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Home My WebLink AboutBCOI-24-54 2025 The Commonwealth of Massachusetts ime.;-, Town of 'g.Yq 7)1 YARMOUTH >-► �; .0 H; 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: Surfcomber on the Ocean Trade Name: Surfcomber on the Ocean BCOI-24-54 — Identify property address including street number, name, city or town, and county Certificate Expiration Located at 107 SOUTH SHORE DR SOUTH YARMOUTH, MA 02664 May 23, 2025 Floor Occupancy_ Use Group Other Use Group Classification(s) 01st Floor 16 R-1 Hotels,motels, boarding houses, BLDG 1-12 Units etc. BLDG 2-4 Units Allowable Occupant Load 02nd Floor 17 R-1 Hotels, motels, boarding houses, BLDG 1-13 Units etc. BLDG 2-4 Units 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 Munici al Chief Name of Municipal Building p R- ();LI Commissioner ; lDate to of Inspection /_/Signature of Municipal Fire Signature of Municipal Building /of IssuanceChief CommissionerJ �/ 0 . Y�o TOWN OF YARMOUTH {. 10•3 BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION April 01, 2024 PAYABLE UPON RECEIPT (X) Fee Required $169.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: k b I. 5 5k"G Dr • 5 . YAStmou-hK I MA oa6G.y Name of Premises: 5 u �r Co,M0p Gr or, 4kic O«avv Tel: 5 O$ 314 8Q?j o Purpose for which permit is used: £P 6RA t 56 f15 O JJ A L. t-R o'f£ L R Licenses) or Permit(s) required for the premises by other governmental agencies: �'. 9 � License or Permit Agency �� 6' 2014 Lcc, Set' ; • pKb\;c. Poet }{E,I4--(K pt eyUILD►NG DJ pq�TMENT L . tot Gime wait Ya. 146A04 Derr — Cc c yfo+sx Kiq Z4 rtvs ,l41'034'S 74Q F(eAvrw tor /�,i \np' 1 �(� Certificate to be issued to 51.4 Cc o n.btr \-.L C Tel: Soto — 39 44 q 3 b 0W Address: lo '?- S • 5\40,c fir• 5 . `(ARMot,.t,t, AAA- 0a6C0 Owner of Record of Building 'Su 51tI., a" o\a Address t0 '} S S . 5knoic Or• S. YA(zma+t MA- ea`Gt{ Present Holder Certificate -314 5414> „\3 o' , 1 / - / G. M . FMffre o r rson to whom Title rtificate is issued or his agent ({ I S I a oat-{ 1 Date • Email Address: \u 5k•o%-ck n c t M 1;L . C oN1 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# bc:of05/23/2024-05/23/2025 7 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-500-5017560-2024A PRIOR NO. WCC-500-5017560-2023A ITEM 1. The Insured: Surfcomber LLC DBA: Mailing address: 107 South Shore Drive FEIN:**-***0581 South Yarmouth, MA 02664 Legal Entity Type: Limited Liability Company Other workplaces not shown above: 2. The policy period is from 01/01/2024 to 01/01/2025 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 No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 000120204 INTER SEE CLASS CODE SCHEDULE Minimum Premium $271 Total Estimated Annual Premium $3.425 GOV GOV Deposit Premium $892 STATE CLASS MA 9052 State Assessments/Surcharges $2,961.00 x 4.8200% $143 This policy, including all endorsements, is hereby countersigned by 12/07/2023 Authorized ignature Date Service Office: HUB International New England LLC 54 Third Avenue PO Box 696 Burlington MA 01803 Wilmington, MA 01887 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission.