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HomeMy WebLinkAboutBCOI-23-1759- , d \ / / / � / / k § 11i H- N. k \ -ck a = . k ƒ ƒ S o � ka-6 \ j \ Z. w a) 8f c§ E S / \ t c o �/ \ \ 10 ± o » c I ) E e \ 5 5 ® z / 5 to —' o S \ C / \ / »k & E ® .2 o @ 2 % a. J \ \ / �\ \1/4\-i\--C21 � k0 G . � 2o § 0. £ » <C 7 7 £ a/ t / � \ § co / // / < CO) $ a / I � = / � 22 CO 2 . o % q . f \ O M \ co \ c ID © 0 I o a te % / / 0 g .c - 2 k § 2 k k / �� $ O gG « , £• � \ o) � Q ■ a. / / 2 ~ / \ . , ,T.") � f 6. E t k $ @ 2 & = 0 a 0 c 2 E § \ 3 ( B c.) ..c f E k o A \ f \ f � / % U C o k k § k j \ % § ■ $ f / 2 ee 2 a) ® ma) \ / ]\ 2 & 2 a k § ƒ2 o , LL z o m a 0 a. _c u) . ) � kk _ . 5 k R -t '- a - 5 2 ° m / 0 >2 = k \ k - -c § 7 = 5 / f ® a = ° o \ _ § \ \ e — F \ - \4 2 c m e f a ■ C m _ a O. % t } = 2 2 $ § a / Q ƒ 2 0 U c \ § a -J g .0 \ » \ 2 c 22 m # % & ° — ! f 0 / 2 $ m \ M k \ as\ * _ C Rti TOWN -4 ; UTE, INCI EPART ENT . 1146 Route 28, South 'Yarmouth, MA 02664 508-39 -2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION September 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: `22- Name of Premises: S- i T 0-f- Tel: -s(vee' Purpose for which permit is used: LA.c ,Jo 2 L1C z ^s-� License(s) or Permit(s) required for the premises by other governmental agencies: Agency RECEIVED License or Permit SEP 2 9 2023 BUILDING DEPARTMENT BY Certificate to be issued to t S /D-c (2v 2 l Tel: `fig S -Loco Address: "Z_Z 7� t-010_0,\ Owner of Record of Building Address Present Holder of Certificate Gi tin /j Si ature of person to whom Title Certificate is issued or his agent C1 )Z& 17ic ILJ Email Adclross: C C� a cis td e reso.T . ( o'er 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 ISSUE YOUR CERTIMPENSATION FICATE OF INSPECTION. FORM WITH THIS APPLICATION OR WE CANNOT Certificate of Inspection# (o/- aZ-3--i c/ S 12/31/2023-12/31/2024 Di 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. WMZ-800-8003721-2023AI PRIOR NO. WMZ-800-8003721-2022A ITEM 1. The Insured: Travis Hospitality Inc DBA: Bayside Resort Hotel Mailing address: Rt 28 FEIN:*'-""7972 225 Main Street West Yarmouth, MA 02673-0000 Legal Entity Type: Corporation Other workplaces not shown above: See Location 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 $ 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 000362922 INTER SEE CLASS CODE SCHEDULE Minimum Premium $274 Total Estimated Annual Premium $11,843 GOV GOV Deposit Premium $3,091 STATE CLASS MA 9052 State Assessments/Surcharges $12,441.00 x 4.1800% $520 This policy, including all endorsements, is hereby countersigned by " -4/`— - 03/15/2023 Authorized ignature Date Service Office: Baldwin Krystyn Sherman Partners LLC dba 54 Third Avenue 410 University Ave. Burlington MA 01803 Westwood, MA 02090 WC 00 00 01 A (7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission.