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HomeMy WebLinkAboutBCOI-23-1703 2025 The Commonwealth of Massachusetts Town of ;/° Ao`, 1g) YARMOUTH a "�: a -°It.ORATE,' 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: Econolodge BCOI-23-1703 Trade Name: Econolodge Identify property address including street number, name, city or town, and county Certificate Expiration Located at 59 ROUTE 28 WEST YARMOUTH, MA 02673 June 29, 2025 Floor Occupancy_ Use Group Other Use Group Classification(s) 01st Floor 24 R-1 Hotels,motels,boarding houses, 24 units 101 &102 may not be rented etc. to quest with children.Swimming pool, game&laundry&vending room, Allowable Occupant Load 02nd Floor 25 R-1 Hotels, motels,boarding houses, 24 Units etc. Managers Apartment 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 ,. Date of Inspection / // Commissioner Lt Signature of Municipal Fire Signature of Municipal Building - I9 Date of Issuance �+ n Chief Commissioner , / L °F�;�k TOWN OF YARMOUTH " .,__ o C • BUILDING DEPARTMENT " T: �" 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION May 01, 2024 PAYABLE UPON RECEIPT (X) Fee Required $214.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, 1 hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 5 12.,0 ute. c) $ 1 \NI . y U 4' 4 Name of Premises: e COv101 O A.P, Tel: Cog }_ .3 Purpose for which permit is used: ( \'tk rut A a\ j.� QCi'O License(s) or Permit(s)required for the premises by other governme t 1 agencies RECEIVED License or Permit Agency '--------- ----- MAY 0 8 2024 BUILDING re� By: Certificate to be issued to e1: c ‘ 44-l- 069B Address: _ eN3 1?ip4Q a. g vN • yet^( \ ti A. . 0-2 6333 Owner of Record of Building pNI it it-J . Address 55 PA . ag . Present Holder of Certificate c Q i)crit / t&-4-ej 16\fic1 1,4- Signature o person to whom Title Certificate is issued or his agent O 510 L I924.2 II Date Email Address: C ovi c \ Air c C.t.Pe CO d ( �Vy1,0 .Co VA_. I 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# /500/. —)9 06/29/2024-06/29/2025 NOTICE } NOTICE TO K ' TO EMPLOYEES ' ' //ya�" EMPLOYEES ale The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Lafayette City Center, 2 Avenue de Lafayette, Boston, Massachusetts 02111 800-323-3249 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: Associated Employers Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WCC-500-5030196-2023A 11/24/2023- 11/24/2024 POLICY NUMBER EFFECTIVE DATES 600 Longwater Drive- Ste 300 HUB International New England LLC Norwell, MA 02061 (781)792-3200 NAME OF INSURANCE AGENT ADDRESS PHONE Econo Lodge 59 E Main Street West Yarmouth, MA 02673 EMPLOYER ADDRESS 11/03/2023 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 NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER The Commonwealth of Massachusetts . . Town of 'O ;, YARMOUTHgp) 3,� ►- c .0 H; 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: Econolodge BCOI-23-1703 Trade Name: Econolodge Identify property address including street number, name, city or town, and county Certificate Expiration Located at 59 ROUTE 28 WEST YARMOUTH, MA 02673 June 29, 2025 Floor Occupancy_ Use Group Other Use Group Classification(s) 01st Floor 24 R-1 Hotels, motels, boarding houses, 24 units 101 &102 may not be rented etc. to quest with children.Swimming pool, game&laundry&vending room, Allowable Occupant Load 02nd Floor 25 R-1 Hotels,motels, boarding houses, 24 Units etc. Managers Apartment 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 Commissioner Mark - D ae of Inspection /,/-///t! Lt Signature of Municipal Fire Signature of Municipal Building //� Date of Issuance U Chief Commissioner �7 7,r� r /�'/� `f•Y4R4 TOWN OF YARMOUTH o - 1� .Td BUILDING DEPARTMENT � 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION May 01, 2024 PAYABLE UPON RECEIPT (X) Fee Required $214.00 ( ) 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: 5 9 O y04! tkte g \4 . yMo�{*� Name of Premises: E coy,O 1 O P, Tel: tTg •1 }' 31 Purpose for which permit is used: Q t License(s)or Permit(s)required for the premises by other governme t 1 agencies. RECEIVED License or Permit Agency ----- MAY 0 8 20211 BUILDINGti4 m., By Certificate to be issued to i el: jos r 069 Address: cq 1274E a,2 \N • yuK�nno�lln c4 A . -2 631 Owner of Record of Building 'pN1 C1 Pq . Address 5 D_A . 2g Present Holder of Certificate pQv (1/ ditSi / -ej 1-4(.EYI iCAf Signature o person to whom Title Certificate is issued or his agent Q 510 L1 PZ-2 L Date Email Address: _ e(r) j c\ VY<<U' .CO Yvl_,. 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# cp -- 0 06/29/2024-06/29/2025 NOTICE NOTICE TO k TO M L PEES q EMPLOYEES EMP O / O'41 v,. The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Lafayette City Center, 2 Avenue de Lafayette, Boston, Massachusetts 02111 800-323-3249 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: Associated Employers Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WCC-500-5030196-2023A 11/24/2023 - 11/24/2024 POLICY NUMBER EFFECTIVE DATES 600 Longwater Drive- Ste 300 HUB International New England LLC Norwell, MA 02061 (781)792-3200 NAME OF INSURANCE AGENT ADDRESS PHONE Econo Lodge 59 E Main Street West Yarmouth, MA 02673 EMPLOYER ADDRESS 11/03/2023 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 NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER The Commonwealth of Massachusetts Town of z�Y; 9) YARMOUTH io 5 4.,''a: 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:Econolodge BCOI-23-1703 Trade Name:Econolodge Identify property address including street number,name,city or town,and county Certificate Expiration Located at 59 ROUTE 28 June 29,2025 WEST YARMOUTH,MA 02673 Floor Occupancy_ Use Group Other Use Group Classification(s) 01st Floor 24 R-1 Hotels,motels,boarding houses, 24 units 101&102 may not be rented etc. to quest with children.Swimming pool, Allowable Occupant Load game&laundry&vending room, 02nd Floor 25 R-1 Hotels,motels,boarding houses. 24 Units etc. Managers Apartment 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 D:te of Inspection /Commissioner /Chieature of Municipal Fire Conat ssi of Municipal Building(2);/1aricipe: '?/��,'Date of Issuancer {��/�/Chief Commissioner / 1`/r - '� TOWN OF YARMOUTH �o BUILDING DEPARTMENT .ve,MAg.(4- A,•,:c1 , 7 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 i APPLICATION FOR CERTIFICATE OF INSPECTION May 01, 2024 PAYABLE UPON RECEIPT (X ) Fee Required $214.00 ( ) 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: NAStreet and Number. çoak . Name of Premises: E CO'V't O\ o .e. Tel: cj O -4- 1 - O G 3 Purpose for which permit is used: QC� tO � License(s) or Permit(s) required for the premises by other governme t 1 agencies. RECEIVED License or Permit Agency E---- -- --- ---- MAY 0 8 2024 BUILDING leftps., By' • Certificate to be issued to t) •‘ sirVI \L C. 6 A CDV1,z\a t , ,el: 3c . 4 4-1 ^ 0 Co e' B Address: t2� C o.2 E \r,k u,(wwL\\ y rix A . o (o.+.. Building of Record of 1.-)pi oil.' P r . Address S 5 Ca - 28 - Present Holder of Certificate c \i aryl_ {u, -I- B\Actl-tik - it e- t '4".."`" ' l'i\ 10/11-cie,AT Signature o person to whom Title k\ Certificate is issued or his agent 06 0 L /07-34.2 L1 Date Email Address: ?