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BCOI-23-1737 2025
,mpg Y.4 TOWN OF YARMOUTH Office of the Buildin Commissioner f�c0 -- g 1146 Route 28, South Yarmouth, MA 02664 `Nam. T- 4',/ u MAT[ACHEESe 508-398-2231 ext. 1260 Fax 508-398-0836 �i''PORATEO`-4 `` APPLICATION FOR CERTIFICATE OF INSPECTION July 01, 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 atf the following address: Street and Number: 3 8 S 0 tr& M QA. (1 3 J-(,.�t7r Name of Premises: C ap4cx S n 0Arr 5 40 V Tel: SD€ ' 7 b U -2-8 ( 2 Purpose for which permit is used: ese.A_ ok-rtk k S License(s)or Permit(s)required for the premises by other governmental agencies: RE C E I �/ D Lo aLicense or Permit �o�� Agency JUL 15 2024 x n 5 la cn-n 03 tit„f ood s44411 Lien 60 4kiA Its Bu!L.i ray if pARTme, Certificate to be issued to Q J-o t r\ Vc-r-.> v — Tel: 3 0 $- 7 kp o-Z g t 8' Address: 30 $ © \a M o,.r S't'., Sc). >,cs o-h-,./ ,/v\A 0 Zb Gil Owner of Record of Building 5 c 1,J 9 n-I-e,-fAs i 1+n` ci.b6 _ Cr . -etAsst.-cam 0 140\i�,` Address 3© $ 0\a. Maw.. Si , S� I 024,by Present Holder of Certificate C r.\�-\,a c'\n err-,S 'J r d dam'- ?A�.Lk Signature o rson to whom Title Certificate is issued or his agent 1 I I CI 2-1 ate Email Address: C4Co IJ w o-5aN 57 Q 5 M aS . cp,r1 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 CA OT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# - 73•, 08/31/2024-08/31/2025 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-500-5018780-2024A PRIOR NO. WCC-500-5018780-2023A 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 05/04/2024 to 05/04/2025 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 $ 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 SCHEDULE Minimum Premium $296 Total Estimated Annual Premium $502 GOV GOV Deposit Premium $510 STATE CLASS MA 9052 State Assessments/Surcharges $173.00 x 4.8200% $8 This policy, including all endorsements, is hereby countersigned by 04/09/2024 Authorized ignature Date Service Office: The Hilb Group of New England LLC 54 Third Avenue 973 lyannough Road Burlington MA 01803 Hyannis, MA 02601 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. The Commonwealth of Massachusetts Town of ;g..Y IFUYARMOUTH ,c$t `4'' ''y 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: Captain Farris House Trade Name: Captain Farris House BCOI-23 1737 Identify property address including street number, name, city or town, and county Certificate Expiration Located at 308 OLD MAIN ST August 31,2025 SOUTH YARMOUTH, MA 02664 Floor Occupancy_ Use Group Other 01 st Floor 4 R-1 Hotels,motels,boarding houses, 4-Bedrooms 1 Kitchen 1 Living Room Use Group Classification(s) etc. 1 Dining room Library 02nd Floor 4 R-1 Hotels,motels,boarding houses, 4-Bedrooms Allowable Occupant Load etc. Other 2 R-1 Hotels,motels,boarding houses, Annex-1st-2 Bedrooms 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 Chief Name of Municipal Building 7 a a ^ / P Mark to of Inspection /"y',f�c/L Commissioner Signature of Municipal Fire Signature of Municipal Building 4 Date of Issuance 7/2 ��' Chief Commissioner 7 The Commonwealth of Massachusetts . ,* Town of `� Y YARMOUTH 07! 4 :O .F� y \`'.