HomeMy WebLinkAboutBLDCI-23-000768 The C mo ealth of Massachusetts
City\Town of
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YARMOUTH
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Try / New and Renewal Certificate of Inspection
In accordance with the Massachusetts State Building Code, Section 110.7
Identify Name of Establishment Certificate No.
Issued to BLDCI-23-000768
Business Name: First Congregational Church of Yarmouth
Trade Name: First Congregational Church of Yarmouth
Identify property address including street number,name,city or town and county
Certificate Expiration
Located at 329 ROUTE 6A 9/1/2023
YARMOUTH PORT, MA 02675
Other
Use Group Floor Occupancy Use Group
Classifications(s) A-3 Amusement/Church/Gym/Library/Museum 342 Persons in pews
01st Floor 344 A-3 2 Persons wheelchair
Spaces
Allowable
Occupant Load
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 life safety features. This certificate shall be framed behind glass and/or laminated and posted in a conspicuous place within the space as directed
by the undersigned. Failure to pose or tampering with the contents of the certificate is strictly prohibited.
Name of Municipal Name of Municipal Mark Grylls Date of �` A
Building Commissioner 1t5�9ection -/ A
Signature of Municipal42 / ate of
Signature of Municipal
Building Commissioner Issuance Zq 0z.
Fee: $50.00
BLD Certoflnspection.rpt
°i R, TOWN OF YARMOUTH
7,1• 1� BUILDING DEPARTMENT
kA .:� "
aow„,: n 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
August 1, 2022 PAYABLE UPON RECEIPT
(X) Fee Required $50.00
( ) No Fee Required
In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a
Certificate of Inspectionn for the below-named premises located at the following address:
Street and Number: 32r-�' N ,(� Sr,ta `(o p o 4& Port
Name of Premises: f- YOfi1 ldliot Tel: `J A--3€ 2- fOCt7 7
Purpose for which permit is used:
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
- -lt.St- COvkgt€_9cl.kdv.La02-
Certificate to be issued tcCilW d c yyak-A4 O Tel: 5�` 360 - Co c2 7 7
Address: '3 k.(a i S+, y O c.tf-{,` port NA O Zb7S
Owner of Record of Building
Address
Present Holder of Certificate
.;) (Wm( (o6trrc g_
Signature of erson o whom Title
Certificate is issued or his agent %--7-a D-
Date
Email Address:
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# B(,DC.f—23 ODD7(00k
09/01/2022-09/01/2023
x.:pi
Church Mutual Insurance Company, S.I.
N - NCCI CARRIER CODE NO. 16853 WC 00 00 01A
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
1. The Insured: FIRST CONGREGATIONAL CHURCH Policy No. 0187606 07-302281
OF YARMOUTH
Renewal of: 0187606 07-170554
Individual Partnership
Mailing address: 329 ROUTE 6A X Corporation or
YARMOUTH PORT, MA 02675-1817 See Schedule
Federal Employers I.D.#
Inter/Intrastate Risk I.D. #
Other I.D. #
Other workplaces not shown above: See Schedule Contact
Phone Number
2. The policy period is from 12/2 3/2 0 21 12:01 a.m. to 12/2 3/2 0 2 2 12:01 a.m. standard time 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: MA
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:Bodily Injury by Accident $ 500, 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 states designated in Item 3 .A. of the Information Page
and ND, OH, WA, WY.
D. This policy includes these endorsements and schedules: See Schedule
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.
Premium Basis Rate Per
Code Total Estimated $100 of Estimated
Classification No. Annual Remuneration Remuneration Annual Premium
See Item 4 . Extension WC 00 00 01A
Total Estimated Annual Premium $ 1, 950
Expense Constant$ 3 3 8 Taxes and Surcharges $ 72
Minimum Premium $ 288 (MA) 9101 Deposit Premium $ 2, 022
See Item 4 . Extension WC 00 00 O1A for the Taxes and Surcharges for:
MA
Premium Adjustment Period: Annual Countersigned by:
Servicing Office: Church Mutual Insurance Company, S . I . Date: 10/29/2021
Producer: ALEX PEREZ
Church
Mutual
Copyright 1987 National Council on Compensation Insurance.
Original INSURANCE