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Home My WebLink AboutBLDCI-17-000948-06 • The Commonwealth of Massachusetts City\Town of YARMOUTH New and Renewal Certificate of Inspection In accordance with the Massachusetts State Building Code,Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name:MARGARET E.SMALL ELEMENTARY SCHOOL BLDCI-17-000948-06 Trade Name:GYMNASIUM/CLASSROOMS/CAFETERIA Identify property address including street number,name,city or town and county Certificate Expiration Located at 400 HIGGINS CROWELL RD 12/31/2023 WEST YARMOUTH,MA 02673 Use Group Floor Occupancy Use Group Other Classifications(s) A-3 01st Floor 172 A-3 Amusement/Church/Gym/Library/Museum 172-CAFETERIA 172-GYMNASIUM Allowable 20 CLASSROOMS Occupant Load LIBRARY VISUAL AID ROOM 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 life safety features. This certificate shall be framed behind glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned.Failure to pose or tampering with the contents of the certificate is strictly prohibited. Name of Municipal Name of Municipal Mark Grylls Date of Building Commissioner Inspection Signature of Municipal Signature of Municipal Date of Building Commissioner Issuance Fee:$0.00 BLD Certoflnspection.mt _a i. urrli. io,....:: , I fr� , .` .i . i-D I N C 4t :� RTM N,. , k„ \MA,,,,,, ,:s,!i,,,;,hW 1146 Route 28, South armmmoutlh, MA 02664 SO 398-223I e. 't':Vizigo,,, - C E IV F-: p ----.. ..._ . ......„ :::_.:, 1 APPLICATION FOR CERTIFICATE OF INSPECTION I � �t� i 1 F 2022 November I, 2022 PAYABLE UPON RECEIPL_______ J ( ) Fee Req irgE �t_DINt; DEF'/�Ftfi1„f NT (X) No Fee Requ ` 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: 5i/,/ c- `t.� .t (1/L/Livi`i / a - a �;Name of Premises: k: L. 5 v -i-C .. , ,4r Tel: :... ' - ?. 7 2 2. - Purpose for which permit is used: t_. 44 il C,r 4 i c '.-:1 _--- License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to 9'/ 4- "t ` �0 Tel: .. O / 7 <: 9 7 . ,, -- �� :/a t/rn/L./'-,. A4 7 Address: 47/ ` `" �, q A ° Owner of Record of Building e A At L 4,1eti ' 4 , 1 4,,p f h i . Al d4 t Address 1 rp'1 zi ..�.. , "op;,.../ A. 4 P .. t ... 4?2 . , Present lder of Certificate „-----) ) ..--- /5Te.,. /4/ p k Signature of person to whom Title Certificate is issued or his agent _.. t /J/ Date F 1nail Address: 'le-. -rl,`5 - re- S 1 0 A . , / Ki 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 # 12/31/2022-12/31/2023 - Individual Self-Insured Midwest V"D&8plQyers Excess Workers' Cmnmpmmsatimw and &^�� EmnpUmyersLiability Imdwmnm�y Policy �/��w�"�m� ~�~,°"�r�� va��ronmomwx° �� c�e�m�m��Qm � �� Policy No.: EVVC006911 |mdomnUy Coverage Provided: Specific and Aggregate Excess Workers'Compensation and Employers Liability Indemnity i ' 1. Insured: Dennis Yarmouth Regional School District %. Mailing Address: 298 Station Avenue South Yarmouth,MAU2684 3. Named States: NYaammohuaottn | 4. Excluded States: None 5. Policy Period: . 07/01X2022 0701�023 `Both' days start at 12:01 A.M.standard time at the Insured's address shown in Item 2 of this schedule. G. Specific Retention: Each $500.000 ' ' Each Employee for Disease: $500.000 7. Specific Limit Each Accident: . (a) Policy Part One,VVodeerm Compensation: STATUTORY (b) Policy Part Two, Employers Liability: $1,000,000 D. Specific Limit Each Employee for Disease: Policy Part One,Workers'Compensation: STATUTORY | (a) Policy Part Two, Employers Liability: $1,000.000 9. Aggregate Retentlow Rate aoo Percentage n[Normal Prwm|um: 482.64% Estimated Normal Premium: $301,389 (n) Minimum Retention: $1.425.531 (d) Aggregate Loss Limitation: $500.000 � � 1O. Aggregate Limit: *3,000,000 11. Classification ofOperations: See Endorsement Experience Modification Factor: 1.000000000 (b) Other Modification Factor: 1.000000000 cmo'SCn (8'13) 147ss North Outer Forty Drive,Suite 3nn Chesterfield,MO 63017 pane I",z (636)1*9-7000 www.mwaz.cum � _ __ ' Indkvidua| Se|f-Inmwrod ^rmmdpvw�st Employers Excess VVwrhmra' Cono9ensmtimnand 4 , colillp- �� Employers Liability Indemnity Policy UAamnKLav«xmxewmww . Scliedu|ePawm 12. Premium: (a) Rate per*100ofPayroll: .1560 (h) Policy Minimum Pvamium: $58278 (c) Total Estimated Policy Premium: $64.753 (d) Doposi\Pmmm ��4 io � .753 (n) Deposit Flat Charges: me (f) Total Deposit Premium and Flat Charges Payable anFollows: $64.753 10. Endorsement Serial Numbers: See Endorsement Schedule 14, Service Company: Guardian Claims Services, LLC P.0. Box(B) Kingston, K4A02384' | ! Ooontemignod M|DVVEST EMPLOYERS CASUALTY COMPANY Licensed Resident Agent Date Authorized Representative � | � � cme-Scx (n-za) m7ss North Outer Forty o,wn svuesnu Chesterfield, MO 63017 Page zvrz (63*)4*97000 www.m~co.cvm rs Endorsement Schedule r A bapkLaYCOMMNYe • Named Insured: Dennis Yarmouth Regional School District Policy Term: 07/01/2022 to 07/01/2023 Policy No.: EWC006911 Endorsement Edition Date Effective Expiration Date Description Code Date Date Created CMB-11 (08-13) 07/01/2022 07/29/2022 CMB-199 (01-20) 07101/2022 07/29/2022 CMB-ES (8-13) Page 1 of 1 Date Printed: 08/04/2022 .., ,... a. Ett � / �:� Endorsement i '' Casualty Company 1. ti 14ERKIABY COMPANY* rF Endorsement Effective: 07I0112022 Policy No.: EWC006911 Named Insured: Dennis Yarmouth Regional School District {amendment to Schedule Item 11 Schedule Item 11 is amended to read as follows: 11. Classification of Operations: Estimated Rate Per Estimated Annual $100 of Annual State Code Classification Payroll Payroll Manual Premium MA 7380 CHAUFFEURS & HELPERS NOC $281 ,880 5.32 $14,996 A 8868 SCHOOLS-PROFESSIONAL $40,017,776 .64 $256,114 MA 9101 SCHOOLS-ALL OTHER $970,479 3.'12 $30,279 Total Annual Payroll: $41,270,135 Total Annual Manual Premium: $301,389 Total Manual Premium: $301,389 (a) Experience Modification Factor: 1 .000000000 (b) Other Modification Factor: 1 .000000000 Normal Premium: $301,389 Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY ( ,Q,(2 ^ — k-f 1 11 i; -"I/' '' /''/ a VA ✓' Authorized Representative Secretary President This endorsement forms part of the Policy to which attached, effective on the inception date of the Policy unless otherwise stated herein.All other terms and conditions of the Policy remain unchanged. CM1:3--11 (8-13) Page 1 of 1 Date Printed: 08/04/2022