HomeMy WebLinkAboutBHOU-24-15 4 � /3G� ti — / J / Office Use Only
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. , ;', _O Permit#
CA'::. . 1-3 RECEIVED FEE $50.00
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Yr''ti :FA ' MAY 12 2025 \ Z . Map
1— Lot
BUILDING DEPARTMENT
By
MANAGER /SEASONAL EMPLOYEE HOUSING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
APPLICATION FOR: MANAGER UNIT(S) (ZSEASONAL EMPLOYEE HOUSING
HOTEL/ MOTEL ADDRESS: 13) `)) ,P..-J # , (C1)I L _ 4 Yw T)0 v669
SPECIFY STREE #AND NAME 1
OWNER: r " '�`1 l >fJ0 3 'WO
J.(IE Q ' LEGA AD SS TEL. #
MANAGER: f 6 2.4 k&I ) �—�I VI C- A190✓G,.) r 6s 9 r 14 DOC
NAME ,,j LEGAL ADDRESS j /T�EL.#
ON SITE PROCTOR f�'/I�' Paid l / /� -611
NAME ROOM NUMBER CELL#
EMAIL CONTACT_f"4 Yhbr/ Q-61// litlet,tooi a iAt
TOTAL NUMBER OF LICENSED ROOMS:
NUMBER OF MANAGER/OWNER UNITS I ROOM NUMBERS C_ 5�erekl C 1/11 v'0NUMBER OF SEASONAL HOUSING UNITS : 4 (APRIL Ist—OCTOBERd 31')
15% MAX
ROOM NUMBERS: I JO 1 17-� 1I¢� 2.20i 23 3/ 2-3
I
I will comply with all applicable Town of Yarmouth Zoning Bylaws and all other applicable laws.
Seasonal employee housing shall be used solely by employees and shall not include family members or non-employees. chi'
I understand that any false statement(s)will be just cause for denial or revocation of my permit and may result in the town �� _
taking further legal action.
I declare under penalties of perjury that the s ements herein contained are true and correct. `
�
Applicant's Signature: / U7A.
Date: 1;0'6
Owner's Signature(or attachment) ki Date: )//'/
Approved By: Date:
Building Commissioner(or designee)
Updated 3/24
NP 154332244
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
1. Insured: Policy Number: TWC4572735
Gayatri Krupa Corporation
DBA:Ambassador Inn&Suites
1314 Route 28 _Individual _Partnership
South Yarmouth,MA 02664 X Corporation
Other workplaces not shown above:
None Federal Tax ID: 200550066
Producer: Risk Id:
The Baldwin Group Southeast LLC Renewal of: TWC4395642
410 University Ave
Westwood,MA 02090-2311
2. The policy period is from 3/9/2025 to 3/9/2026 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 State(s)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 2,235
STATE ASSESSMENT / 87
TOTAL ESTIMATED COST 2,322
Minimum Premium 396
Deposit Premium 2,322
Issue Date:2/1/2025 Countersigned by:
u orized Representative
A