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HomeMy WebLinkAboutBCOI-23-1751- �; TO ... E V, ri f H ING I / 4 . T ;4„,m,` 1.146 Route 28, South �ar ��outh, MA 0266408 3 8-2231 ext. 1260 • 0\ APPLICATION FOR CERTIFICATE OF INSPECTION September 7, 2023 PAYABLE UPON RECEIPT (X) Fee Require $150.00 ( ) No Fee Require 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: /3 (/-) y `h F or f Oz 6 4- Name of Premises: Co!den 3 q,h pLIZ 7l'ex fle c Tel: 5-0 . 4? Purpose for which permit is used: R E C E I V E D License(s) or Permit(s) required for the premises by other governmental agencies: '--- �--- License or Permit Agency SEP 2 01023 (o r I C teens e I fi5 NC:ff.°�I BUftDING DEPARTMENT By Certificate to be issued to Coo10) • J Cd.)c. T), ti Tel: (/ 3 1— Li )— /7a (:,21/ Address: 13- Q --e C vo i cj, pi (- 1- Owner of Record of Building ci e_� 5 I ,�v l C- 1 Address 1 I ' 1 ( P�. ch 2 l:'�t" Present Holder of Certificate G-t II c1 co Signatureek- of person to whom Title Certificate is issued or his agent 9 // 1 Z /z3 1/\ c�'/ Date EmailAddress: 30 / eh3Q poe IYtP Noo- CM 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 CA OT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# IC.0 1— 43.../7,�- L 12/31/2023-12/31/2024 • ✓- -ilriLi L ,� . Y A NOTICE L r , r NOTICE TO TO EMPLOYEES A EMCo PLOYEES0 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Lafayette City Center, 2 Avenue de Lafayette, e 0 Boston, Massachusetts t 02111 800-323-3249 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I(we)have provided payment to our injured employees under the above mentioned chapter by insuring with: Associated Employers Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY W C C-500-5028097-2022A POLICY NUMBER 12/15/2022- 12/15/2023 c 973 lyannough Road Dowling and 0 Neil Ins Agcy DATES 9 y Hyannis, MA 02601 NAME OF INSURANCE AGENT ADDRESS (508)775-1620 Golden Jala no Tex Mex Cuisine Inc PHONE EMPLOYER 134 Route 6A Yarmouth Port, MA 02675 ADDRESS 11/21/2022 MEDICAL TREATMENT DATE 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. of the services provided by the treating physician will be paid by the insurer if the treatmentcis tnecessary 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 NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 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-500-5028097-2022A PRIOR NO. NEW ITEM 1. The Insured: Golden Jalapeno Tex Mex Cuisine Inc DBA: Mailing address: 134 Route 6A Yarmouth Port, MA 02675 FEIN:"'-*""7667 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 12/15/2022 to 12/15/2023 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 $ Bodily Injury by Disease $ 500,000 each accident 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 No. Total Annual Of E Atimated Remuneration Remuneration Annual Premium INTRA INTER 111111111 SEE CLASS CODE SCHEDU_E Minimum Premium $259 Total Estimated Annual Premium GOV GOV Deposit Premium $745 STATE CLASS $191 MA 9079 State Assessments/Surcharges $430.00 x 4.1800% $18 This policy,including all endorsements,is hereby countersigned by Authorized6ignature 11/21/2022 Service Office: 54 Third Avenue Dowling and 0 Neil Ins Agcy Burlington MA 01803 973 lyannough Road Hyannis, MA 02601 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with Its permission. 2 $ 7 � • cp $ /k / Q. t m as iN # \ W / a> Mt ¢ I a / G \ 3 ® c � t O ¢ § $ U = ° m = £ \ -,N \ .0 _ _ ' ) ƒ / o � 2S / a a5 co § 2 \ § \ § fa 2 C § o ] m m t c m 0 O § a tS % ca co c § ) 2 a3 \ Z / � » \ a 0 o \ n o - c °« a a / \ % c o J / S \ E& $ k § ) :- / co \ C. U3 ) ^ E /_ / ■ kxx = 7 ® e $ ® F ( k $ & % « E ) ° _ co I C -- / c & / \ \ \ @ 7 E i / / § O k 2k \ § F- C § as c0 co E ° f § a) oE / S \ e2 � � = £ 2 % ■ O ® co • Q © E / a -c cT3 2 � _ -a C cc § % 222 � § moca.m c , E E \ k f k } \ k / j o. in u _ E 77 ■ og 3 = 0 \ c _ _ ® 9 � ` Co co) k 2 \ § @ § § i- ■ / f 2 �J2 \ \ a) k 2 a 22@ a,E E o 0 � \ \ } \ /0 ¢ / 7 „ E / \ \ d 0 m -t o 2 2 § 2 / j .0/ a 0 ® k7 E ¥ f § La m � � E co \ ( - \ ) \ § 0 Q , cr cts — —I a) L / 2 4 / § .$ \ _ # = ® CD \ _ o g % % 2 / S i \ § 0. ■ o U o o c 5 z o 2 ° 2 F. ° ` \ • � � 2 o k 3 \ % • _ a) % 0 � o E c co £ 0) 2 // oF `1R"�., ,N \ TOWN OF YA 'I U r i t °‘ ) , BUILDING fk0 " ,t,_,.7 y 1146 Route 28, South Yarmouth, MA 02664 50 -3 ) -2231 (At. 1260 :' w` - ON APPLICATION FOR CERTIFICATE OF INSPECTION September 7, 2023 PAYABLE UPON RECEIPT (X) Fee Requir $150._0 0 f) ( ) No Fee Requir m— a 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: 11 .,>(-/ .r' 4a /1 ',/‘ 1-i ' i, i, 1/ i /''g/i r F € ' Name of Premises: CO l ►e n 3 t da.r fJ2 7) "`ex flex, Tel: 50' - 4 3 Purpose for which permit is used: E F :_, License(s) Di or Permit(s)required for the premises by other governmental agencies: r"°"" - '� .-°"_� License or Permit 12 1 I Agency I t «1 Bar INC; IW =o'tt?rM Y . Certificate to be issued to ' a ICI j i 0, )- (1 Tel: LP 3 '`- ;- ..- 9'7 c",- = I Address: 1 „ ~-ee _ ' A`t tit t'(.,t �`- 1 k' " +' Owner of Record of Building (. -, I i . i , Address =). 1 .r, ,m ,,l- ,., ,t:>f t t`t l 1 9 / Present Holder of Certificate ',,,. Z-- 4,7 w '. e / Signature of person to whom Title Certificate is issued or his agent e) 1 2 -' Date Email Address: 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 CA OT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# DC:,I)I---43�/-7s'" 12/31/2023-12/31/2024