HomeMy WebLinkAboutBCOI-23-1758 2025 The Commonwealth of Massachusetts
Town of og Y9 .AI
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YARMOUTH , u-i 3,4,1•,4,
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: South Shore Early Ed
Trade Name: South Shore Early Education BCOI 23 1758
Identify property address including street number, name, city or town, and county Certificate Expiration
Located at 367 ROUTE 28 November 3, 2025
WEST YARMOUTH, MA 02673
Use Group Classification(s) Floor Occupancy Use Group Other
01 st Floor 100 1-4 Adult and/or child day care Class 1-15 Class 2-16
facilities Class 3-16 Class 4-50
Allowable Occupant Load
3 Person in Kitchen and Office
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.
al Chief Name of Municipal Building
Name of Municipal Commissioner Mark G Sr Date of Inspection /titZ)49/
Signature of Municipal Fire Signature of Municipal Buildin /
Chief Commissioner Date of Issuance jf
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 26158
POLICY NO. AWC-400-7041052-2024A
PRIOR NO. AWC-400-7041052-2023A
ITEM
1. The Insured: DC Porcellis Pizzeria&More LLC
DBA:
Mailing address: C/O Candace Cook 130 Cottonwood Rd FEIN:**-***4801
Harwich,MA 02645
Legal Entity Type: Limited Liability Company
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 $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 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 001273502
INTER SEEi CLASS CODE SCHEDULE
Minimum Premium $205 Total Estimated Annual Premium $1,524
GOV GOV Deposit Premium $1,579
STATE CLASS;
MA 9079 State Assessments/Surcharges
$1,139.00 x 4.8200% $55
This policy, including all endorsements,is hereby countersigned by 04/17/2024
Authorized ignature Date
Service Office: Brown&Brown of MA LLC
54 Third Avenue 500 Victory Road, Marina Bay
Burlington MA 01803 North Quincy,MA 02171
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation insurance.
RECEIVED
OCT 28 2024
BUILDING DEPARI Mt NT
NOTICE NOTICE
TO TO
EMPLOYEES t /1' EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
Lafayette City Center, 2 Avenue de Lafayette, Boston, Massachusetts 02111
800-323-3249
As required by Massachusetts General Law,Chapter 152, Sections 21, 22, &30, this will give you
notice that I(we)have provided payment to our injured employees under the above mentioned
chapter by insuring with:
A.I.M. Mutual Insurance Company
NAME OF INSURANCE COMPANY
P.O. Box 4070 Burlington, MA 01803-0970
ADDRESS OF INSURANCE COMPANY
AWC-400-7041052-2024A 05/04/2024-05/04/2025
POLICY NUMBER EFFECTIVE DATES
500 Victory Road, Marina Bay
Brown & Brown of MA LLC North Quincy, MA 02171 (617)471-1220
NAME OF INSURANCE AGENT ADDRESS PHONE
DC Porcellis Pizzeria&More LLC 731 Main St Rt 28 S Yarmouth, MA 02664
EMPLOYER ADDRESS
04/17/2024
DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL FACILITY
HOSPITAL ADDRESS
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