HomeMy WebLinkAboutBCOI-24-35 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:Days Inn Hotel BCOI-24-35
Trade Name:Days Inn
Identify property address including street number,name,city or town,and county Certificate Expiration
Located at 69 ROUTE 28
WEST YARMOUTH,MA 02673
April 23,2025
Floor Occupancy_ Use Group Other
Use Group Classification(s) 01st Floor 20 12-1 Hotels,motels,boarding houses, 20 Units
etc.
Allowable Occupant Load 0tst Floor 59 R-1 Hotels,motels,boarding houses, 59 Units
P etc. Lounge toom
Managers Apt
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.
Name of Municipal Building c 7//li/_I�G�\IT
Name of Municipal Chief Mar Its _ Date of Inspection —(
Commissioner /'�
Signature of Municipal Fire Signature of Municipal Building / I J/ Date of Issuance /Z
Chief Commissioner ��(� .Jt—//// y
TOWN OF YARMOUTH
0 -.641'� . y BUILDING DEPARTMENT
\ ML.. M 3LJ'� 1146 Route 28, South Yarmouth, MA 02664 508-396
APPLICATION FOR CERTIFICATE OF INSPECTION [MAR 0 024
March 1, 2024 PAYABL� 400 PU NT
(X) Fee t(tyuuc —
( ) 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 premiseses located at the e following Vaddress:
Street and Number: ) (Lt J� r v " t S I �M d- V II
�2CrT3
Name of Premises: Am 5 INN Tel: 5C/X — 77s _ Z�32
Purpose for which permit is used: Eta 1 Ire 41'ri'? cent,-
License(s)
or Permit(s)required for the premis�by othef governmental agencies: .�
q
License or Permit Agency
g,t'l (.e(1,141q4 be_ itetakiviA frA / 4-e/4.t
Ay
Certificate to be issued to p�-�-Z �F:U /V(T C�9(�.j� Tel: St)� - 7'7Si: Z 33 2 `�� ,�
Address: 6 ur—'L W? 'f' v�l%�l 4)41—• M� 0 L 041
� Ca
Owner of Rec rd of Building b e U C�
Address SaeM� C,i otbw .
Present Holder of Certificate PA-0.I p&-V h.tv oc (.,0 r►I?
•per/ iro2a-ar
Signature of person to whom Title
Certificate is issued or his agent 03-0 9-2
Date
Cc�M 5Q Li
Email Address: bey1 S ►n[\ N��9 � et �i(L�Q,�,� � ceil 1 7�3 J— '?8-7_(i (o
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 #
04/23/2024-04/23/2025
r»
'RKERS COMPENSATION AND EMPLOYERS LIABILItY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance 4ompany
54 Third Avenue, Burlington, Massachusetts 01803-0070
P (800)876-2765 NCCI NO 40959
POLICY NO. W+CC-500 5027250 2023A
PRIOR NO. WICC-500 5027250 2022A
ITEM
1. The Insured;; l'ari Devang Corp
DBA
Mailing addr : 69 MainYarm treet FEIN **"*"0836
outh,MA 02673
West
Legal Entity CorporatIon
Other workplaces not l wn above:
i
k
2. The policy is from Op/0912023 to 06109/2024 12:01 a.m.standard time at the insiured`s mailing address.
3. A. Worker oritpensatioonn nsurance:Part One of the policy applies to the Workers Compensation Law of the
states I here:
B. Emplo rs'Liability Instsance:Part Two of the policy applies to work in each state listed in item 3.A.
The Iimiisof liability under Part Two are: Bodily Injury by Accident i
i 500,000 each accident
Bodily Injury by Disease 500,000 policy limit
j Bodily Injury by Disease $ — 500,000 each employee
C. Other SOS Insurance: Coverage Replaced by Endorsement WC 20 0306 B
D. This PoH includes these Endorsements and Schedules: SEE SCHEDULE
\./ 4. The premium fir this policy vyill be determined by our Manuals of Rules,Clas$ifications,Rates and Rating Plans;
All information required required below is subject to verification and change by audit.
Classificatfonst 4,
t Premium BasisRates
4 --�
i
Code i Estimated ' Per$100 Estimated
No. Total Annual i Of Annual
Remuneration Remuneration Premium
4
1
i
INTRA i 4 4 i • 617
f I
INTER SEE CLASS CODE SCHEDULE { I {
__ _____.._____.__._ _.___.._.__._.____._____.__
Minimum Premium '' c q Total Estimated annual Premium $752
1_ O Deposit Premium $193
GOV GOV
ISTATE'GLASS
MA 1 9052 State Assessmerits/Sureharges,
$444.00 x 4.180E'I% $19
p� y ` m9= e _ ;j �___�
k --__ - .:
This poky,including rserrtertt�,is hereby countersigned by �-�- � ' 0510512023
Authon ' nature Date
:
i ,
Service(ice: Dowling and 0 Neil Ins Agcy {
54 Third Avenue 973 lyannough oad
Burlington MA 01803 Hyannis;MA 0 01
`/ WC000001 A(7-11
uwith Its ot the Nedonat ncit on Compensation Insurance,
I
1
1
Days I • :►.'ice:•a West
Y`l.o Cape Cod
Area
! ays1nnh 109,A„ .
�nl.
BY WYNDHAM
s �, ;,!�j►1
Registration -w •
'lie- #: '' 4 1'-?'rr:G=� `/
CIS
• di''-
•
lest Signature:
By signin•-hove,I agree to these terms and conditions
Terms and Conditions:(1)I agree that liability for my bill is not waived and agree to be held personally liable in the event that the
indicated person,company or association fails to pay part or full amount of these charges.Bills are payable upon presentation.I
shall be responsible for any loss or damages to the premises or contents. (2)The property is privately owned and management
reserve the right to refuse service to any one and will not not be responsible for injury or accidents to guests or loss of money,
jewelry or any personal valuables of any kind.
Initials:
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