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HomeMy WebLinkAboutBCOI-23-1721 2027 '' YA� .. TOWN OF YARMOUTH ,,. 0\ Office of the Building Commissioner • 1146 Route 28, South Yarmouth, MA 02664 , - �/ 508-398-2231 ext. 1260 Fax 508-398-0836 MATTACHEESE /~CORPORATE%r. '� `- APPLICATION FOR CERTIFICATE OF INSPECTION July 1, 2026 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: 41� R�11't l� ' Name of Premises: I r �e__ i 1 I�.C,1-1'll�l Tel: (Sbg)3 to 2-3 1 $ _. Purpose for which permit is used: 0* c 4J -* L.bci sttl------ License(s) or Perinit(s) required for the premises by other governmental a eancies: UU License or Permit Agency Certificate to be issued to' J-e tI i-rtr' —1-0 Prppe.r{i e (-5o 5)3 62-31`bZ- Address: 61 . -t ) icPr ,n o?v r --WI 1Pcsr'-t-,►mot Pr L-�-c--' Owner of Record of Building V—1 n i -Fc r, � �Z(o1 Address o[2 12.m0}e-- �, ' t.1.a+-m ai pcsi--r . Nl Pr o 2-(0-I Present Holder of Certificate D R-- I...we( - >LFAA.40,A7 t)\r\rt .r- 1 ature of per to whom Title JUN � 8 2026 ertificate is issued or his agent 10/ I g/Z-LO Date BUILDING DEPART Email Address: CcQ COO&N 116,orat...I f f C,4M� 1 • C.ZTh G 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-23-1721 07/16/2026-07/16/2027 • — • ; .. - • . ' , , - , • _ n - ,• ' • . • -- RECEIVED JUN 18 2026 BUILDING DEPARTMENT THE ,.•' ©Y - - . - HARTFORD Policy Number 08 WEC BT3XBU Policy Effective Date 06/23/26 Jennifer Stuart Hospitality& Design, LLC 92 ROUTE 6A YARMOUTH PORT MA 02675 Dear Hartford Insured, Re: An Important Message to Workers Compensation Policyholders The control of workplace accidents and injuries should be among the highest priorities of your firm. Each accident wastes precious human and financial resources, and introduces inefficiencies into your operations. From a practical standpoint, the control of accidents, and their inevitable costs, simply makes good business sense. An effective risk engineering program can save you money and aggravation, can positively impact your loss experience (and thus your premium), and most importantly, can help you maintain solid control of your operations. As a service to you, our valued customer, the Risk Engineering Department of The Hartford in cooperation with your independent agent, can assist you in establishing risk engineering strategies. If you would like assistance, please complete and return to us the reply portion of this brochure, or contact your independent agent. Services Available The following is a description of some of the services that we provide. The types of services that may be appropriate for your business depend upon the nature and size of your operations and the specific risk engineering services you have requested. The cost of risk engineering services may or may not be a part of your insurance premium. This depends on the extent of the requested services, agreements stated in your insurance policy and program, and statutory regulations that may require us to provide risk engineering services. 1) Reference Materials — Information about risk engineering topics that can be provided or made available to you to help you to enhance your risk engineering program. 2) Telephone Consultation — We can hold a teleconference with you to help you to evaluate your risk engineering program, identify areas for improvement, and recommend ways to implement such improvements. 3) Onsite Consultation — This consists of visiting your premises and helping you to assess and remedy your risk engineering needs onsite. This level of service is usually only appropriate for larger, higher hazard operations. The following are examples of some of the services that could be provided onsite: o A review of your safety program to determine its adequacy and recommend modifications to that plan where needed. o Specific hazard evaluations, including ergonomics, industrial hygiene or material handling. o An initial survey and evaluation to address potential safety and health hazards. o Consultation to help management establish a comprehensive loss prevention Program. o Periodic summaries of accidents and analysis of causes. o Follow-up visits to check on progress and to provide continuing assistance when required. Form 97485 18th Rev. Printed in U.S.A. Page 1 of 4 Process Date: 05/14/26 Policy Expiration Date: 06/23/27 A Word About OSHA The Occupational Safety and Health Act of 1970 and similarly approved State Plans require employers to provide their employees with safe and healthful places to work. The Occupational Safety and Health Administration (OSHA) of the U.S. Department of Labor and similar State agencies enforce the regulations and apply penalties (civil and criminal) for non-compliance. New standards have been developed, and through application and interpretation, standards change. You should make yourself aware of the standards that are applicable to your operations, and assure yourself that reasonable efforts are made to be in compliance. Copies of the standards are available through most libraries, or can be obtained through OSHA or the U.S. Government Printing Office. You should know that neither The Hartford, nor any other party, can fulfill your obligations under the Law. Questions related to your legal obligations should be referred to your legal counsel. Some Safety Reminders from The Hartford: Have you considered: o The need to formalize your safety efforts to assure compliance and document your efforts? o The need to acquire Material Safety Data Sheets on all hazardous materials and the need for training on appropriate safety measures for your employees? o Requirements for record keeping of injuries, illnesses, and exposure to hazardous substances? o Assessing each job task to determine hazards and needed controls? o Measuring each exposure to hazardous substances to determine the need for control or personal protective equipment? o What mechanisms are in place to periodically verify that exposure controls (guards, ventilation systems, etc.) are still in place and working? o What specific training your employees and your supervisors need to avoid hazards in the workplace? o What specific OSHA standards apply to your business? o What mechanism exists to promptly investigate all accidents and `near-misses' to limit the chance of another occurrence? o The financial impact an injury or illness has on your business? o What resources are available to you to help prevent accidents and illnesses? Thank you for your business. Sincerely, The Hartford's Risk Engineering Department Form 97485 18th Rev. Printed in U.S.A. Page 2 of 4 THIS BROCHURE IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY. IT IS NOT INTENDED TO BE A SUBSTITUTE FOR A COMPLETE ON-SITE SAFETY INSPECTION CONDUCTED BY A QUALIFIED RISK ENGINEERING SPECIALIST. READERS ARE ENCOURAGED TO HAVE SUCH AN INSPECTION CONDUCTED BOTH TO PROMOTE WORKPLACE SAFETY AND TO COMPLY WITH APPLICABLE LAW, FOR ADDITIONAL INFORMATION OR ASSISTANCE, EITHER TELEPHONE OR MAIL THIS FORM TO YOUR HARTFORD AGENT OR NEAREST OFFICE OF THE HARTFORD NOTICE TO ARKANSAS POLICYHOLDERS The Hartford is required by law to provide its policyholders with certain accident prevention services at no additional cost as required by ARK. Code Ann. §11-9-409(D) and Rule 32. If you would like more information, call The Hartford's Risk Engineering Department, One Hartford Plaza, COG1, Hartford, CT 06155 at 1-866-586-0467. If you have any questions about this requirement, call the Health and Safety Division, Arkansas Workers' Compensation Commission at 1-800-622-4472. NOTICE TO CALIFORNIA POLICYHOLDERS The Hartford is required by law to provide its policyholders with certain occupational safety and health risk engineering consultation services as required by the California Labor Code, §6354.5, at no additional charge. If you would like more information call The Hartford's Risk Engineering Department at 1-866-586-0467 for occupational safety and health risk engineering consultation services. California Workers Compensation insurance policyholders may register comments about the insurer's risk engineering consultation service by writing to: State of California Department of Industrial Relations Division of Occupational Safety and Health P.O. Box 420603 San Francisco, California 94142 NOTICE TO PENNSYLVANIA POLICYHOLDERS The Hartford maintains and provides accident and illness prevention services as required by the nature of the policyholder's business or its operation, in accordance with the Pennsylvania Workers' Compensation Act. For more information about these services contact your Hartford Agent or nearest office of The Hartford. NOTICE TO TEXAS POLICYHOLDERS Pursuant to Texas Labor Code §411.066, The Hartford is required to notify its policyholders that accident prevention services are available from The Hartford at no additional charge. These services may include surveys, recommendations,training programs, consultations, analyses of accident causes, industrial hygiene and industrial health services. The Hartford is also required to provide return-to-work coordination services as required by Texas Labor Code §413.021 and to notify you of the availability of the return-to-work reimbursement program for employers under Texas Labor Code §413.022. If you would like more information, contact The Hartford at 1-866-586-0467 and email contactriskengineering@thehartford.com for accident prevention services or 1-877-952-9222 and email CentralClaimCenter.WCEDM@thehartford.com for return-to-work coordination services. For information about these requirements call the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) at 1-800-687-7080 or for information about the return-to-work reimbursement program for employers call the TDI-DWC at 1-512-804-5000. If The Hartford fails to respond to your request for accident prevention services or return-to-work coordination services, you may file a complaint with the TDI-DWC in writing at http://www.tdi.texas.00v or by mail to Texas Department of Insurance, Division of Workers'Compensation, P.O. Box 12050, Austin, Texas 78711. Form 97485 18th Rev. Printed in U.S.A. Page 3 of 4 Request for Technical Resources To The Hartford's Risk Engineering Department: Yes - I am interested in obtaining information concerning: General Topics Business Continuity Construction Accident Analysis Business Travel Safety Construction Site Consultation Accident Investigations - Contingency Planning Overview - Construction Equipment Hazards - Establishing a Risk Engineering Emergency/Disaster Response - Hazard Communication Program - Hazard Recognition Emergency Evacuation Drills - Ladders &Scaffolds — Safety Committees - Emergency Preparedness Planning Trenching & Evacuation Fall Protection Ergonomics Industrial Hygiene Property Back Injury Prevention Hazard Communication Automatic Sprinkler System Computer Workstation Industrial Hygiene (general) Flammable Liquids - Cumulative Trauma Disorders - Indoor Air Quality F• ire Prevention and Protection Ergo Train-the-Trainer Noise Exposures F• ire Drill and Evacuation - Telecommuting - Respiratory Protection Hot Work Permit Program Transportation Workers' Compensation Other Topics 3-D Driver Training Bloodborne Pathogens Business Risk Management Driving Defensively Drug Screening General Liability Investigations - Fleet Newsletter Machine Safeguarding Product Liability Programs — Guide to Successful Driver Mgmt - Return to Work Programs Safety Training School Bus Driving Tips Slip and Falls Security/Terrorism Name Company Policy# Address City&State Zip Code Email Address: Telephone For more information on the above, you can visit our website at https://www.thehartford.com/riskengineerinq Or you may forward your request to: Fax line: 1-860-723-4459 Or mail to: The Hartford Financial Services Group Risk Engineering Department One Hartford Plaza, COG1 Hartford, CT 06155 Form 97485 18th Rev. Printed in U.S.A. Page 4 of 4