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HomeMy WebLinkAboutBCOI-23-1711 2025 The Commonwealth of Massachusetts Town of o '4ay YARMOUTH ois °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:Ambassador Inn&Suites Trade Name:Ambassador Inn&Suites BC0I-23-1711 Identify property address including street number,name,city or town,and county Certificate Expiration Located at 1314 ROUTE 28 SOUTH YARMOUTH,MA 02664 June 12,2025 Floor Occupancy_ Use Group Other Use Group Classification(s) 01st Floor 36 R-1 Hotels,motels,boarding houses, 36 Units&Lobby etc. Allowable Occupant Load 02nd Floor 52 R-1 Hotels,motels,boarding houses, 52 Units-Managers Apt 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 ''1 Mark G s to of Inspection u Gi I Commissioner p up Signature of Municipal Fire Signature of Municipal Building G Chief Commissioner ate of Issuance `' . 7`ciRk. TOWN OF YARMOUTH �' � — DEPARTMENT BUILDING ce MATTA3�`�"SE/_ hy 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 . oQpOR►i CC�� ;/- 7 APPLICATION FOR CERTIFICATE OF INSPECTION May 01, 2024 PAYABLE UPON RECEIPT (X ) Fee Required $337.00 ( ) 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: I 33 / 4 ) 4©U T E' t 2-9' Name of Premises: a Y I'Y) Y StJ ) Tel: C G j✓vr� �ss c� � � � 3� I Purpose for which permit is used: a � taJPeC-/iH) o License(s) or Permit(s) required for the prem es by other go rnmenagencies: RECEIVED License or Permit Agency [ MAY 0 8 2Q24 B U I By._fiittkir. Certificate to be issued to Alty) kcsarivy 1 VI Yl 5LrfC J Tel: C 8) 3 cat-(-/000 Address: Owner of Record of Building Ci • Address 13 /L ) pa u.'f- e # , s O valyM4L , 2-66 Present Holder o Certificate A-7-1)be ci J ,' 1 y) 4 s Lu )- 1 isie-,, ei V, IT - hAtinaa-e/ Si p a e of person to whom Title Ce ificate is issued or his agent "3"tf/2-021/ Date qd Email Address: 4 w hrosadoY e ' am..____ 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 # eal--07 3 17 /l 06/12/2024-06/12/2025 NP 145906360 Technology Insurance Company, Inc. A Stock Insurance Company WORKERS COMPENSATION WC 99 00 01 B AND EMPLOYERS LIABILITY 1 of 5 INSURANCE POLICY INFORMATION PAGE Ncci Code:39071 I. Insured: Policy Number: TWC4395642 Gayatri Krupa Corporation DBA:Ambassador Inn&Suites 1314 Route 28 Individual _Partnership South Yarmouth,MA 02664 X Corporation Other workplaces not shown above: Federal Tax ID: 200550066 None Producer: Risk Id: Baldwin Krystyn Sherman Partners.LLC Renewal of: TWC4219545 410 University Ave Westwood,MA 02090-2311 2. The policy period is from 3/9/2024 to 3/9/2025 12:01 a.m.at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here:Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $500,000 each accident $500,000 policy limit $500,000 each employee C. Other States Insurance:Part Three of the policy applies to the states,if any.listed here: All states except ND,OH,WA,WY and States)Designated in Item 3.A D. This policy includes these endorsements and schedules: See Extension of Information Page 4. The premium for this policy will be determined by our Manuals of Rules.Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM 2,423 STATE ASSESSMENT 99 TOTAL ESTIMATED COST 2,522 Minimum Premium 400 Deposit Premium 2,522 Issue Date:2/1/2024 Countersigned by: orized Representative l_j