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The Commonwealth of Massachusetts
U
Town of ° Y9
YARMOUTH
-00R0E.9
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:The Inn at Yarmouth Port BCOI-24-29
Trade Name:The Inn at Yarmouth Port
Identify property address including street number, name, city or town, and county Certificate Expiration
Located at 168 ROUTE 6A
YARMOUTH PORT, MA 02675 April 2,2026
Floor Occupancy_ Use Group Other
Use Group Classification(s) 01 st Floor 1 R-1 Hotels, motels,boarding houses, 1 Bedroom&Sitting
etc. Area/Bath/Office
Allowable Occupant Load 02nd Floor 6 R-1 Hotels,motels, boarding houses, 6 Bedrooms/Bath/Owners Apt
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 Chief Name of Municipal Building Mark Grylls Date of Inspection 17 ///7 jaNg—
Commissioner
/
Signature of Municipal Fire Signature of Municipal Building
Chief Commissioner ate of Issuance 7 r/ lzr-
t• = g YA �� TOWN OF YARMOUTH
O
,� ,_=} Office of the Building Commissioner
1146 Route 28, South Yarmouth, MA 02664
cck _ 4, 508-398-2231 ext. 1260 Fax 508-398-0836
_ MATTACHEESE q
+CORPURAIE�
APPLICATION FOR CERTIFICATE OF INSPECTION
March 04, 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: /6p 1 e 6 / 1-
Name of Premises: 7 c //VN Q 1- l arrn vu Po r 1- Tel: SOS `7 LP/— 7 '(7/,j
Purpose for which permit is used: Q e d ? ,are a_/(A 5
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
C x)c. 0 c \c‘S ,e ca ,
6'A
Certificate to be issued to '"tNe.e_ \ „.,/ Q \ (fit C M 6 Jk'r Tel: S o 4 141 /54 LO
Address: \ln ‘eik c,.c.r.c, t-k �e ,-4- , wt,tr 07615
Owner of Record of Building RCp( -?co Q t,r sc c e s LA4,
Address \cs % uk i V P. \( Sc. N- 0, M P v c - o. Q c,
Presen Holder of Certificate \"Z(-1DC. ode c't:t S L t.(
Signature of person om Title
Certificate is issued or his agent v27 -x
Date r. T__ _. _..
Email Address: 5 -" "iv vac 4 %c „+c••ecs ck . L) •-'• i MAR 13 2025
ESQ .Ct Oh_
V ,:) P ENT
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-24-29
04/02/2025-04/02/2026
WORKERS COMPENSATION AND EMPLOYERS' LIABILTY
INSURANCE POLICY—INFORMATION PAGE
INSURER: POLICY NO: WE242737A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET ENDORSEMENT EFF 05/29/2024
DEDHAM, MA 02026 NCCI Company No: 21059
Account No:
FEIN: 99-2464691
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
ESSENTIALLY BALANCED & GROWING LLC THE HILB GROUP OF NEW
168 ROUTE 6A ENGLAND LLC
YARMOUTH PORT, MA 02675 PO BOX 1990
HYANNIS, MA 02601
AGENT NO.: 20762
LEGAL ENTITY: LIMITED LIABILITY COMPANY (LLC)
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD: From: 05/29/2024 To: 05/29/2025
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
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: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 221 Annual Premium: $ 642
Audit Period: ANNUPiL Additional/Return Premium:
Comments : CORRECT NAMED INSD NAMED INSURED
Issued At:
Date: 0 5/10/2 0 2 4 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
PRODUCER COPY