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Home My WebLink AboutBCOI-23-1709 2026 ';.-i- Y4T TOWN OF YARMOUTH. / Office of the BuildingCommissioner t } 1146 Route 28, South Yarmouth, MA 02664 0.11 508-398-2231 ext. 1260 Fax 508-398-0836 ..MATTACHEESE q/'/ ,Cn N RPORATEC ✓` �"` -` J APPLICATION FOR CERTIFICATE OF INSPECTION March 04, 2025 PAYABLE UPON RECEIPT (X) Fee Required$121.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 8 7 /24-e_ te Name of Premises: V KA Iti-.44- , D N„,-Ctr 0,,4),J l4 Tel: 60 n O5O , Purpose for which permit is used: a/ee JC i r44• 3 ill License(s) or Permit(s)required for the premis ? u s by other governmentalthgencies: -RECEIVED P Lipense or Permit ��/�/ Agency MAY 0 8 2025 Zw/I-i- (1 / BUILDING DEPARTMENT By Certificate to be issued to .eax , t C-tt✓A Tel: 6(74;03 f`O006 Address: 7 0 ,2-41, ea-8 Ak/i Owner of Record of Building 7,,y,p i T . 1:::›J' 6,4 a,,%,¢(4,., Address 0 7 % Le.c S-J-i g-e/„,..`�"6 g.,v¢, o 1 ti1' P ent Hold o Ce i cate oc2‘,0ief"3 h 4.,owe ' , fr-es, Signature of rson to whom Title Certificate is issued or his agent V$-1").-11 //! Date Email Address: f,4v?04.eu- A Ou.,t/( AO &.^.- 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#BCOI-23-1708 04/19/2025-04/19/2026 - The Commonwealth of Massachusetts Print Form i - ..r Department of Industrial Accidents r'F '� • , ,E--- 1-4' Office of Investigations r, ! 1 Congress Street, Suite 100 4.,, Boston, MA 02114-2017 �-4 www.nass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Vi&.ka c c, /4 t (tea u„I-4y al b I u--4.Address: )6c1 ?eL e 2 i City/State/Zip: �C . yieG1 ';a-ta taiiCA Phone #: &/'--e3te 6 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. E Restaurant/Bar/Eating Establishment 2.❑ 1 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.Lf 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. [Nd workers' comp. insurance required]** 11.0 He lth Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12. Other-a' I SL $ tV7?7 i 1 *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#l. 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 e fy, under II • , ins , . , ' allies of perjui-'that the information provided abov is true and correct. Signature: � / '�✓� `� Date: //,) „ coi n Phone#: ( (/-" 3 L' ' 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 og vA TOWN OF YARMOUTH 0. Office of the Building Commissioner „' 1146 Route 28, South Yarmouth, MA 02664 fr� y) 508-398-2231 ext. 1260 Fax 508-398-0836 MATTACHEESE /4'00 q , FOORATE°, • : APPLICATION FOR CERTIFICATE OF INSPECTION March 04, 2025 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 premises located at the following address: �� Street and Number: s!'OV /ge- Name of Premises: Va 2v-t-o w7 -i- u 4470I Jcr Tel: 6n'0?8-6 ga Purpose for which permit is used: 1/VeJc4y S(.1k .w+— r iee-do RECEIVED License(s) or Permit(s) required for the premises by other governme t o4� al agencies: �~ MAY 08 2025 License or Permit Agency e00) 0�/p/N `/-si-lA P BUILDING DEPARTMENT 'AA- l� ey. Certificate ificate to be issued to .z ; 6..luv4-,. Tel: Ci-,- 936'-O&)b Address: 7 / ' 28 de Jr A Owner of Record of Building X.�.2 ---17- /3 I` �i-id v, ,' Address `7 ,ii4- -1- 440.3aO t 4.4 Ca irZ,b Pres nt Holder oCertificate 2 o2 O Q; e.40,...4,..-p, ignature of p son to whom Title Certificate is issued or his agent ;1—A'�,L- Date Email Address: ,/e,�+c0 e,�,c1-4, co ci y Ca) C. , COsv/ 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#BCOI-23-1709 04/19/2025-04/19/2026