HomeMy WebLinkAboutBCOI-23-1749 2024 Ts
a)
o 44' ° m
p rn a N N -0� _
cn
Lii c`) a a)
CU) N a) U) E p c a '�\
'.E. O cE OQ' c N +
Cac c . \-�
O O J .c �� c r-c- h�
V N L -r— \ "...
m o � -0 .3
d m a) 2 < a)
s mCC cc. F- F a)
p ia00)O ES U
rnLOCOH a) ca
u)Ti.0
0
•c c
� o ;Q
Z^ `O C 0 0 c
N L O U
O 7 co c >. a 7
a V O V •U c
43 rn a> cav o 0
z a) c
o a. c o CI
�.92
ph
th O o , 0
bo `o
CD _ O 0 0v) o0. =
y D a-0 -t ‘. 1
C C LI N (`6 ` c U
U) isd Q' O ca
a) a) ` y N 0 "0 N N
o C O H ti U o
ascn v.. = m CZ G co — •E 4
p I C a As a N < dioo
= c �0 v W o o H • m
L O ° Ili
�
00 a)
L C
a a) co '6 a w 2 _cU) —
Gu0CLV,) E0N vNw - o)
RI *_ N0)
Q Za) N Q
c >' t a Cr)a 0 G) "r Z (n a 0 p Q v m
E 0 N UJ 3 O c E
'� a NZ C ?� c) s C a
E L U
O _ CD c Op v! O N o O a
O 'a c co m a°) 1°a) ) 'CO.) `)
V 0 m ~ CE Q c o 0 c
s a .2 c`a o .N a) .N
as � ww o r co
d �+ a .n a) E m E
c
o a a) s � Z U CZ cm U
O L cn
C) O. +a) N
6 tt c
O
CO O O
a)
to O v) N I— c to
N N � _orQ
c .a C Rf = ,\A
cr
r+
0 v = 0 N to
0 co am to
L .a = O c
d N V To co C a U a v
a) U) O C. 00 '� ca a E
cco 2 O U c« O
:::: OU a) C t N N m
c.) N Q I— e c a)
co
c Z (n U
hQ ~ , '
r am " 1146 Route 28, South Yarmouth, MA02664 08-3€8- 3J ext-
. .., RECEIVED
APPLICATION FOR CERTIFICATE OF INSPECTION SEp 13 2023
September 1, 2023 PAYABLE UPON R
L IN(;DEPARTMENT
(X) Fe Re ' .
( ) 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 l ocated at the following address:
Street and Number: ` A / `�7�
Name of Premises: �4�1�tid i t;:te/4- 41/4ee.-- MA,l Tel: _ ? - 7:7k-C-0 Y 5
Purpose for which permit is used: kY" l'/ N` / ^,.K.
License(s) or Permit(s) required for the premises by other governmental agencies: _
�
License or Permit Agency —_\
Certificate to be issued to Gill-A,�✓N'c<f�; 42.(* fel� .,1 -1/(..5 —633�
Address: /4 /5',y✓A7 'Sr- --T:o CA-)e.l 2✓e 7j� el,? 7
Owner of Record of Building
Address
Present Holder of Certificate 6, Oi,Q c) `.S F*, 'c p !..r'7-/S/!/24 a T
P . A -L P tle -
Signature of person to whom Title
Certificate is issued or his agent 7.- .7
.r Date 6:7
Email Address: ece Cl,./ T /�d /961/ . 6-<-_, "1
Cv
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# 6 C 0/ --v 3- -7
12/31/2023-12/31/2024
40h4Cu.l i J .
NOTICE NOTICE
TO TO
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111
(617) 727-4900 — http://www.ma.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:
Hartford Accident and Indemnity Company
NAME OF INSURANCE COMPANY
One Park Place, 300 South State St, 7th Floor Syracuse NY 13202
ADDRESS OF INSURANCE COMPANY
08 WEC AY9G9D 09/01/23 - 09/01/24
POLICY NUMBER EFFECTIVE DATES
84 MYRON ST STE A
AXIA INSURANCE SERVICES INC WEST SPRINGFIELD MA 01089 (413)-205-2942
NAME OF INSURANCE AGENT ADDRESS PHONE
Giardino's Tastee Tower, Inc 242 MAIN ST WEST YARMOUTH MA 02673-4659
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 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
Form WC 88 20 01 E Printed in U.S.A.