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HomeMy WebLinkAboutBCOI-23-1760 2024 7 a) ƒ ? \ f # \ d r \ 7 ¢ 9 a / a \ t / ■ = m 0 ¢ L. = §_ a) � � = e = , 2 3 / \ / / ƒ Ee - aE % 5 ) c Oco CO F ® 6 § 2 / / % i as \ j / .b & = � § - fa 2 g ) 0 ] mmk % c Q ° § 0 § a 2 % o \ r f & a) 2 ° # \ 5 2 / 3 ¥ $ ¢ & _ ca 5 a & § n EI \ �o 2 ° § k ( 0 0 \ ) = ° c § k > £ = 4 \ 07e )ti . U a eo / & r LU Rt0ChOI / \ \ cu / . < 2 2 % ƒ 4 < 2 / 20 . O k O $ $ / p 2 2 2 2 / E � � n � = o ems / / \ \ / / \ � � Q1 k < 2 RI ( ) c / / df =cz ] § ■ tb 2 2 % CC § . _ \ g § \ ) $ / /� \ k / j 9 E a 2 e To 3 c \ / § � ^ 2 / \ a. � � 0 § 2 E E \ § R § t % / 2 7 / 2 \ \ 2k Z a _ / � EE ] E f a % \ } \ ƒ\ o . - a) \ C >a) . E 5 c 2 5E \ $ § \ / / } _0/ 0 a) ......4........, m \ 7 r ¥f n \cas u. 8 / 4 > e = _ 2 \ ' A lo 0 v / / / Cl) T.: ..i4 a 0 , $ C . 2/ 0 a m 2 = % 7 \ 75 c 2 © ai S ® \ 0 2 v Q 0 oC 2 2 S 2 o a 2 9 E f § � J J 2 \ f \ \ o 0 @ @ { \ 4 k k < 1- c / )\ £ } /§ Tar, ' r1 ENT(oi. ; r INCg t :: o$` 1146 Route 28, out °�a nac utl , I 0266408 398-2231 t. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION September 1, 2023 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) 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: �( Q 'QU t€ 6 h i�l 1 mnJrh Poc T r rr A j 7S Name of Premises: �}j ��r s ni.J + kPJIJGYCS Uerll) Tel: 9Q g - 3602 60 60/ Purpose for which permit is used: e e 1 eiu a-PIIyT License(s) or Permit(s) required for the premises by other governmental agencies: RECEIVED License or Permit Agency ---- ©off L cCQ Y SEP 2 9 2023 BUI D ENT By. Certificate to be issued to V'J JDe 2SDk.) Cs)E L,1-Q Tel: <? S L)020G Address: SO, 619Nefrx, QRT (70 De, Ny �b RoNcs , nnn QO I Owner of Record of Building (�, f} Q f'c o u Address qe COT Coed I B Q JS ie(e, in() ,Oc2 o�M Present Holder of Certificate J _)D e5n3 c oZ✓c y IrJc 7<D40 b-n w o Signature of person to whom Title Certificate is issued or his agent D S 1 c3G Cj I c O c j Date Email Address: t,,po e=,cc_nc .cp QLR)€(S PscJC\4r.nrJOKS . case-) 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# 12/31/2023-12/31/2024 NOTICE NOTICE TO =,A TO ,,mairr EMPLOYEES �`R EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MASSACHUSETTS 02111 617-727-4900 - http://www.state.ma.us/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: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222, Braintree, MA 02185-0000 ADDRESS OF INSURANCE COMPANY 014005035572123 01/01/23 -01/01/24 POLICY NUMBER EFFECTIVE DATES RogersGray 410 University Avenue, Westwood, MA 02090 O NAME OF INSURANCE AGENT ADDRESS PHONE# Oliver's & Planck's Tavern 960 Route 6A, Yarmouthport, MA 02675-0000 EMPLOYER ADDRESS 01/12/2023 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 services 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