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1146 Route 28, South;h Yarmouth,outh, IA 02664 -3 -22 1 RaEl
APPLICATION FOR CERTIFICATE OF INSPECTION SEP 2 6 2023
September 1, 2023 PAYABLE UPON REC I41,
ILDING DEPARTMENT
EA
(X) Fee Require 0.00
( ) 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: GZ � �
Name of Premises: YA i fyj' i ym y _Tel: %:s 2 CAC
Purpose for which permit is used: e-5` A/C
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to( � �i �- � �,�� Tel: ?](g.Z 9 ct(z
Address: EZ
Owner of Record of Building .G-‘4-6,ask r Address ZZ�' .�
Present Holder of Certificate v ‘Nr‘.)
Signature of person to whom Title
Certificate is issued or his agent - ZC
Date
Email Address:
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 be:ore 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# 3`/7$7
12/31/2023-12/31/2024
Workers Compensation and Employers Liability
Insurance Policy
Insurer ID No(s): 34355
MA Retail Merchants WC Group Inc. Carrier Polic #:
PO Box 859222-9222 Y Policy Period
Braintree, MA 02185-0000 014005032709123 01/01/2023 to 01/01/2024
Information Page Renewal Policy
FEIN:043316074 Carrier Prior Policy#:014005032709122
Item 1: Named Insured and Address Agency
1696 Corp. RogersGray
Old Yarmouth Inn 410 University Avenue
223 Main Street Westwood, MA 02090
Yarmouthport, MA 02675
Other Workplaces Not Shown Above: See Schedule of Operations
Additional Named Insured: See Additional Named Insureds if Applicable
Type of Business: Corporation Federal lD#: 043316074
Risk ID: 000000000 NCCI I Bureau#:34355
Unemployment ID#: File#:014005032709123
Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2023 to 12:01AM on 01/01/2024 based on the insured's mailing
address time zone.
Item 3. Coverage:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed:
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 $500,000.00 each accident
Bodily Injury by Disease $500,000.00 policy limit
Bodily Injury by Disease $500,000.00 each employee
C. Other States Insurance:
D. This policy includes these endorsements and schedules:
WC000000C(01/15),WC000308(/), WC000414A(01/19), WC000422C(01/21), NOE(01/01), WC200102(01/14),WC200301(04/84),
WC200302A(09/08),WC200303D(08/10),WC200306B(06/13),WC200405(06/01), WC200601A(07108)
Item 4: Premium
The Premium for the policy will be determined by our Manual of Rules, Classifications,Rates and Rating Plans. All information required below
is subject to verification and change by audit.
Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium
Total Estimated Remuneration
Annual Remuneration
See Schedule of Operations on Following Page(s)
Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit
$259.00 $6,597.00 $6,597.00 $0.00 $0.00
Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by:
Braintree MA 02185-0000 01-19-2023
Form#WC 00 00 01 C
(Ed.)
C Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved.
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