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`1 ,� HNYS' '.gg�!r. INC .. M. .
1146 R Route 28, South Yarmouth, MA 02664 508-3 8-2 F
APPLICATION FOR CERTIFICATE OF INSPECTION APR 19 2023 w
April 1, 2023 PAYABLE UPON RECEIPT BUILDING DEPARTMENT
By.
(X) Fee R e 69.00
( ) 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: 10 50 Bh asc r 1��
Name of Premises: S(Ari-c_aMber- on %a. OCeah Tel: Soo 3qy 9g34
Purpose for which permit is used: O P E r2 qi►o N a F N b TE L
License(s)or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Lic . Sere.;- Public Qoal. `(I4RM . \AS8L1 k
lic dPfC2ATE KoTeL `Alm\ . Kt.Ai-SH 1)EP?•
(+:c . S/tot ay oV Kazirdoo,s M6Aa►s
9 ynQm. NEA(...spt DE-eT.
(Pool a hen.S)
Certificate to be issued to Su.v-ccoolber LL. C Tel: wv 3ace 8q 30
Address: 16 S. Shores 17r. S• `12tnno,44ti, M . 624,6Li
Owner of Record of Building Kerry �rj odd
Address 'bl-E0 W. 3opv2, Sd. Warn„ NM 03a'3 8
Present Holder of Certificate Thtol c1 G• M
.�. _ / G.M .
Sit are of.er'!a n to whom Title
Ce I'cate is issued or his agent 9 I or aoa 7
Date
Email Address: \v S -v L.d \\b-m2:L . eons •
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# J1-a3-00,5 7 76,
05/23/2023-05/23/2024
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-500-5017560 2023A
PRIOR NO. WCC-500-5017560-2022A
ITEM
1. The Insured: Surfcomber LLC
DBA:
Mailing address: 107 South Shore Drive FEIN:•****0581
South Yarmouth, MA 02664
Legal Entity Type: Limited Liability Company
Other workplaces not shown above:
2. The policy period is from 01/01/2023 to 01/01/2024 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 $ 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
Remuneration Remuneration Annual
Premium
INTRA 000120204
INTER SEE CLASS CODE SCHEDU_E
Minimum Premium $274
Total Estimated Annual Premium $3,897
GOV GOV Deposit Premium
STATE CLASS $1,010
MA 9052 State Assessments/Surcharges
$3,427.00 x 4.1800% $143
This policy, including all endorsements,is hereby countersigned by
12/08/2022
Authorized ignature Date Service Office:
54 Third Avenue HUB International New England LLC
Burlington MA 01803 PO Box 696
Wilmington,MA 01887
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation InsuranCe
used with Its permission.