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TO
1p` aUT
tlitti INC EPA 11'1 ENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 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: 61 3 AI`k tTES `{2, -t
Name of Premises: Mc%) CAP-- kTI4
L-E- C., C[_-.0 B Tel: 0U —3G1 c4-35(�
Purpose for which permit is used: X LtL y Lvt CAL(j Us'-eR37 9 1
License(s) or Permit(s) required for the premises Hy oth r governmental agencies: 0,,5
License or Permit Agency
RECE ; VED
NOV 14 2023
Certificate to be issued to 1 ICJ -4'; e 1 c1 U L ' CA l/( 2 Tel: 6 b*�Yt t-�'—-C l i T
Address: S ,� TLC Bu eBy
Owner of Record of Building •14 4 'Tr,,`s
Address t3 flu T` 5�;�-i* Y0.31-0A-cn JVII� i
Present Holder of Certificate "I
Signature of person to whom Title
Certificate is issued or his agent a 193
�g Date
Email Address: 1�040 {C ink.ece
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# /3C0/— 3--!?? '
12/31/2023-12/31/2024
G.)
NOTICE = NOTICE
__Ail� ,
TO
fylin
TO
EMPLOYEES (Napr� �<;
� EMPLOYEES
_SY
The Commonwealth
of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 &30, this will give you notice
that I(we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
N or Af1c
NAME OF INSURANCE COMPANY `��
-A'-n E.st 2ls"� Vac- C M G cA` 44`tS4"
ADDRESS OF INSURANCE COMPANY
3(MO 77+ Cy2-C/2-3 26 24 ; 4
POLICY NUMBER A EFFECTI ATES
tAccek„Ur�, �i� t�Z�i rl c L / �G 'Lc1C�+ .r tie )edex - t(cz k 150:-(1- , C� Y)
NAME OF INSURANCE AGENT ) ADDRESS - ' a PHONE#
$-/t. -a l� , :- A k Y._ fct.3 c��kk -Pc ice . Yeir-vvie,ttL /
AA
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DA n.
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
CAP Cc't SP`i 7f L ►il 1. . MA
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
I
il
..:- Wesco Insurance Company
A Stock Insurance Company
WORKERS COMPENSATION
AND EMPLOYERS LIABILITY WC 99 00 01 B
INSURANCE POLICY 1 of 5
Ncci Code:26135 INFORMATION PAGE
1. Insured
Mid-Cape Racquet&Health Policy Number: WWC3670774
193 White's Path
S Yarmouth,MA 02664
Other workplaces not shown above: _Individual _Partnership
None X Corporation
Producer: Federal Tax ID: 043073961
Maguire Insurance Agency,Inc. Risk Id:
One Bala Plaza Renewal of: TWC4141401
Bala Cynwyd,PA 19004
2. The policy period is from 9/20/2023 to 9/20/2024 12:01 a.m.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:Massachusetts
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:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$100,000 each accident $500,000 policy limit $100,000 each employee
C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here:
All states except OH,ND,WA,WY and State(s)Designated in Item 3A.
D. This policy includes these endorsements and schedules:See Extension of Information Page
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
TOTAL ESTIMATED ANNUAL PREMIUM
STATE ASSESSMENT 3,549
TOTAL ESTIMATED COST 126
Minimum Premium 3,674
Deposit Premium 37
Issue Date: 8/4/2023 Countersi gnby:ed 3,675
Authorized Representative