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Home My WebLink AboutBCOI-23-1715 2025 , - _V••11R o TOWN OF YARMOUTH y- CCA4. " �a .,�.o BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION May 01, 2024 PAYABLE UPON RECEIPT (X) Fee Required $133.00 ( ) 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'p located at the following address: Street and Number: )c '6p 1 Nxb b 0U1 Name of Premises: Cot P& C tit N Tel: S08 - 3 Q ,z 3 f f Purpose for which permit is used: M 0 7e L. License(s) or Permit(s) required for the premises by other governmental agencies: RFCF1VFD License or Permit Agency MAY 09 23 B 4E[9EPARTMENT Certificate to be issued to RA/1i,9:)f _ 4 Pc CM Tel: 5-08- 3 ce-c231 r Address: ,. . i/.! _.: .! _.1.' ' Liti ' MA- 42.6'4# Owner of Record of,Building l.,, •!f 7 Address ] A ' r. L Present older of Certif • - s'r 1.i.'�s/ A:1_ /,% J I Signtit i o person to whom Title Certfr • e is issued or his agent OS-- OQ _ ,ZO,Lq Date Email Address: C CV bt-OdQ, ¶Vt4O(L' CiaWl, 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# (--7 06/08/2024-06/08/2025 �' / --a3' 1 /l.c" /SOS e o YAM r' . 4 Print Form The Commonwealth of Massachusetts hw_ .... Department of Industrial Accidents Office of Investigations , ► 1 Congress Street, Suite 100 0„, '""r Boston, MA 02114-2017 00 ?� °" $1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: C4Pii,/Ck+1 � i - E �Jg Address: 0 6 ROLCL ,( 128 m 4Thone 14-City/State/Zip:s0u ( } jM,0 #: 608 - 3qg — �� ij Are you an employer? Check the appropriate box: Business Type (required): 1. qi I am a employer with d 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 .❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, Iwith no employees. [No workers' comp. insurance req.] 12.0 Other *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' com e sation insurance for my employees. Below is the policy information. Insurance Company Name:v24-40 M1J C& efdY,Cf Insurer's Address: p. o. d'Ok ((2 City/State/Zip: )RTT i C bogy JT. oS3 - 0 113 Policy # or Self-ins. Lic. # PD P S,(10,!3-2, 41/s Expiration Date: 10 - 17 2029 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 certify, under the pains and penalties of perjury that the information provided above is true and correct Signature: p �__� Date: O 0 q '' 2O) 4 Phone #: 5A 34 - 2i( 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 ' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Depai tilient of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02 1 1 4-20 1 7 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 7/2010