HomeMy WebLinkAboutBLDCI-16-006087-06 The ComeIn 11th of Massachusetts
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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
Business Name: SURFCOMBER, INC. BLDCI-16-006087-06
Trade Name: SURFCOMBER MOTEL
Identify property address including street number, name,city or town and county Certificate Expiration
Located at
107 SOUTH SHORE DR 05/23/2023
SOUTH YARMOUTH, MA 02664
Use Group Floor Occupancy Use Group Other
Classifications(s)
R-1 01st Floor 16 R-1 Hotel/Motel/Boarding House/Transient BLDG. 1 -12 UNITS
BLDG.2-4 UNITS
02nd Floor 17 R-1 Hotel/Motel/Boarding House/Transient BLDG. 1 -13 UNITS
Allowable
BLDG.2-4 UNITS
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
Building Commissioner Inspection 6
Signature of Municipal Signature of Municipal Date of
Building Commissioner /` Issuance 0/ 4
ee:$169.00
BLD Certoflnspection.rpt
!a TOWN OF YARMOUTH
r , . �j BUILDING DEPARTMENT
��3".T,,C" SS6)3 `' 1146 Route 28, South Yarmouth, MA 02664 508-398- 1 ext. 1260
t_
m. RECEIVED
APPLICATION FOR CERTIFICATE OF INSPECTION APR 07 2022
April 1, 2022 PAYABLE UPON RECEIPT BUILDING DEPARTMENT
(X)Fe Re uired $162 _
( ) No Fee Required ,-,
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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: 1O Soc,, SOOr2 ' 1r C .
Name of Premises: ' l-4,v cc o cn b e.r I n c_ Tel: Sog 39 H eq 3 6
Purpose for which permit is used: N olret—
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
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L;c. J}o.ase, tNAW-d64.5 Maier:al5 \(i}2 He AC-INVETT•
Certificate to be issued to Su t-c c 0 Mb CI S r c . Tel: So b 3 q“ 8 9 3 a
Address: ►a"R- S• Stio,g_ pr. S. '1 pi 0,,,A, . MA Oa66Lj
Owner of Record of Building 1Cci'"3 .� otal
Address 340 w• 3oeQA R wR41,3(3Q 1 Nl 0 3a-4- 8
Present Holder of Ce icate J u s\ ' S v.3 o tck G .M .
G. M .
S'.gna a of person whom Title
C rti cate is issued or his agent Li-6- a a
Date
k.1 1-0L(- @ \Yid\-l�rt?��L L . Com
Email Address: V
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# ' ,i- hp— O p(p()&1—0 0
05/23/2022-05/23/2023
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. WCC-500-5017560-2022A
PRIOR NO. 'WCC-500-5017560-2021A
ITEM
1. The Insured: Surfcomber Inc
DBA:
Mailing address: 107 South Shore Drive FEIN:**-***6310
South Yarmouth, MA 02664
Legal Entity Type: Corporation
Other workplaces not shown above:
2. The policy period is from 01/01/2022 to 01/01/2023 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 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: Coverage Replaced by Endorsement WC 20 03 06 B
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.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 000120204
INTER SEE CLASS CODE SCHEDU_E
Minimum Premium $276 Total Estimated Annual Premium $3,779
GOV GOV Deposit Premium $980
STATE CLASS
MA 9052 State Assessments/Surcharges
$3,315.00 x 4.1800% $139
This policy, including all endorsements, is hereby countersigned by 12/16/2021
Authorized Signature Date
Service Office: HUB International New England LLC
54 Third Avenue PO Box 696
Burlington MA 01803 Wilmington, MA 01887
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
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