HomeMy WebLinkAboutBCOI-23-1709 2025 The Commonwealth of Massachusetts - -
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YARMOUTH losit Ord
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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:Yarmouth Country Cabins BCOI-23-1709
Trade Name:Yarmouth Country Cabins
Identify property address including street number, name, city or town, and county Certificate Expiration
Located at 864 &878 ROUTE 28 April 19, 2025
SOUTH YARMOUTH, MA 02664
Use Group Classification(s) Floor Occupancy_ Use Group Other
01st Floor 1 R-1 Hotels, motels,boarding houses,
Allowable Occupant Load 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 Chief Name of Municipal Building t Inspection Mark II o of
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Commissioner
\Signature of Municipal Fire Signature of Municipal Building Date of Issuance l
Chief Commissioner 61 ZS-/z. y
k a 'Y. ` o, TOWN OF YARMOUTH
�' '' -y BUILDING DEPARTMENT
`� " ,�; .�':a 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
March 1, 2024 PAYABLE UPON RECEIPT
(X) Fee Required $100.00
( ) No Fee Required
In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a
Certificate of Inspection for the below-named-nf premises located at the following address:
Street and Number: 0 ! /�- e gg
Name of Premises: l /4/Lvu 0 u'+ L 00144.7(77 C,4Tel: (7 ' V( -3O
Purpose for which permit is used: �2,450.v,4- / (16 #0,4; e A9i414 l-1 / "
License(s)or Permit(s)required for the premises by other goVernmental agencies: ' �"
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License or Permit Agency ey /`��ti • 0� '•-.,$s
/1e,4- /-A 1 ce 49,4 o4 / /1 \c4 i
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Certificate to be issued to /-P,li4ie D��A2✓v4NN/ Tel: ' 1-7—g3 Os'()-6
Address: 7g �c � 2-e/ //
G(0020.46
Owner of Record of Building -82,i, d`.S-- P ', /v Val 0,1/
Address Co 7 ,1i4 ivie S 7 , ,f /u o -J �4' 2 y7/
Present Holder of Certificate Ge,e,14" / i , 4/`a-/ov.,t44,1 /
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Signature of p r n to whom TitleJ//
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Certificate is issued or his agent /S/ 79/
Date
Email Address: /fre ie 07/d ao,UtiT✓�y C 0/- • 004'1
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 #
04/19/2024-04/19/2025 &0/ 3'-1/.�
The Commonwealth of Massachusetts Print Form
P.� Department of Industrial Accidents
1 .e Er Office of Investigations
1 Congress Street, Suite 100
'A., x Boston, MA 02114-2017
; s�• ` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information k
Please Print Legibly
Business/Organization Name: Cato u'7" l-1'N 4/ (' 4 i i�a."f
Address: ,y6c,/, 2,,/„ gis
City/State/Zip: sc).. yeft,,0 u e j'1 & Phone #: (/?-' ..,/ rit° 6
(
Are you an employer? Check the appropriate box: Business Type (required):
1.ElI am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
.__. [..No workers' comp. insurance required] 8. ❑ Non-profit
3. We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** 11.❑ He lth Care
4.III We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12. Other lj dC��L 4'it/tn(0�✓' ✓
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby er ify, under t ins i alties of perjury that the information provided abov is true and correct.
Signature:. Date: /���' r�
2 q �� p d
Phone#: (- (�J e3 ^- 0 b9
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia