY AK8XE EFFECTIVE DATES
POLICY NUMBER PO BOX 9011 (800)-304-8242 -_
WELLESLEY MA 02482 PHONE
CORCORAN &HAVLIN INSURANCE GROUP ADDRESS
NAME OF INSURANCE AGENT
135 ROUTE 28 WEST YARMOUTH MA 02673-4653
Hari Hospitality Inc ADDRESS
EMPLOYER
DATE
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY)
MEDICAL TREATMENT employment
out of and in the course the ovis'ons of the
reasonable hospital and medical services i accordance
e°.given to then injured employee. The
The above named insurer is required in cases of personal injuries arising g
Workersto furnish adequate and Act. of the First Report of Injury mustprovided by the The
employee may select
his A copy The reasonable cost of the services p ed for
g
may select or her own physician. and reasonably connected to the work related
physician willa bes pa by the insurer, ift thet treatment, e is
are haryerebynotified that the insurer has arranged injury. In cases requiring hospital attention, employees
such attention at the
ADDRESS
NAME OF HOSPITAL
TO BE POSTED
BY EMPLOYER
Form WC 88 20 01 E Printed in U.S.A.