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� AwT I WN OF YA MOUT
o. BUILDING I EPA_
ENT
AV
1146 Route 28, South Yarmouth, MA 02664 5( 39 2231 ext. 1260
} 1
APPLICATION FOR CERTIFICATE OF INSPECTION
April 1, 2023 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: 6 1(1(2— , 1
/� ,�J `l (w'd I r.7df YGt.r'n.,,,a7 l'low L 1L.{e
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Name of Premises: 1A r,Q t4 -Y I a/L Tel:
Purpose for which permit is used: 4(1 w,�,,�, i
RFCFIVED
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency APR 7 2023
fR 1Y La n i'VICM a_ 5, Dfr./... BUILDING DEPARTMENT
Certificate to be iss ed to Yr opt ; , a hill Tel: &S&S`—3i,2..-7c h c
Address: 6 Ira nt ,u-1- ! . 'At
Owner of Record of Building a p e 'arc- AMON du ilea
Address 6,1 `_-
Present Holder of Certificate 5/1 L
jYea6r4✓cr
Signature o erson to who Ti;
Certificate is issued or his ag t Z-J` 2- Z3
Da e 71
i
Email Address: vvt, h7dt l . COr✓d
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#
05/08/2023-05/08/2024
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800)876-2765 NCCI NO 26158
POLICY NO. VC-100-6023781-2023A
PRIOR NO. WVWC-100-&023781-2022p,
ITEM
1. The Insured: YARMOUTH NEW CHURCH PRESERVATION FOUNDATION INC
DBA:
Mailing address: 266 MAIN ST RT 6A FEIN:**-***8907
YARMOUTH.MA 02675
Legal Entity Type: Corporation
Other workplaces not shown above:
2. The policy period is from 04/01/2023 to 04/01/2024 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 $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 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 1138562
INTER SEE CLASS CODE SCHEDULE
Minimum Premium $182 Total Estimated Annual Premium
$225
GOV GOV Deposit Premium $226
STATE CLASS
MA 8810 State Assessments/Surcharges
$31.00 x 4.1800% $1
This policy,including all endorsements,is hereby countersigned by ;i o�
03/24/2023
Authorized gnelure Date
Service Office: Roger Keith&Sons Insurance Agency Inc
54 Third Avenue
Burlington MA 01803 1575 Main Street
Brockton,MA 02301
WC 00 00 01 A(7-11)
Incl a copyrighteddes material of the National Council on Compensation Insurance,
permission.
From: Ruth CoutMla rcoutinho@rogerkeith.corn 6'
Subject Certificate of Insurance ;
Date: April 11,2023 at 422 PM � f
To: wlpeat@gmail.com
Hi Leslie,
The WC website finally updated your policy,please find attached the certificate for
Town of Yarmouth 23-24. Sorry for the hold up,have a nice day.
Sincerely, RECEIVED
Ruth Coutinho APR .l 3 2023
Receptionist/Administrative Assistant
BUILDING DEPARTMENT
Roger Keith&Sons Insurance Agency By
Gammons Insurance
328 Bedford Street
Lakeville, MA 02347
Office: (508) 947-3460
Fax: (508) 947-6844
rcoutinho@rogerkeith.com
Please send all certificate requests to: certificates@rogerkeith.com
Accateri CERTIFICATE OF LIABILITY INSURANCE omaismoomoto
0 111PBA29
11414 CERTIFICATE IS MOW AS A MATTER OF$NFORMATIOM ONLY AND CONFERS NO RIGHTS UPON TILE CEIRTWICATE HOLDER.,THIS
CERTIFICATE DOES NOT ARRIMATIVELY 0111 NEGATIVELY AMEND.EXTEND CR ALTER THE COVERAGE AFFORDED BY 111E POLICIES
MOW THIS CERTIFICATE OF INSURANCE DOES NOT COMMUTE A CONTRACT SE'FRIEEN Ito aletrOte Ill AUTHORIZED
REPRESENTATIVE OR PRODUCER.ARO TIE CERTIFICATE HOLDER.
IMPORTANT: a Ilse isrETlsss.MOW Is so ADOSTIONAL mum,Os poSsy(IAA)must Aens AMTIONAL 1skm it s.sofforiot
tT SUClROGATION to MTi1I1iEt1,tobjout to the term and carmlitthamt at tits pokey.sorb&policies msy some.anendamtememt A Mararsnt an
Iiels Ralik/HA dells not contr►enlists Is His csNDcs/s beMdm ills Ilse at suctii sus).
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ROGER KEITH&SONS INSURANCE AGENCY INC ,. 45081583=1tt18 IR&
1575 Man St
BROc KTOrl M WW1 MaweRA, AIM MUTUAL INS CO 3375$
MIMEDIsulrees;
YARMOUTH NEW CHURCH PRESERVATION FOUNDATION INC INEVOIMTc
�ssMetes
2613 MAJN St RT
E
YARMOUTH MA 02675 onsessn F
COVERAGES CERTIFICATE MEMEL 680118 REVISION RUMEN:
TIC IS TO CERTIFY THAT THE ON er s:c OFMAUPANCE LISTED BELOW HAVE EOM IAN TO THE b NAMED MOVE FOR THE PoUCY PERIOD
*MATED NOTWITHSTAMOING ANY REQUIREMENT.TAN OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MY PERTAIN.THE'INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS.
ENCLUSIORS APO CONDITIONS OF SUCH PouctES OF MTS SHOWN MAY HAVE BEEN mamma BY PAA7 Cam.
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