( o'V1 oI 0 ,A Q, C LtP e CO A R trykcLA . Co VA_. Instructions: Make check payable to: Town of Yarmouth MA 02664 1146 Route 28, South Yarmouth, 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 f.4 4-20 06/29/2024-06/29/2025 NOTICE * 4 NOTICE TO _ TO ` 1N ` EMPLOYEES / 'yq�' EMPLOYEES 644 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Lafayette City Center, 2 Avenue de Lafayette, Boston, Massachusetts 02111 800-323-3249 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: Associated Employers Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WCC-500-5030196-2023A 11/24/2023- 11/24/2024 POLICY NUMBER EFFECTIVE DATES 600 Longwater Drive - Ste 300 HUB International New England LLC Norwell, MA 02061 (781)792-3200 NAME OF INSURANCE AGENT ADDRESS PHONE Econo Lodge 59 E Main Street West Yarmouth, MA 02673 EMPLOYER ADDRESS 11/03/2023 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 NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER The Commonwealth of Massachusetts Town of `°f ,,4,. 'Ik....p.rf YARMOUTH c '� y ,,RPU R AIEa�,/ 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: Econolodge BCOI-23 1703 Trade Name: Econolodge - Identify property address including street number, name, city or town, and county Certificate Expiration Located at 59 ROUTE 28 WEST YARMOUTH, MA 02673 June 29, 2025 Floor Occupancy_ Use Group Other Use Group Classification(s) 01st Floor 24 R-1 Hotels,motels, boarding houses, 24 units 101 &102 may not be rented etc. to quest with children.Swimming pool, game&laundry&vending room, Allowable Occupant Load 02nd Fiour 25 R-1 Hotels, motels. boarding houses, 24 Units etc. Managers Apartment 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 Chief62 Mark D:te of Inspection Commissioner ////4 Signature of Municipal Fire Signature of Municipal Building 1 Date of Issuance j , Chief Commissioner =,ice r !/1� L/ o TOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION May 01, 2024 PAYABLE UPON RECEIPT (X) Fee Required $214.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: '3(3 c&o uk-e. O U �V10 Name of Premises: £ C_OVi01 O e. Tel: Qg • t �G 31 Purpose for which permit is used: at ‘15) License(s)or Permit(s)required for the premises by other governme t 1 agencies. RECEIVED License or Permit Agency ----- MAY 0 8 2024 BUILDING By: Certificate to be issued to f el: `jo$ 4-k- 0 69 9 Address: cg ‘?i,) e ' art . \la^C v11�. M A . 210i-3 Owner of Record of Building pNl 01.1 P . Address 35 - 2$ �` 2 Present Holder of Certificate co ' c p di6i / u -c1 B\t, VA t4�Yl-x-led Signature isonthwhom Title Certificate is issued or his agent Q 510 11 1.010-q 11 Date Email Address: eCOV10\ Car cod (" o `M,,,1 , Co - 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 WOO R 'S COMPENSATION T OF INSPECT ANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE Certificate of Inspection# b(pl-43" 0 06/29/2024-06/29/2025 NOTICE ? * 1 c NOTICE TO TO PL YEES a EMPLOYEES 141 EM O /y The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Lafayette City Center, 2 Avenue de Lafayette, Boston, Massachusetts 02111 800-323-3249 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: Associated Employers Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WCC-500-5030196-2023A 11/24/2023- 11/24/2024 POLICY NUMBER EFFECTIVE DATES 600 Longwater Drive - Ste 300 HUB International New England LLC Norwell, MA 02061 (781)792-3200 NAME OF INSURANCE AGENT ADDRESS PHONE Econo Lodge 59 E Main Street West Yarmouth, MA 02673 EMPLOYER ADDRESS 11/03/2023 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 NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER The Commonwealth of Massachusetts - . - fr) Town of ;:; o, YARMOUTH ,a ,,,a .o - . \--,?RPORAr 0�. 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: Econolodge BCOI-23-1703 Trade Name: Econolodge Identify property address including street number, name, city or town, and county Certificate Expiration Located at 59 ROUTE 28 June 29, 2025 WEST YARMOUTH, MA 02673 Floor Occupancy_ Use Group Other Use Group Classification(s) 01st Floor 24 R-1 Hotels, motels,boarding houses, 24 units 101 &102 may not be rented etc. to quest with children.Swimming pool, Allowable Occupant Load game&laundry&vending room, 02nd Floor 25 R-1 Hotels,motels, boarding houses, 24 Units etc. Managers Apartment 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 Chief Name of Municipal Building Mark P Date of Inspection /,/// Commissioner l Signature of Municipal Fire Signature of Municipal Building ��/j� Date of Issuance •r /�� L Chief Commissioner �— '�� j . 2. 8 a _ c a ` 5 '.00 2)E .° N d M � E 0 � ) -- •Q. O c Ern 0 N N § c M a0 M 0 .c p- N ��Y N O N E � aci c � cr V i ,,z yr m •C 10 N cv C1 C o73ca E y V m le -) ate V {\� V o 3 c� a 2-c r "V �y. inea A rn .I•EEa) .F y ca U N .O a; ..a. N co m m C a t. 7 > p Q a o `o O Qo CO C L L a)QmNO C C N so 0 C 111 to G m2 p ° V c CO a `• Of y h O O 3 := y -a .y o 0 o 0 o N ,� .2 Q E E o N oas O o oY r °a ° C v ' ° o ` o m = = O V c s s .0 y G d > m m iliodV C d p �.. p `� `�. CI fq I .� o rn N E v,,, Y N! �! v i G RI Q a C p pp Q N .- G 2 G O = Wwv° awxcaUi ' 0 Q F Y- ai .. r.. : j a. ca It 0 0 nC 1 m O W V o ��Zco m 0zyoi a) CD C >- 3 P N � �a u) Ia d G = H W a Ev E v m E d o 'e 00 c > cmi r c��a = m m a 'h :10 N N .0 p l3 U 0 O C C.) C o N N 0.H V ` e (Q V C E Q 7 C w c Z 3 0 a '_a) 20 OO CO L w w y E y F Z v t c a E .E .E E E c E 0 = - R 0 90 U O � t � ZU in0 L. c 4 y v CO C • ++ U C 5 c p cC rn m O a 'C L w 8 U)) U C as N lb' a) h a)N III o 0 r N >, Nv . 'a O - c0 t Na) J awl) � C a.6 i a)c ivL. O r d 0 a O el, N IL ezx 3 a) co �v 0 :? ` U 1. a) y 0 0 0 U C o U * C J C. o w. cv a C L. AI U O O co 13 V en O N Trj o a) C H Q ~ m c w E O).E Z to U A TO N F YA '° rt lu BUILDING. DEPARTMENT 'r` n v ` 1146 Route 28, South Yarmouth, NIA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION May 1, 2023 PAYABLE UPON RECEIPT (X) Fee Required $214.00 ( ) 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: � Vi \-- "/ci i`vvia V1,q o,'Z G4..3 Name of Premises: C co vl t> i©A e___ Tel: �5 8 - 3�o 3— �C3_ G (cell') Purpose for which permit is used: OA)/rt a - 'S 1. License(s) or Permit(s)required for the premiby other governmental Agencies: RECEVFD License or Permit Agency .._ ,.. __ .lL . MAY 0 8 2023 BUIL y7-7 NT By Certificate to be issued to , r, t Tel: S o8 . 441, 0 b 11 Address: S 9 i, , Vy. ai inn xu'3(^ T61 1_02 Owner of Record of Building O v e MO Address . ..1,-Yme_. as /,c e Present Holder of Certificate sc Q_ aA ollnoue., ' (41'41 61Az 4) mayykq er )t, c Signature f person to whom t Title u Certificate is issued or his agent o S O-23. Date Email Address: ?(n1104,0`e cc corJ re YVlce_`I I, WW1_ C. 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# V 3_j7 73 06/29/2023-06/29/2024 /CoV1D /aye, NOTICE } NOTICE TO e ; ' TO PEES ' ' I:" EMPLOYEES EMPLO JJ/ yC�b'y-_ The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Lafayette City Center, 2 Avenue de Lafayette, Boston, Massachusetts 02111 800-323-3249 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: Associated Employers Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY W CC-500-5030196-2023A 11/24/2023- 11/24/2024 POLICY NUMBER EFFECTIVE DATES 600 Longwater Drive - Ste 300 HUB International New England LLC Norwell, MA 02061 (781)792-3200 NAME OF INSURANCE AGENT ADDRESS PHONE Econo Lodge 59 E Main Street West Yarmouth, MA 02673 EMPLOYER ADDRESS 11/03/2023 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 NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER