HomeMy WebLinkAboutBCOI-23-1711 2027 g YA TOWN OF YARMOUTH
1
C Office of the Building Commissioner
' 14, 1146 Route 28, South Yarmouth, MA 02664
) 508-398-2231 ext. 1260 Fax 508-398-0836
MATTACHEESE
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cfRPpRATE
APPLICATION FOR CERTIFICATE OF INSPECTION
June 1, 2026 PAYABLE UPON REC
(X) Fee Requi d$337.00
( ) No Fee Require
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: 13/Li) v-i _2q . 2' imty -(1 ne0 d2C2C Lj
Name of Premises. ( )A) >9/T7J' Tel:CSC'F)3 y -LIOCO
Purpose for which permit is used: Ayhta b I j vtA /ve2/l'o
License(s)or Permit(s)required for the premises by other goven enUall agencies:
License or Permit Agency
Certificate to be issued to/-111f?.01-5S91"D6C,1 NA) _Ait.1 Tel: ( - a z>
Address: 131 Lt • SO ',�LM.Q Lx-f ii , //V O.266 L,
Owner of Record of Building (-4/1-y/ ' 1 i` I / le V PA- rOe_ J•
Address Yrt C' —
Present Hol r of ertificate �4a,'v I V711 .SLu fC.))
7 0 6 111
Si et erson to whom itl .�
Certi c to is issued or his agent x.2.0 ,
c� to
Email Address: 1 Ea'VYl J OfS ayei ec ,et k
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-23-1711_
06/12/2026-06/12/2027
NP 79$484
AmTrust Insurance Company
A Stock Insurance Company
,4455 LBJ Freeway Suite 700
Dallas, TX 75244
WORKERS COMPENSATION WC 00 00 01 A
AND EMPLOYERS LIABILITY 1 of 5
,INSURANCE POLICY IN.FORMATION PAGE
'Insured; Polley Number: KWCI433$70
Gayatri Krupa Corporation
DBA;Ambassador Inn&Suites
1314 Route 28 Federal Tax ID: 200550066
South Yarmouth,MA 02664 Board File
Other workplaces not shown above: Number:
See Extension of Information Page Renewal Of: TWC457273 5
Producer: Entity: Corporation
Millennial Specialty insurance,LLC Ncei Code:
122 W 26th Street,2 SIC Code'
New York,NY. 10001
2.The policy period is from 3/9/2026 to 3/9/2027 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
hemMassachusetts
Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3./V
The limits of our liability under Pan Two are:
Bodily Injury by Accident S500,000 each!accident
Bodily Injury by Disease $500,000 policy limit
Bodily Injury by Disease $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 attached endorsement schedule.
4.The premium fur 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 2,290
STATE ASSESSMENT 92
TOTAL ESTLMATED COST 2,382
TOTAL ESTIMATED COST
396
Deposit Premium 2,382
'AAA ,
Issue Date: H30/2026 Countersigned By:
Authorized Repreiezitate.ii
4
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The Commonwealth of Massachusetts
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Town of ��
YARMOUTH ��i '' - 1
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+�CpRPp RATE��bA
New and Ranewal Certification of i..aNc..iion
In accordance with the Massachusetts State Building Code, Section 110.7
Identify Name of Establishment Certificate No.
Issued to Business Name:Ambassador Inn & Suites BCOI 23 1711
Trade Name:Ambassador Inn & Suites
Identify property address including street number, name, city or town, and county Certificate Expiration
Located at 1314 ROUTE 28 June 12, 2027
SOUTH YARMOUTH, MA 02664
Floor Occupancy_ Use Group Other
Use Group Classification(s) 01 st 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 Marl I - )ate of Inspection l —
p Commissioner /'� p 9/�S i 6
Signature of Municipal Fire Signature of Municipal Buildi of Issuance 7 / ///
Chief Commissioner /4,