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HomeMy WebLinkAboutBCOI-23-1737 2024 90�-- .-.'4 TOWN OF YARMOUTH gto,r aN BUILDING DEPARTMENT ,.,"..-. A rt {S[: Y,'.� •s Y� ,.,�C; : 1146 Route 28, South Yarmouth, MA 02664 508-3 - APPLICATION FOR CERTIFICATE OF INSPECTI9N JUL 18 2023 July 1, 2023 PAYABLE UPON RECE Pt ,,;,LDNG DEPARTMENT (X) Foes ( ) 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: 3O `6 — `3 t © \ 1`'0,;(-) Sf•. S , , yani.400-ft, , M4 0 z L 69 Name of Premises: Cc ?fa in lac r►s H-0 J Tel: S 0 0 -7(00-2g I' Purpose for which permit is used: 0� ¶ NO k si— License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Vv Certificate to be issued to CA?IQ,^ --c;k r s'+5 l- -0 u s sz.. Tel: 5 O g - 7 to 0 -21 1 ? Address: ;O$ pkd. (`-i ())A Si-, 1 So. yorMtoil-Ini VA O-zbley Owner of Record of Building J c vJ rAe..s e i., 4-N c . c1'1-krjY C S f 5` Address 3 0f Old Moan S+ . ) S o .1 yorAtoo+h, M9- O.Zbby Present Holder of Certificate c p+�,n �o�rr, o S e airiAJC14- - ‘ 1\n it-r-..\-- /0 LA)NkAr Signatu of person to whom Title Certificate is issued or his agent ZIt 7'202j Date Email Address: Ca,OI JWa+con 5 7Q p.ic •CO 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# 13 03/-r3---/73 , Zbfl/11 ( �IS t3 I 08/31/2023-08/31/2024 d iZs-yD 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-500-5018780-2023A PRIOR NO. WCC-500-5018780-2022A ITEM 1. The Insured: JCW Enterprises Inc DBA: The Captain Farris House Mailing address: 308 Old Main St FEIN:**-***9195 South Yarmouth, MA 02664 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 05/04/2023 to 05/04/2024 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 $ 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: 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 001057635 INTER SEE CLASS CODE SCHEDUrE Minimum Premium $298 Total Estimated Annual Premium $845 GOV GOV Deposit Premium $866 STATE CLASS MA 9052 State Assessments/Surcharges $508.00 x 4.1800% $21 This policy, including all endorsements,is hereby countersigned by G 04/04/2023 Authorized ' nature Date Service Office: Dowling and 0 Neil Ins Agcy 54 Third Avenue 973 lyannough Road Burlington MA 01803 Hyannis, MA 02601 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation insurance, used with Its permission.