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Home My WebLink AboutBCOI-23-1782- \ § / Q ƒ / k \ \ 173 a 7 § a) (a jil 2 _o o ■ 2 g\ G / r U 0_ m = _ a) \ § 2 � __ `lc)) t m 6 ] S / o. �s / § 4 'f o 00 0 rt- c § k � � % / ) o ' G c k E q a OO . c ° & z % c 0 \ \ £ ' a a S c c 0 , ^ 0 . CO 40 % o J \ / a-/ \ ■ g 0 ƒ / o c S ■ @ 2 . clr a>_ / & 2 c 22 £ eke1111 J / U C � 7 $ § ,E _k22f Ilrhl°4. � k � Ce• °r � E % § � % / E � G � e = a , I £ \ ■ 6E # ¥ R § O Ce ® E w ■ \ _ , \ % \ 7 2 m2 O mt a \ � � < WIz � s 2k � � � / $ o ¥ k@@ $ $ g t7 & 5 5 2 © � \ � � � k = / k \ 5 . \ ca) / \ \ 0.\ k \ § 0 CI \ 10 'f 2 � � 2k ® % $ , 3 % m f 2 2 o E a E / \ U } \ ƒ\ E 0. tea / ac E c = _ / •2 '5 » = n _ ■ ¥ \ & a) o a ° 2 m f 8 ƒ -8/ a) 3 . $ o $ E ® £ § � § ) a) Jo k © / \ : } 1 2 c § g ® c § . 77. a) C 2 � 0 \ o I.E. ■ e 0 e £ SI / g57 } TO TO 2 a) 2 0a = CD- - \ 2 \ Q o § 2 0H E2tin/ \ %Zi / ( m m k ƒƒ ® z mo ' 7r ",„ ,, , A 1146 Route 28, South -Yar Louth, MA 02664 50 -39 22 1 e t, 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: 41? kit. C 4 Name of Premises: C H 4-7 ri ll- o f 6- Tel: . o 8 36 2 - 1‘3 ,18 Purpose for which permit is used: License(s) or Permit(s) required for the premises by other governmental agencies: RECEIVED License or Permit Agency OCT 2 3 2023 662 445 - N- r- lci� BUIIfD� DEPA T T - ay' ( Certificate to be issued to 134-x f-tlL INo/K Atv 6 (LC Tel: 36 Z �3 Address: 2 I `1 I-T - 6 4- ? y.4-k t'-(0 u 1-i-4- `t)o R. 1 /. meA— D 2 t 7 ,4 Owner of Record of Building '4 a-X r&(Z, 'at-R.K-(o U'rl4- 1�d a,r- if a (...0t NG CI C....1—C r, Address Pa 13oX fro- 3 , E45r De-N,vtt E4 �9- 02,6 4I `1 Present Hold r of Certificate � eCt-e 2 (A/N it-.-(iU 6 L.L. C, Signatu e of person to whom Title / /2 Certificate is issued or his agent /0/ // o 2-3 Date Email Address: 73/6:- ® f�' l e 2 WO$17i !A-L(T/ . co et.{ 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# /: ..1]i—• _-3,— /7 ef Z 12/31/2023-12/31/2024 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-500-5024303-2023A PRIOR NO. WCC-500-5024303-2022A ITEM 1. The Insured: Baxter Innkeeping LLC DBA: Chapter House Cape Cod a/o Baxter Yarmouthport Holdings LLC Mailing address: PO Box 1503 FEIN:**-"'0520 East Dennis, MA 02641 Legal Entity Type: Limited Liability Company Other workplaces not shown above: See Location 2. The policy period is from 02/11/2023 to 02/11/2024 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 O No. Total Annual Annual Remuneration Remuneration Premium INTRA 001194667 INTER SEE CLASS CODE SCHEDU_E Minimum Premium $273 Total Estimated Annual Premium $1,595 GOV GOV Deposit Premium $411 STATE CLASS MA 9052 State Assessments/Surcharges $1,143.00 x 4.1800% $48 This policy, including all endorsements, is hereby countersigned by f 01/11/2023 Authorized i6 gnature Date Service Office: Dowling and 0 Neil Ins Agcy 54 Third Avenue Burlington MA 01803 973 lyannough Road Hyannis, MA 02601 • WC 00 00 01 A (7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission.