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Home My WebLink AboutBldci-23-004582 The Comm ealth of Massachusetts —" ty\Town of ;,:Il= -,�01= YARMOUTH T.'mum 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: Baxter Innkeeping LLC BLDCI-23-004582 Trade Name:Chapter House Identify property address including street number,name,city or town and county Certificate Expiration Located at 277 ROUTE 6A 2/27/2024 YARMOUTH PORT, MA 02675 Use Group Floor Occupancy Use Group Other Classifications(s) R-1 01st Floor 6 R-1 Hotel/Motel/Boarding House/Transient 6 ROOMS Allowable 02nd Floor 5 R-1 Hotel/MoteVBoarding House/Transient 5 ROOMS 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 3 !23 Signature of Municipal Signature of Municipal Date of Building Commissioner ./ Issuance 3/51? J Fee:$100.00 BLD_Certofl nspection.rpt (01. TOWN OF YARMOUTH "It . ki BUILDING DEPARTMENT MTo.TA�i,=� '9 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 RECEIVED APPLICATION FOR CERTIFICATE OF INSPECTION FEB 15 2023 January 1, 2023 PAYABLE UPON C IPT (X) Fe gigquifedV eOMENT ( ) No -- 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: 1,11 /ova 64 0144A) Name of Premises: Cof-4'P 7 A ,se, Tel: 7Oo° 41. Purpose for which permit is used: 110? � /A3 0 h 7,4-14.R4 GE. License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency d A7f- 640(/te- 6'94- Certificate to be issued to /34 i7 iA- /A/A/l12 t" - Tel: SO 9,4 2_ V?Ve Po g77 S Address: 'fro e8 o!c /s o3 , 10-sr 46/v its, X-(4- 02 6 4/f ( Cf—�c J Owner of Record of Building yA/ N4c.) + ?� fli c4tAJ J, G` e- Address 2, 1 dx /53 fpsr /7btw,s , i69 i Present Holder of Certificate RAX74- avk /r1�v1 Signa a of person to whom Title Certi icate is issued or his agent /s /2�3 Date Email Address: "P iL 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# ,36WI-073-{jb 02/27/2023-02/27/2024 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-500-5024303-2023A PRIOR NO. WCC-500-5024303-2022A ITEM 1. The Insured: Baxter Innkeeping LLC DBA: Chapter House Cape Cod a/o Baxter Yarmouthport Holdings LLC Mailing address: PO Box 1503 FEIN: "'0520 East Dennis,MA 02641 Legal Entity Type: Limited Liability Company Other workplaces not shown above: See Location 2. The policy period is from 02/11/2023 to 02/11/2024 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 001194667 INTER SEE CLASS CODE SCHEDULE Minimum Premium $273 Total Estimated Annual Premium $1,595 GOV GOV Deposit Premium $411 STATE CLASS MA 9052 State Assessments/Surcharges $1,143.00 x 4.1800% $48 This policy,including all endorsements, is hereby countersigned by /'/ - 01/11/2023 Authorized 'Signature Date Service Office: Dowling and 0 Neil Ins Agcy 54 Third Avenue 973 lyannough Road Burlington MA 01803 Hyannis, MA 02601 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with Its permission. Associated Employers Insurance Company Insured: 5024303 Producer: 10083-002-001 Baxter Innkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: **-***0520 Issue Date: 01/11/2023 Policy Number: WCC-500-5024303-2023A Endorsement Effective Date: 02/11/2023 Policy Period: 02/11/2023 - 02/11/2024 Endorsement Number: ENDORSEMENT SCHEDULE The forms listed below are included in this policy: Form No. Form Description Applicable States Policy Effective Date WC 00 00 00 C Policy Conditions 02/11/2023 WC 00 03 10 Sole Proprietors, Partners, Officers and Others 02/11/2023 WC 00 03 11 A Voluntary Compensation and Employers Liability 02/11/2023 WC 00 04 04 Pending Rate Change End. MA 02/11/2023 WC 00 04 14 Notification of Change in Ownership 02/11/2023 WC 00 04 22 C MA TERRORISM RISK INSURANCE PROGRAM MA 02/11/2023 WC 20 03 01 MA Limits of Liability Endorsement MA 02/11/2023 WC 20 03 02 A MA Assessment Charge MA 02/11/2023 WC 20 03 03 D MA Notice to Policy Holder Endorsement MA 02/11/2023 WC 20 03 06 B MA Limited Other States Insurance Endorsement