HomeMy WebLinkAboutBCOI-24-54 2026 r F YA4ite.
4-• TOWN OF YARMOUTH
�,� �. Office of the Building Commissioner
�� b g 1146 Route 28, South Yarmouth, MA 02664
y; 508-398-2231 ext. 1260 Fax 508-398-0836
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'` APPLICATION FOR CERTIFICATE OF INSPECTION
April 01, 2025 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: (C. 11 f--' i R2,
Name of Premises: 5,7 ) c` C:- t-A 73 E i? Tel: (56 ) 3 9 t -- 4 IT g
Purpose for which permit is used: !; ` L ,, 1
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency [1R E C E I V E
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Certificate to be issued to „c,f- c -t1.32 i-L ( Tel:(ser�) 39g ?2z aU,tiliry� r .ARrr yr
Address: I't c rl 4. "7IZ to `I4\t-a-t o:-a , µ rA CYz liL- q By -
Owner of Record of Building ,. t i.N ,7 ►s C>rl'o
Address ( s 'bk; r 7 5,,.,. v. ,(A ems-, .; .a , o-.t A ez CAD �{
Pres t Holder of Certificate f's e_c ec,..(13i,z, L-L.C
SvR_V G•M
Si a of'person to whom Title
Certificate is issued or his agent ti- i N - a
Date
Email Address: `3 S+ e L-.� (J - -14 t r ,L t A( L , (i,,,
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#BCOI-24-54
05/23/2025-05/23/2026
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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-500-5017560-2025A
PRIOR NO. WCC-500-5017560-2024A
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 01/01/2025 to 01/01/2026 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 $267 Total Estimated Annual Premium $3,238
GOV GOV Deposit Premium $843
STATE CLASS
MA 9052 State Assessments/Surcharges
$2,772.00 x 4.6800% $130
This policy, including all endorsements, is hereby countersigned by 12/12/2024
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.
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