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Home My WebLink AboutBCOI-24-78 2025 ^.AriTOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION September 23. 2024 PAYABLE UPON RECEIPT (X ) Fee Required $478.00 ( ) 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: 3t i , 1,0E37 > t'�("SL(7-1-(, M f\^026 70 Name of Premises: yGlF7 11 Oti7`F-1 Q%O RT Tel:t5O0 775-`?6.5 7 Purpose for which permit is used: License(s) or Permit(s) required for the premises by other governmental agencies: RECEIVED License or Permit Agency SEP 2 3 2024 Bu DI BY _ tir4-P1- Certificate to be issued to ,3y7 W r3-r yARfrpuTh LC�Tel: Address: / /CD 4--/P07rtveLt. Avt', rr-30o, /N60-C9 l,HPcO7LL-1-2- 1 Owner of Record of Building ,Sp4-1 A.5 if: ( Rio— Addy ess Present Holder of Certificate 0--2_ • S "nature of person to who Title Certificate is issued or s agent 9/2.3/2_024 -- /I Date I Email Address: GC.�X i I Ct 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# �` (�1 �j R_ 5/31/2024-5/31/2025 Technology Insurance Company, Inc. A Stock Insurance Company WORKERS COMPENSATION WC 99 00 01 B AND EMPLOYERS LIABILITY 1 of 5 INSURANCE POLICY INFORMATION PAGE Ncci Code: 39071 1. Insured: Policy Number: TWC4341607 343 WEST YARMOUTH LLC DBA:YARMOUTH RESORT 110 HARTWELL AVE SUITE 300 Individual Partnership Lexington,MA 02421 Corporation X LLC Other workplaces not shown above: None Federal Tax ID: 883553954 Producer: Risk Id: Boyd&Boufford Insurance Agency,LLC Renewal of: TWC4201681 167 S.River Road,Unit 10 Bedford,NH 03110 2. The policy period is from 12/16/2023 to 12/16/2024 12:01 a.m.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: Massachusetts B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $1,000,000 each accident $1,000,000 policy limit $1,000,000 each employee C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here: All states except ND,OH,WA,WY and State(s)Designated in Item 3.A D. This policy includes these endorsements and schedules: See Extension of Information Page 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. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM 2,220 STATE ASSESSMENT 89 TOTAL ESTIMATED COST 2,309 Minimum Premium 400 Deposit Premium 311 Issue Date: 10/30/2023 Countersigned by: Authorized Representative Technology Insurance Company, Inc. WC 99 00 01 B 2 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: 343 WEST YARMOUTH LLC Policy Number: TWC4341607 EXTENSION OF INFORMATION PAGE FOR ITEM #1 ITEM 1: NAMED INSURED and WORKPLACES NAMED INSURED: 343 WEST YARMOUTH LLC Fein: 883553954 DBA: YARMOUTH RESORT WORKPLACES: Location Number 1. 343 Route 28 West Yarmouth, MA 02673 Technology Insurance Company, Inc. WC 99 00 01 B 3 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: 343 WEST YARMOUTH LLC Policy Number: TWC4341607 EXTENSION OF INFORMATION PAGE FOR ITEM#3.D ITEM 3.D: ENDORSEMENT SCHEDULE State Form Number Description WC990001B DECLARATIONS PAGE WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC000404 PENDING RATE CHANGE ENDORSEMENT WC000406A PREMIUM DISCOUNT ENDORSEMENT WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC000422C TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT MA WC200301 MASSACHUSETTS LIMITS OF LIABILITY ENDORSEMENT MA WC200302 MASSACHUSETTS -ASSESSMENT CHARGE MA WC 200303C MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT MA WC200401 MASSACHUSETTS PENDING PREMIUM CHANGE ENDORSEMENT MA WC200405 MASSACHUSETTS PREMIUM DUE DATE ENDORSEMENT MA WC2 00601A MASSACHUSETTS CANCELLATION ENDORSEMENT MA WC200604 MASSACHUSETTS POLICY DEFINITION ENDORSEMENT Technology Insurance Company, Inc. WC 99 00 01 B 4 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: 343 WEST YARMOUTH LLC Policy Number: TWC4341607 EXTENSION OF INFORMATION PAGE FOR ITEM#4 ITEM 4: SCHEDULE OF PREMIUMS Premium Basis Rate Per Estimated #of Code Total Est. Annual $100 of Annual Classifications Emps No. Remuneration Remuneration Premium Massachusetts Hotel—All Other Employees & Salespersons, Drivers 7 9052 154,500 1.20 1,854 MA Rate Deviation 0 9037 0.00 -93 Manual Premium 1,761 Total Manual Premium 1,761 Premium for Increased Limits Part Two: 2% (1000/1000/1000) 9812 35 Premium to Equal Increased Limits Minimum