HomeMy WebLinkAboutBCOI-23-1703 (2025) •
The Commonwealth of Massachusetts
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Town of ,�� 't:�o
ilt4., YARMOUTH os! :��°4
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) 01 st 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 Chief Name of Municipal Building Mark' D:te of Inspection / '/
Commissioner j' /��/�
Signature of Municipal Fire Signature of Municipal Building �� 'Date of Issuance
Chief Commissioner /:— - r////y
v
4A TOWN OF YARMOUTH
( — � BUILDING DEPARTMENT •
,,` MATTACnsc � � 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
"�.o.,:c •
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:
ukecStreet and Number: O U Yvto
Name of Premises: E COV1O 1 C) �, Tel: 5 0 - 7 4 1 - O {e3--e3
Purpose for which permit is used: \ QCA t9
urp
License(s) or Permit(s) required for the premises by other governme t l agencies.
RECEIVED
License or Permit Agency
MAY 0 8 2024
BUILDING C E i` ' �L�
Certificate to be issued to '\ 01 L 1, OS Vicinftz i ' ,el: cA - i 4-1 - 0 (A 9
Address: • 4# ,,. A _ — •
Owner of Record of Building 1)pNi rf Ntta .
Address 5 - 28 -
Present Holder of Certificate 7 p\i aryl_ p u
r
I �
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Signature o person to whom Title
Certificate is issued or his agent 061021 /)-3V1
Date
C C0Wt-
Email Address: r( �� Ay_p� � (Ct- P e CO a 6,`) VYL 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 # 13CD/43 420
06/29/2024-06/29/2025
A
NOTICE � * j NOTICE
TO
« 1 f TO
H !
EMPLOYEES //Jygy; EMPLOYEES
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