HomeMy WebLinkAboutBCOI-24-22- 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:Go Dutch Colving LLC
Trade Name:The Escape Inn BCOI-24-22
Identify property address including street number,name,city or town,and county Certificate Expiration
Located at 1237 ROUTE 28 February 17,2025
SOUTH YARMOUTH,MA 02664
Floor Occupancy_ Use Group Other
Use Group Classification(s) 01st Floor 6 R-1 Hotels,motels,boarding houses, 6 Units&Office
etc.
Allowable Occupant Load 02nd Floor 7 R-1 Hotels,motels,boarding houses, 7 Units
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.
Name of Municipal Building
Name of Municipal Chief Mark GryliV Date of Inspection �(�
Commissioner
Signature of Municipal Fire Signature of Municipal Building �
Date of Issuance ,,. _c 9 V
Chief Commissioner
• 7 TOWN OF YARMOUTH
BUILDING DEPARTMENT
•!0.;.,") 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 nV\
APPLICATION FOR CERTIFICATE OF INSPECTION V l '
IO.
January 1, 2024 PAYABLE UPON RECEIPT 1
(X) Fee Required $130.00
( ) 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: 1211 R O V f e Zg
Name of Premises:zT E- E S C 4 p& t C(/ Tel: 1O 12 3'1 2.( 5
Purpose for which permit is used: 1.l C es/l Se
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency RECEIVED
FEB 26 2024
BUILDING DEPARTMEN
251c4/o I3ccc tt Um-m(Q By
—i
Certificate to be issued to &o pu'1k lt CO I f v,vl� tot C. Tel: 41 D/ Z 3`3 7 64 5 •
Address: ZS *4 ai V ¢v V u a *3 ifuL-IvaPDRe r ,s2( Q -0 (02 $yo_ Q�
Owner of Record of Building &o fl v-{o Co II v t 4 L L.C [J p
Address 23 M.itnA 4ve 4.3 weuaDvfel R( OZ try 0 �5
Present Holder of Certificate
/1'ti4 A/B b-i R
Signs re of person to whom Title
Certificate is issued or his agent O2//t) /L y
Date
Email Address: ,gyve tee Scc2 pe pin (o'M
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# OC()/- 4a1-
02/17/2024-02/17/2025
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S I
y WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue,Burlington,o Massachusetts 01803-0970 NCCI NO 40959
(8
POLICY NO. WCC-500-5023306-2023A
PRIOR NO. WCC-500-5023306-2022A
ITEM
1. The Insured: Go Dutch Coliving LLC
DBA: The Escape Inn FEIN:«»'1171
Mailing address: Newport,RI 02840
Legal Entity Type: Limited Liability Company
Other workplaces not shown above: See Location
2. The policy period is from 10/19/2023 to 10/19/2024 12:0 a.standarde at t��Pened o ailingoaddress.
f the
3. A. Workers Compensation Insurance:Part One of the policy applies
states listed here: MA policy applies to work in each state listed in item 3.A.
B. Employers'Liability Insurance:Part Two of the po cy 50n accident
item each
The limits of liability under Part Two are: Bodily Injury by Accident $ __500 000 policyc
Bodily Injury by Disease $ _500 0�0 each employee
limit
Bodily Injury by Disease $
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, Lassifcetions,Rates and Rating Plans.
All information required below is subject to verification and change by
udi
- -
I Estimated Per$100Of Estimated
Annual
Remuneration
Total AnnualRemuneration Premium
INTRA 001186515
INTER 111111111 SE.CLASS CODE SCHEDU E
GO
Total Estimated Annual Premium $655
Min
o Premium $271 Deposit Premium $672
.V GOY
STATE CLASS State Assessments/Surcharges $17
�� 9052 $346.00 x 4.8200%
09/18/2023
This policy,including all endorsements,is hereby countersigned by Authorized ignature Date
Starkweather&Shepley Ins Brkg Inc
Service54 Thr Avenueen: PO Box 549
BurlingtonTn Providence,RI 02901
MA 01803
WC 00 00 01 A(7-11)
Includes copyrighted material at the National Council on Compensation insurance,
used with as permission.
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