Charge 9848 40 Total Premium Subject To Experience Modification 1,836 Experience Modification N/A 1,836 Merit Rating 1.00 9884 0 Terrorism 3% 9740 46 Catastrophe (other than Terrorism) 0% 9741 0 Expense Constant 0900 338 Total MA Premium 2,220 DIA Assessment 4.82% 9751 89 Total MA Cost 2,309 TOTAL ESTIMATED ANNUAL PREMIUM 2,220 STATE ASSESSMENT 89 TOTAL COST 2,309 Technology Insurance Company, Inc. WC 99 00 01 B 5 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: 343 WEST YARMOUTH LLC Policy Number: TWC4341607 PAYMENT SCHEDULE Statement Payment Closing Date Due Date Description Amount Due 12/16/2023 Downpayment $311.00 1/16/2024 Installment 1 of 9 $222.00 2/16/2024 Installment 2 of 9 $222.00 3/16/2024 Installment 3 of 9 $222.00 4/16/2024 Installment 4 of 9 $222.00 5/16/2024 Installment 5 of 9 $222.00 6/16/2024 Installment 6 of 9 $222.00 7/16/2024 Installment 7 of 9 $222.00 8/16/2024 Installment 8 of 9 $222.00 9/16/2024 Installment 9 of 9 $222.00 Total Cost$2,309.00 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to PART ONE all terms of this policy, we agree with you as follows: WORKERS COMPENSATION INSURANCE A. How This Insurance Applies GENERAL SECTION This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. A. The Policy Bodily injury includes resulting death. This policy includes at its effective date the Infor- 1. Bodily injury by accident must occur during the mation Page and all endorsements and schedules policy period. listed there. It is a contract of insurance between 2. Bodily injury by disease must be caused or ag- you (the employer named in Item 1 of the Infor- gravated by the conditions of your employment. mation Page) and us (the insurer named on the In- The employee's last day of last exposure to the formation Page). The only agreements relating to conditions causing or aggravating such bodily in- this insurance are stated in this policy. The terms of jury by disease must occur during the policy this policy may not be changed or waived except period. by endorsement issued by us to be part of this policy. B. We Will Pay B. Who is Insured We will pay promptly when due the benefits required You are insured if you are an employer named in of you by the workers compensation law. Item 1 of the Information Page. If that employer is a C. We Will Defend partnership, and if you are one of its partners, you are insured, but only in your capacity as an em- We have the right and duty to defend at our expense ployer of the partnership's employees. any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to in- vestigate and settle these claims, proceedings or C. Workers Compensation Law suits. Workers Compensation Law means the workers or We have no duty to defend a claim, proceeding or workmen's compensation law and occupational suit that is not covered by this insurance. disease law of each state or territory named in Item 3.A. of the Information Page. It includes any D. We Will Also Pay amendments to that law which are in effect during the policy period. It does not include any federal We will also pay these costs, in addition to other workers or workmen's compensation law, any fed- amounts payable under this insurance, as part of eral occupational disease law or the provisions of any claim, proceeding or suit we defend: any law that provide nonoccupational disability 1. reasonable expenses incurred at our request, benefits. but not loss of earnings; 2. premiums for bonds to release attachments and D. State for appeal bonds in bond amounts up to the State means any state of the United States of amount payable under this insurance; America, and the District of Columbia. 3. litigation costs taxed against you; 4. interest on a judgment as required by law until E. Locations we offer the amount due under this insurance; This policy covers all of your workplaces listed in and Items 1 or 4 of the Information Page; and it covers 5. expenses we incur. all other workplaces in Item 3.A. states unless you have other insurance or are self-insured for such E. Other Insurance workplaces. We will not pay more than our share of benefits and costs covered by this insurance and other 1 of 6 0 Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved.