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HomeMy WebLinkAboutBldcii-22-003875 The Common ea h of Massachusetts Ci \ �\ wn of YA ' , UTH _rL — 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: Howard Lodge Masonic Trust BLDCI-22-003875 Trade Name: Howard Lodge Masonic Trust Identify property address including street number, name,city or town and county Certificate Expiration Located at 20 DAVIS RD 2/24/2023 SOUTH YARMOUTH, MA 02664 Use Group Floor Occupancy Use Group Other Classifications(s) A-3 01st Floor 100 A-3 Amusement/Church/Gym/Library/Museum Fixed Seating Allowable 01st Floor 125 A-3 Amusement/Church/Gym/Library/Museum Additional Seating Occupant Load 01st Floor 175 A-3 Amusement/Church/Gym/Library/Museum Function Room/Tables &Chairs Total:225 Persons 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 / Signature of Municipal ( 9 P Signature of Municipal Date of Building Commissioner ( / Issuance J 3/.L Z Fee: $100.00 BLDCertofl nspection.rpt �``°t---- TOWN OF YARMOUTH . VIP BUILDING DEPARTMENT VA MATTAtM tVVIP r 1?.(f) �.�.,«�, 1.146 Route 28, South Yarmouth, MA 02664 508-398- t __. RECFWED APPLICATION FOR CERTIFICATE OF INSPECTION JAN 1 O 2022 i,, C _l_y�v !fl January 1, 2022 PAYABLE UPON ' ; ' I'ING DEPARTMENT (X)Fee Requ i - ._.:,:-:,:— ( ) 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 attthe following address: Street and Number: -O 94 U/j RO A cr SSAIY1 00 74 J `�/((� © (L/ Name of Premises: /-6(,U//x a i. U c f to /f f q/Y1 Tel: 90 le—MP— 6 3e Purpose for which permit is used: ,ri License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to Nokia IZLoI P/14c-s©M'6-T(t,c Tel: 52, 5/ d'- ,er3e, Address: 2,(9 P/tv1S A(i4C 7 i //R/n®Oh/ Dg-649 Owner of Record of Building // a it d Loire /5tt--p'c q/7? Address 2O d4k/lS /--(c ad Li y2/' mloa-t4 MA-0P66y ,i Present Holder of Certificate ,zuspd 1-Q fP /nLAvfri/G 7 Avsr - At4v ,4i,t;/-i.7_,ze 9(;/.<40(..-.04.-t-- Signature o erson to whom Tit i Certificate is issued or his agent s /m �02� e ate 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# •02/24/2022-02/24/2023 ' d ter;. Howard Lodge Masonic Trust Workers' Compensation LIMITS Workers'Compensation Coverage(Coverage A)Massachusetts Statutory Employers' Liability(Coverage B) Bodily Injury by Accident Each Accident ¢ $500,000 Bodily Injury by Disease Policy Limit $500,000 Bodily Injury by Disease—Each Employee Limit $500,000 Other States'Insurance(Coverage C) A lies t pp o all states except the monopolistic states of ND, OH, WA,WY and those covered under Coverage A. 9 Statutory TERMS AND CONDITIONS • Waiver of Subrogation—available upon •Voluntary Compensation and Employers Liability request Coverage Endorsement, WC000311, NOT Included BASIS OF PREMIUM State Classification 1Class 7 _ Estimated y i s,. Code .__ Payroll...._.._..... ._,._. _ MA Clubs-&Clerical:Social 19061 P $1,500 FORMS WC000000C Workers Compensation and Employers Liability Insurance Policy WC000115 Pending Law Change to Terrorism Risk Insurance Program Reauthorization Act Of 2015 WC000404 Pending Rate Change Endorsement WC000406A Premium Discount Endorsement WC000414 Notification of Change in Ownership Endorsement WC000421D Catastrophe (Other Than Certified Acts of Terrorism) Premium WC000422B T Terrorism Risk Insurance Program Reauthorization Act WC000425 Experience Rating Modification Factor Revision Endorsement WC200301 Massachusetts Limits of Liability Endorsement WC200302 Massachusetts-Assessment Charge WC200303C Massachusetts Notice to Policyholder Endorsement WC200401 Massachusetts Pending Premium Change Endorsement WC200405 Massachusetts Premium Due Date Endorsement WC200601A Massachusetts Cancellation Endorsement WC200604 Massachusetts Policy Definition Endorsement °Eastern JOIN US FOR GOOD' ; i Please refer to the policy for specific terms,conditions,limitations arid exclusions.A specimen copy of the policy is available for your review.Policy conditions supersede this document.