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1146 Route 28, South Ya -mouth, MFYA: 02664 508-398-2 31 e ! �=
AUG 112023
APPLICATION OR CERTIFICATE OF INSPECTION
BUILDING DEPARTMENT
By:
August 1, 2023 PAYABLE UPON RECEIPT
(X) Fee Required $50.00
( ) 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: 3 ZR u.t,N Sfi \tctpotfl Fo r-r
Name of Premises: t.(,rat. pP- yc.t.p b1.1 Tel: SOS--3 6 2_ (p9 77
Purpose for which permit is used: 1
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
-**-Ft rst Co i c� pp
Certificate to be issued to C 4,14'0 t,,o f Q o Lt1-4.t Tel: S -3 6 Z. �p 9 77 (\_
Address: 32 M c 5.t w S-t, `(ar cx.tf4 Port MA-- 0242 '7 S
Owner of Record of Building
Address
Present Holder of Certificate
vS .�cQM l/V LS A,Gc L..
gnature of perso to wh m Title
Certificate is issued or his agent &r-6 _2 3
Date
Email Address: /9-;DIq I, P . yQm Eu 7' , U 4 6
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# 6C(2/..d 31—z/.�
09/01/2023-09/01/2024 T
•yS
Church Mutual Insurance Company, S.I.
NCCI CARRIER CODE NO. 16853 WC 00 00 01A
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
O
O
a
O
1. The Insured: FIRST CONGREGATIONAL CHURCH Policy No. 0187606 07-473117
OF YARMOUTH
Renewal of: 0187606 07-302281
Individual Partnership
Mailing address:329 ROUTE 6A
YARMOUTH PORT, MA 0 2 6 7 5-1817 X Corporation or
Federal Employers I.D.# See Schedule
Inter/Intrastate Risk I.D. #
Other I.D. #
Other workplaces not shown above: See Schedule Contact
Phone Number
2. The policy period is from 12/2 3/2 022 12:01 a.m. to 12/2 3/2 0 2 3 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
our 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: Part Three of the policy applies to the states, if any, listed here:
All states except states designated in Item 3 .A. of the Information Page
and ND, OH, WA, WY.
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.
Premium Basis Rate Per
Code Total Estimated $100 of Estimated
Classification No. Annual Remuneration Remuneration Annual Premium
See Item 4 . Extension WC 00 00 01A
Total Estimated Annual Premium$ 1, 895
Expense Constant$ 338 Taxes and Surcharges $ 70
Minimum Premium $ 292 (MA) 9101 Deposit Premium $ 1, 965
See Item 4 . Extension WC 00 00 01A for the Taxes and Surcharges for:
MA
Premium Adjustment Period: Annual Countersigned by:
Servicing Office: Church Mutual Insurance Company, S . I .
Date: 03/18/2023
Producer: LAURA J. ROGGERO
Church
Copyright 1987 National Council on Compensation Insurance. Mutual
Original
INSURANCE
8 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY POLICY NO. 0187606 0 7-4 7 3117
EXTENSION OF INFORMATION PAGE
co
ITEM 4.CONTINUED PAGE NO. 1
0
Rates Per Estimated Annual Premiums
Estimated Total $100 of
CODE Annual Remun- Subject to
CLASSIFICATION OF OPERATIONS NO. Remuneration All Other
eration Modification
MA-20
LOC. 1
SIC: 8661 NAICS : 813110
329 ROUTE 6A
YARMOUTH PORT, (Barnstable) MA
02675-1817
001-001
FIRST CONGREGATIONAL CHURCH OF
YARMOUTH
FEIN: 04-6110040
From 12/23/2022 To 12/23/2023
RELIGIOUS ORGANIZATION: 8868 182, 16S 0 . 64 1, 166
PROFESSIONAL EMPLOYEES & CLERICAL
(Amended)
RELIGIOUS ORGANIZATION: ALL OTHER 9101 18, 293 3 .24 593
EMPLOYEES (Amended)
Deviation 9037 0 . 887 -199
Employer' s Liability (in 000 ' s) 9807 0 . 010 16
Limit: 500/500/500
TOTAL UNMODIFIED PREMIUM 1, 576
TOTAL MODIFIED PREMIUM 1, 576
Merit Rating 9885 0 . 950 -79
STANDARD PREMIUM 1, 497
All Risk Adjustment Program 0277 1 . 000 0
Expense Constant 0900 338
Terrorism 9740 0 . 0300 60
DIA Assessment 0 . 0418000 0935 70 . 00
TOTAL ESTIMATED PREMIUM
1, 895
WC 00 00 01A Church
Mutual
INSURANCE