HomeMy WebLinkAboutBCOI-23-1762- RECEIVED
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' = TOWN OF YAROUTH
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' I.0 BUILDING DEPARTMENT BY ____ _
.� .a` / 1 146 Route 28,South Yarmouth,MA 02664 508-398-2231 e . IIDs ING DEPARTMENT
APPLICATION FOR CERTIFICATE OF INSPECTION
September 1,2023 PAYABLE UPON RECEIPT
(X) Fee Required$150.00
( ) No Fee Required
In accordance with the provisions of the Massachusetts State Building Code,Section 110.7,I hereby apply for a
Certificate of Inspectin for the below-named premises located at the following address:
Sheet and Number: 11-4 Je A V`etE1 ly-( p
Name of Premises:CI R-eS-t )lJP(r -� -4 RLf�J 44 2i Tel: S o "0 C p 2- 1 b
Purpose for which permit is used: 1 i,JQ1 SvL„ cp Re4t,u' ..�
License(s)or Permit(s)required for the premises by other governmental agencies: �.
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License or Permit Agency
i'l('',.i (fib, ( (ire,4 A %ti N
Certificate to be issued to ct tct Tel: l ` 'ati' 1 \'''\
Address: `�j37 Sid47 . i t'*i,j 312{
Owner of Record of Building C Lt-C
Address 9 O Z earn C'S t CA"( , ribCe-hr. A/7 b WOO <�-
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Present Holder of Certificate C .)At . LLC ^
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r re of n to horn Title,
Certificate is issu or his agent 1, 1 ZiZvZ3
Date 1111
Email Address QSe ( �"1°{leo,.. 'st KO(QS tow
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# C U/-tom 3 /-,
12/31/2023-12/31/2024
SAFETY NATIONAL CASUALTY CORP Workers' Compensation and Employers' Liability
1832 SCHUETZ ROAD Insurance Policy Information Page
ST. LOUIS, MO 63146
(888) 995-5300 Policy Period
Policy Number From To
LDC4055543 08/01/2023 08/01/2024
12:01 A.M.Standard Time at the address of
the Insured as stated herein
Prior Policy Number LDC4055543
Transaction
Renewal Issue
1. Named Insured and Address*see below Agent
RESTAURANT GROWTH SERVICES, LLC Stephens Insurance, LLC 61088
3038 SIDCO DRIVE 111 Center Street
NASHVILLE, TN 37204 Suite 100
Little Rock,AR 72201
Telephone:
Customer# Carrier# FEIN# Risk ID# Entity of Insured
16349 371689186 917057680 LLC
*If applicable, Item 1 is continued on attached Named Insured and/or Additional Locations Page:
2. The Policy Period is from 08/01/2023 to 08/01/2024 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: AL CT FL GA IL IN KY LA ME MA MS MO NH NY NC RI SC TN VT VA WV
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 $ 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease $ 1,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to states, if any, listed here:
All states except ND, OH, PR, VI, WA, WY and states designated in Item 3.A.
D. This policy includes these endorsements and schedules: See attached Schedule of Forms and Endorsements.
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.
SEE EXTENSION OF INFORMATION PAGE
Minimum Premium Total Estimated Annual Premium _
Expense Constant
Assessments and Taxes Premium Discount
(Taxes not applicable in Puerto Rico)
Deposit Premium
This is a Three Year Fixed Rate Policy
Premium Adjustment Period: x Annual — Semiannual _ Quarterly _ Monthly
Countersigned this Day of
Issued Date: 08/17/2023 Authorized Representative
Issuing Office: Safety National Casualty Corporation
WC 99 00 00 (07 17)
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