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HomeMy WebLinkAboutBCOI-23-1760 2026 , rle::‘,!I R C ,l E D TOWN OF YARMOUTH tai 29 20 I OfficeoftheBuildingCommissioner:,tiiii-, SEP o ?1 oute 28, South Yarmouth, MA 02664 �' ''17 TTACHECSE BUILDING DEPART .it 98-2231 ext. 1260 Fax 508-398-0836 i,�0 ;b3q By RPORA1EO - APPLICATION FOR CERTIFICATE OF INSPECTION August 15, 2025 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) 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: ')AtRU Street and Number: OW ( 5r , 1 c racksf b Po t''Tr, ENO(), 0 02/. 7-sS- Name of Premises: OZ;i Uvg R,j(J PUq,,,C,yes- 'hue Tel: sD2, 6 a, 6 Q 6 Purpose for which permit is used: Li 0 UOY- & CP n)6e., License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency 06366- 2s - ISM2 Certificate to be issued to 01_,IU0s6 62 LPj IJ Ge S )iU(7, Tel: SQ g " 3„,:!,,,6(D 6 - Address: 9- 60 m KO) i) 'stw mouth Po i t fry / Q r 2 6 � Owner of Record of Building (Y�A-rrhe v i o{mo� c l ° Address Present Holder of Certificate kvatj d&(Silk) C n Q LW0 Weit c MnI pII40 DiNn)e (2_ Signature of person to whom Title Certificate is issued or his agent Date Email Address: (A/RO D e Q SO r) O L I v eYs pstJO PRO Ci t S' Corn 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-23-1760_ 12/1/2025-12/31/2026 ION Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 014005035572125 01/01/2025 to 01/01/2026 Braintree, MA 02185-0000 Information Page Renewal Policy FEIN: 881004889 Carrier Prior Policy#: 014005035572124 Item 1: Named Insured and Address Agency Oliver's&Planck's Inc RogersGray Oliver's&Planck's Tavern 410 University Avenue 960 Main Street MA 6A Westwood, MA 02090 Yarmouth Port, MA 02675 Other Workplaces Not Shown Above: See Schedule of Operations Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation Federal ID#: 881004889 Risk ID: NCCI/Bureau#: 34355 Unemployment ID#: File#: 014005035572125 Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2025 to 12:01AM on 01/01/2026 based on the insured's mailing address time zone. Item 3.Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA 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: Bodily Injury by Accident $500,000.00 each accident Bodily Injury by Disease $500,000.00 policy limit Bodily Injury by Disease $500,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15),WC000414A(01/19),WC000422C(01/21), NOE(01/01), WC200102(01/14),WC200301(04/84), WC200302A(09/08),WC200303D(08/10),WC200306B(06/13),WC200405(06/01),WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant $251.00 $5,961.00 $5,961.00 $0.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: Braintree MA 02185-0000 12-27-2024 Form#WC 00 00 01 C (Ed.05/17) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1 Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 014005035572125 01/01/2025 to 01/01/2026 Braintree, MA 02185-0000 Information Page Renewal Policy FEIN:881004889 Carrier Prior Policy#: 014005035572124 Item 1: Named Insured and Address Agency Oliver's&Planck's Inc RogersGray Oliver's&Planck's Tavern 410 University Avenue 960 Main Street MA 6A Westwood, MA 02090 Yarmouth Port, MA 02675 Schedule of Covered Workplaces Other Workplace Oliver's&Planck's Inc Effective Date: 01/01/2025 Oliver's&Planck's Tavern NAICS Code: 722511 960 Route 6A Division#: 0 Yarmouthport, MA 02675 Workplace#: 0000000001 Mailing: 960 Main Street MA 6A Yarmouth Port, MA 02675 Form#WC 00 00 01 C (Ed.05/17) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1