+,,,PORAt„`i,r 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: Captain Farris House Trade Name: Captain Farris House BCOI-23 1737 Identify property address including street number, name, city or town, and county Certificate Expiration Located at 308 OLD MAIN ST August 31, 2025 SOUTH YARMOUTH, MA 02664 Floor Occupancy_ Use Group Other 01 st Floor 4 R-1 Hotels,motels,boarding houses, 4-Bedrooms 1 Kitchen 1 Living Room Use Group Classification(s) etc. 1 Dining room Library 02nd Floor 4 R-1 Hotels,motels,boarding houses, 4-Bedrooms Allowable Occupant Load etc. Other 2 R-1 Hotels,motels,boarding houses, Annex-1st-2 Bedrooms 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 Munici al Chief Name of Municipal Building / p Mark to of Inspection a/"y',1Jc/[ Commissioner Signature of Municipal Fire Signature of Municipal Building G Chief Date of Issuance /2 Commissioner /2,y The Commonwealth of Massachusetts Town of .6 Y I, YARMOUTH io �- __- y 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: Captain Farris House Trade Name: Captain Farris House BCOI 23 1737 Identify property address including street number, name, city or town, and county Certificate Expiration Located at 308 OLD MAIN ST August 31, 2025 SOUTH YARMOUTH, MA 02664 Floor Occupancy_ Use Group Other 01 st Floor 4 R-1 Hotels,motels,boarding houses, 4-Bedrooms 1 Kitchen 1 Living Room Use Group Classification(s) etc. 1 Dining room Library 02nd Floor 4 R-1 Hotels,motels,boarding houses, 4-Bedrooms Allowable Occupant Load etc. Other 2 R-1 Hotels,motels,boarding houses, Annex-1st-2 Bedrooms 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 Chief Name of Municipal Building Mark to of Inspection 7 L/ Commissioner �t Signature of Municipal Fire Signature of Municipal Building I Date of Issuance 9,2 / Chief Commissioner / / 27 The Commonwealth of Massachusetts Town of 'og.YA ~ It a( -TrI;4 YARMOUTHfoi) 5/? ' . 1450\ ,o _---_, q, `'':s.b.., ATE9`j/ 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: Captain Farris House Trade Name: Captain Farris House BCOI 23 1737 Identify property address including street number, name, city or town, and county Certificate Expiration Located at 308 OLD MAIN ST SOUTH YARMOUTH, MA 02664 August 31, 2025 Floor Occupancy_ Use Group Other 01 st Floor 4 R-1 Hotels, motels,boarding houses, 4-Bedrooms 1 Kitchen 1 Living Room Use Group Classification(s) etc. 1 Dining room Library 02nd Floor 4 R-1 Hotels,motels,boarding houses, 4-Bedrooms Allowable Occupant Load etc. Other 2 R-1 Hotels,motels,boarding houses, Annex-1st-2 Bedrooms 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 Chief Name of Municipal Building jicMark : ', Commissioner to of Inspection ah_) Signature of Municipal Fire Signature of Municipal Building ` Date of Issuance Chief Commissioner 7/2 2 X The Commonwealth of Massachusetts Town of •O�'VA gp) YARMOUTH o$ 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: Captain Farris House Trade Name: Captain Farris House BCOI 23 1737 Identify property address including street number, name, city or town, and county Certificate Expiration Located at 308 OLD MAIN ST August 31, 2025 SOUTH YARMOUTH, MA 02664 Floor Occupancy_ Use Group Other 01 st Floor 4 R-1 Hotels,motels,boarding houses, 4-Bedrooms 1 Kitchen 1 Living Room Use Group Classification(s) etc. 1 Dining room Library 02nd Floor 4 R-1 Hotels,motels,boarding houses, 4-Bedrooms Allowable Occupant Load etc. Other 2 R-1 Hotels,motels,boarding houses, Annex-1st-2 Bedrooms 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 Chief Name of Municipal Building Mark to of Inspection '71Commissioner Jl �" Signature of Municipal Fire Signature of Municipal Building Date of Issuance / / 2 2 Chief Commissioner