HomeMy WebLinkAboutBCOI-24-66 2025 The Commonwealth of Massachusetts
Town of og.Y94
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YARMOUTH ,
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New and Renewal Certification of Inspection `�"°°""`E° /
In accordance with the Massachusetts State Building Code, Section 110.7
Identify Name of Establishment Certificate No.
Issued to Business Name: Parkers River Resort, LLC
Trade Name: Parkers River Reosrt BCOI-24-66
Identify property address including street number, name, city or town, and coup
Located atCounty Certificate Expiration
759 ROUTE 28
WEST YARMOUTH, MA 02673 June 26, 2025
Use GroupClassification(s) Floor Occupanc _
01 st Floor y Use Group Other
24 R-1 Hotels,motels,boarding houses, 24 Units
Allowable Occupant Load etc. Laundry Room
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 �`
Name of Municipal Chief Building
Commissioner Mark ryIIS Cate of Inspection o'is `%
Signature of Municipal Fire Signature of Municipal Building 'If
Chief Commissioner Date of Issuance Z�' Z�
' R4 TOWT OF YARMOUTH
o' .33- BUILDING DEPARTMENT
TecsM\T�TA �_,� 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 $142.00
( ) 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: 1 5 q CI Q re Jt
Name of Premises: Tmz.V*___\--2- ii-tZ 1?c-1/4:0:1-- Tel: �'J `6. /114'46-10 L i
Purpose for which permit is used:
License(s) or Permit(s)required fort e premises by other governmental agencies:
liECEIVFD
License or Permit Agency i r
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5 MAY 0 7 2024
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By
Certificate to be issued to TAVe42 frLte_Tel: 5d 0393 Z:� #A
Address: TTSCi IliAlrV -1".. 5 4 eiY titil /2Z�
Owner of Record of Building r
Address 176 PAX • VAC1.-1'1n Vfl F)k i3
Present Holder of Certificate
(--...."..S_,
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ature of pers to whom Title
Certificate is issued or his agent 5- 14
Date
Email Address: V -t t aez"4'1 Q CCrMCASJ . 44 er
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 ISSU YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection# (C 0t-c ' 6
06/26/2024-06/26/2025
WORKERS COMPENSATION AND EMPLOYERS' LIABILTY
INSURANCE POLICY---- INFORMATION PAGE
INSURER: POLICY NO: WE114835A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET RENEWAL
DEDHAM, MA 02026 NCCI Company No: 21059
t
Account No:
FEIN: 26-1913272
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
PARKERS RIVER RESORT LLC ROGERSGRAY
759 MAIN STREET 410 UNIVERSITY AVE
SOUTH YARMOUTH, MA 02664 WESTWOOD, MA 02090
AGENT NO.: 20577
LEGAL ENTITY: LIMITED LIABILITY COMPANY (LLC)
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD: From: 05/18/2023 To: 05/18/2024
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: $ 500 ,000 each accident
Bodily Injury by Disease: $ 500,000 policy limit
Bodily Injury by Disease: $ 500 , 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: $ 223 Annual Premium: $ 357
Audit Period: ANNUAL Additional/Return Premium:
Comments :
Issued At:
Date: 04/10/2023 Countersigned by