MA 02/11/2023 WC 20 04 05 MA Premium Due Date Endorsement MA 02/11/2023 WC 20 06 01 A MA Cancellation Endorsement MA 02/11/2023 WC 20 06 04 MA Policy Definition Endorsement MA 02/11/2023 EndorsementSch(04/11) Associated Employers Insurance Company Insured: 5024303 Producer: 10083-002-001 Baxter Innkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: "-"'0520 Issue Date: 01/11/2023 Policy Number: WCC-500-5024303-2023A Endorsement Effective Date: 02/11/2023 Policy Period: 02/11/2023-02/11/2024 Endorsement Number: LOCATION SCHEDULE Insured Unit:001 Workplace:001 Business Type:Limited Liability Company Business Type: Chapter House Cape Cod a/o Baxter Yarmouthport Holdings 277 Route 6A Yarmouthport, MA 02675 TAX ID:854310520 Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: (1 t!1 1)LocationSch Associated Employers Insurance Company Insured: 5024303 Producer: 10083-002-001 Baxter Innkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: "*`*0520 Issue Date: 01/11/2023 Policy Number: WCC-500-5024303-2023A Endorsement Effective Date: 02/11/2023 Policy Period: 02/11/2023-02/11/2024 Endorsement Number: CLASSIFICATION CODE SCHEDULE Policy Unit: 001 Unit State Code: MA Policy Unit Name: Baxter Innkeeping LLC Billing Plan:4 Equal Quarterly Payments Classification Class Payroll Rate Estimated Description Code No. Amount Per$100 Premium CLERICAL OFFICE EMPLOYEES NOC 8810 128,600 0.06 77 HOTEL:ALL OTHER EMPLOYEES & 9052 83,961 1.27 1,066 Deviated Premium 1,143 Excess Employers Liability 1.00% 11 EEL Minimum Premium Adjustment 39 Premium Subject to Exp Mod 1,193 Standard Premium 1,193 Expense Constant 338 Terrorism Act Surcharge 64 Total Estimated Premium 1,595 DIA ASSESSMENT 4.18% 48 Total Estimated Premium& Surcharge(s) 1,643 ClassCodeSch(04/11) Associated Employers Insurance Company Insured: 5024303 Producer: 10083-002-001 Baxter lnnkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: 854310520 Issue Date: 01/11/2023 Policy Number: WCC-500-5024303-2023A Endorsement Effective Date: 02/11/2023 Policy Period: 02/11/2023- 02/11/2024 Endorsement Number: INSTALLMENT SCHEDULE Units Billed to this Unit:1 Policy Unit No: 001 Billing Plan:4 Equal Quarterly Payments Policy Unit Name: Baxter lnnkeeping LLC Installment/ DIA Total Amount Due Date Billed Endorsement No. Assessment Down Payment $12 $411 02/11/2023 Billed Installment 1 $12 $411 05/11/2023 Installment 2 $12 $411 08/11/2023 Installment 3 $12 $410 11/11/2023 Total $48 $1,643 InstallmentSch(04/11) Associated Employers Insurance Company Insured: 5024303 Producer: 10083-002-001 Baxter Innkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: "-"'0520 Issue Date: 01/11/2023 Policy Number: WCC-500-5024303-2023A Endorsement Effective Date: 02/11/2023 Policy Period: 02/11/2023-02/11/2024 Endorsement Number: POLICY RATING SUMMARY BY STATE Massachusetts Deviated Premium 1,143 Excess Employers Liability 1.00% 11 EEL Minimum Premium Adjustment 39 Premium Subject to Exp Mod 1,193 Standard Premium 1,193 Expense Constant 338 Terrorism Act Surcharge 64 Total Estimated Premium 1,595 DIA ASSESSMENT 4.18% 48 Total Estimated Premium &Surcharge(s) 1,643 Total Estimated Premium& Surcharge(s) $1,643 RatingSum(01/12) • NOTICE NOTICE TO 1.1t41, J . TO EMPLOYEES , �p� EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Lafayette City Center, 2 Avenue de Lafayette, Boston, Massachusetts 02111 800-323-3249 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: Associated Employers Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WCC-500-5024303-2023A 02/11/2023-02/11/2024 POLICY NUMBER EFFECTIVE DATES 973 lyannough Road Dowling and 0 Neil Ins Agcy Hyannis, MA 02601 (508)775-1620 NAME OF INSURANCE AGENT ADDRESS PHONE Chapter House Cape Cod a/o Baxter Yarmouthport 277 Route 6A Yarmouthport, MA 02675 EMPLOYER ADDRESS 01/11/2023 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER