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Home My WebLink AboutBCOI-24-9- The Commonwealth of Massachusetts 90) Town of YARMOUTH New and Renewal Certification of Inspection In accordance with the Massachusetts State Building Code,Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name:Hallett Funeral Home Inc. BCOI-24-9 Trade Name:Hallett Fineral Home Identify property address including street number,name,city or town,and county Certificate Expiration Located at 273 STATION AVE February 25,2025 SOUTH YARMOUTH,MA 02664 Floor Occupancy_ Use Group Other Use Group Classification(s) 01st Floor 140 A-3 Lecture halls,dance halls, 140 PRSONS churches and places of religious Allowable Occupant Load worship,recreational centers, terminals,etc. This certificate of inspection is hereby issued by the undersigned to certify that the premise,structure,or portion thereof as herein specified has been inspected for general fire and line safety features.This certificate shall be framed behind clear glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned.Failure to post or tampering with the contents of the certificate is strictly prohibited. Name of Municipal Building G Date of Inspection Name of Municipal Chief :%l I gi7 I DA Commissioner Signature of Municipal Fire Signature of Municipal Building / //Gi Date of Issuance 3/J Z 27 Chief . Commissioner L�� .ems"YAP (,,,,,,,� °� `�4 TOWN OF YARMOUTH , aN ;iy BUILDING DEPARTMENT MATTI.CH S•SE �' 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 a.aoraitod"F APPLICATION FOR CERTIFICATE OF INSPECTION January 1 , 2024 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: 273 Station Ave . 941 Name of Premises: Hallett Funeral Home Inc . Tel: 508-398-2285 is t I Purpose for which permit is used: Funeral Home At License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency IiiTLcjI1vIP 1 r--- ---- ---- --- --- Certificate to be issued to Hallett Funeral Home Tel: 508-398-7285 i JAN 1 6 2024 Address: 273 Station Ave . , South Yarmouth, MA 02664 _ Owner of Record of Building Hallett Family Holdings BUILDING DEPARTMENT By. Address 273 Station Ave . , South Yarmouth, MA 02664 Present Holder of Certificate Hallett Funeral Home President Signature of person to whom Title Certificate is issued or his agent January 10 , 2024 Date Email Address: fahallett@hallettfuneralhome . com 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 # t l-d Y-- q 02/25/2024-02/25/2025 T� x: _ - - - - _- - t • .1a= (Policy Provisions: WC000000C) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER:Hartford Accident and Indemnity Company ONE HARTFORD PLAZA HARTFORD CT 06155 THE HARTFORD NCCI Company Number: 110448 Company Code:5 Suffix LARS RENEWAL POLICY NUMBER: 08 WEC AY2LPK Previous Policy Number: New 1. Named Insured and Mailing Address: HALLETT FUNERAL HOME INC (No.,Street,Town,State,Zip Code) 273 STATION AVE SOUTH YARMOUTH MA 02664 FEIN Number: 04-2427758 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Funeral Homes and Funeral Services Other workplaces not shown above:273 STATION AVE SOUTH YARMOUTH MA 02664 2. Policy Period: From 07/17/23 To 07/17/24 ANNUAL 12:01 a.m.,Standard time at the insured's mailing address. Producer's Name: BRYDEN&SULLIVAN INS AGCY INC/PHS PO BOX 1497 SOUTH DENNIS MA 02660 Producer's Code: 08084306 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (866)467-8730 Total Estimated Annual Premium: $2,607 Deposit Premium: Policy Minimum Premium: $275 MA(Includes Increased Limit Min.Prem.) Audit Period:ANNUAL Installment Term:Four Pay(30%Down+2@25%+1@20%) The policy is not binding unless countersigned by our authorized representative. Countersigned by 077 C' ' 07/13/23 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 07/13/23 Policy Expiration Date: 07/17/24 INFORMATION PAGE (Continued) Policy Number: 08 WEC AY2LPK 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 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 the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT-WC 99 03 68 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. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premium $2,032 Expense Constant $338 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement $141 Estimated Annual Premium (before Surcharges) $2,511 Total Estimated Surcharges $96 *See the attached Schedule(s)of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $2,607 Deposit Premium: Policy Minimum Premium: $275 MA(Includes Increased Limit Min. Prem.) Interstate/Intrastate Identification Number: Refer to Schedule of Operations NAICS: 812210 Labor Contractors Policy Number: SIC: 7261 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 07/13/23 Policy Expiration Date: 07/17/24