HomeMy WebLinkAboutBCOI-24-29 2025 The Commonwealth of Massachusetts
Town of
YARMOUTH
New and Renewal Certification of Inspection
In accordance with the Massachusetts State Building Code,Section 110.7
Identify Name of Establishment Certificate No.
Issued to Business Name:The Inn at Yarmouth Port BCOI-24-2g
Trade Name:The Inn at Yarmouth Port
Identify property address including street number,name,city or town,and county Certificate Expiration
Located at 168 ROUTE 6A April 2,2025
YARMOUTH PORT,MA 02675
Floor Occupancy_ Use Group Other
Use Group Classification(s) 01st Floor 1 R-1 Hotels,motels,boarding houses, 1 Bedroom&Sitting Area/Bath/Office
etc.
Allowable Occupant Load 02nd Floor 6 R-1 Hotels,motels,boarding houses, 6 Bedrooms/Bath/Owners Apt
etc.
This certificate of inspection is hereby issued by the undersigned to certify that the premise,structure,or portion thereof as herein specified has been inspected for
general fire and line safety features.This certificate shall be framed behind clear glass and/or laminated and posted in a conspicuous place within the space as directed
by the undersigned.Failure to post or tampering with the contents of the certificate is strictly prohibited.
al Chief Name of Municipal Building
Name of Municipal Mark Gryl ate of Inspection 3 a I alp{
Commissioner Signature of Municipal Fire Signature of Municipal Building G Date of Issuance ///2 2 1/z t
Chief Commissioner 3//
'.01.Y 44 TOWN OF YARMOUTH g'(
o},o, . . y BUILDING DEPARTMENT dj
'� % 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 VI
%�4. �
APPLICATION FOR CERTIFICA OF INSPECTION
RECEIVED
March 1, 2024 ,-- PAYABLE UPON RECEIPT
MAR 06 2024 (X) Fee Required $100.00
( ) No Fee Required
TN
In accordance with the provisions of the a "ts Est to a Id i
le n: Code, Section 110.7, I hereby apply for a
Certificate of Inspection for the below-na • . sm es ocated at the following address:
Street and Number: I to / )LV f-e
Name of Premises: !h c• 7;:/7 pr lAr-mcJ`r-Vi I��. Tel: 50 S' — 77"'7 ' 7 5 y ,:,
Purpose for which permit is used: J f3C( .-t- g,'--e ct, /<
License(s) or Permit(s) required for the premises by other governmental ag ncies:
License or Permit Agency
Comvtnon, V` t c -FO.ct. ,..i.e)
'Le I/4 0e_ 007L.
F=12e _cct p $-r /% ge A Z1-"
Certificate to be issued to Th elnn i r l/4CcMovt4 1fTel: 5 2 3 — 7 44y - 7554„
Address: !'(' ,Qve,ye. 6 -4
Owner of Record of Building 0,47 y i3 d,4 21b1 /AI: .
Address ae ,4o'--c.,4G- 6.M
Present Holder of Certificate i' 1 pc�iC'
(-iY:le c-
Signature of person to whom Title f- ~Certificate is issued or his agent r/-R
Date
Email Address: k F&yS Jvi d ct ct VC,...L P co v . --__
.1
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 co-c --oi /
04/2/2024-04/2/2025
WORKERS COMPENSATION AND EMPLOYERS'LIABILTY
INSURANCE POLICY----INFORMATION PAGE
INSURER: POLICY NO: WE183697A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET RENEWAL
DEDHAM, MA 02026 NCCI Company No: 21059
Account No:
FEIN: 82-3053705
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
DAYBOARD, INC. DOWLING & ONEIL INSURANCE
168 ROUTE 6A AGCY
YARMOUTH PORT, MA 02675 PO BOX 1990
HYANNIS, MA 02601
AGENT NO.: 20762
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD:From: 01/12/2024 To: 01/12/2025
Effective 12:01 A.M.Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
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: $ 1,000,000 each accident
Bodily Injury by Disease: $ 1,000,000 policy limit
Bodily Injury by Disease: $ 1,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM:The premium for this Policy will be determined by our Manuals of Rules,Classifications,Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 221 Annual Premium: $ 862
Audit Period:ANNUAL, Additional/Return Premium:
Comments:
Issued At:
Date:12/04/2023 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
PRODUCER COPY