HomeMy WebLinkAboutBCOI-24-9 2026 The Commonwealth of Massachusetts
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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: Hallett Funeral Home Inc.
Trade Name: Hallett Fineral Home BCOI-24-9
Identify property address including street number, name, city or town, and county Certificate Expiration
Located at 273 STATION AVE February 25, 2026
SOUTH YARMOUTH, MA 02664
Floor Occupancy_ Use Group Other
Use Group Classification(s) 01 st Floor 140 A-3 Lecture halls,dance halls, 140 PRSONS
churches and places of religious
Allowable Occupant Load worship,recreational centers,
terminals,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 Building
Name of Municipal Chief Mark Gr Date of Inspection
I
Commissioner 1-3 �iC i7s
Signature of Municipal Fire Signature of Municipal Building
Date of Issuance if/
/ Z 1--
Chief Commissioner / ( 1/
�g YA , TOWN OF YARMOUTH
iT�= Office of the Building Commission
41171
f g AR O"� 2025l y,{ 1146 Route 28, South Yarmouth, MA 0 6
N ',----ter 508-398-2231 ext. 1260 Fax 508-398-0 3 R-__; NT
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`' APPLICATION FOR CERTIFICATE OF INSPECTION
January 02, 2025 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 at the following address:
Street and Number: 273 Station Ave South Yarmouth, MA 02664
Name of Premises: Hallett Funeral Home Inc. Tel: 508-398-2285
Purpose for which permit is used: Funeral Home
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to Hallett Funeral Home Inc. Tel: 508-398-2285
Address: 973 Station Ave. , South Yarmouth. MA 02664
Owner of Record of Building Hallett Family Holdings
Address 273 Station Ave. , South Yarmouth, MA 02664
Present Holder of Certificate
c-----___ ,V4e.,, 4see.:da,
Si ature of person to whom 'tie
Certificate is issued or his agent 5 , 5
Date
Email Address: fahallett@hallettfuneralhome.com
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# ,3 CD I—c L. q
02/25/2025-02/25/2026
(Policy Provisions: WC000000C)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: Hartford Accident and Indemnity Company
ONE HARTFORD PLAZA HARTFORD CT 06155
THE
H
HARTFORD
NCCI Company Number: 10448
Company Code: 5
Suffix
LARS RENEWAL
POLICY NUMBER: 08 WEC AY2LPK
Previous Policy Number: New
1. Named Insured and Mailing Address: HALLETT FUNERAL HOME INC
(No., Street, Town, State, Zip Code) 273 STATION AVE
SOUTH YARMOUTH MA 02664
FEIN Number: 04-2427758
State Identification Number(s):
The Named Insured is: Corporation
Business of Named Insured: Funeral Homes and Funeral Services
Other workplaces not shown above: 273 STATION AVE
SOUTH YARMOUTH MA 02664
2. Policy Period: From 07/17/23 To 07/17/24 ANNUAL
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: BRYDEN &SULLIVAN INS AGCY INC/PHS
PO BOX 1497
SOUTH DENNIS MA 02660
Producer's Code: 08084306
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
(866)467-8730
Total Estimated Annual Premium: $2,607
Deposit Premium:
Policy Minimum Premium: $275 MA(Includes Increased Limit Min. Prem.)
Audit Period: ANNUAL Installment Term: Four Pay(30%Down+2@25%+1 @20%)
The policy is not binding unless countersigned by our authorized representative.
Countersigned by ej-‘4,901-r) 07/13/23
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 07/13/23 Policy Expiration Date: 07/17/24