HomeMy WebLinkAboutBCOI-24-46 2027 'I-,VAe TOWN OF YARMOUTH
-10"' Office of the BuildingCommissione r
,� � RECEI �lED
A 1 1146 Route 28, South Yarmouth, MA 026 4
,N �. - � 508-398-2231 ext. 1260 Fax 508-398-0$3 '4AR 2 3 2026
/�c.9RPpRATEDN", f BUILDING DEPARTMENT
APPLICATION FOR CERTIFICATE OF INSPECTION —
March 1, 2026 PAYABLE UPON RECEIPT
( ) Fee Required$0.00
(X) 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: a 9 Pi il e S 4-
Yar in D V Po c*
Name of Premises: C I a i p Gre ci k Tel: cog -36 a 4i3 as
Purpose for which permit is used: ()r,C,v C-
License(s)or Permit(s)required for the premises b other g6vernmental agencies:
License or Permit Agency
Sj►u4pr Caty 1-icettse- Ylnto wilt 1-
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Certificate to be issued to v OC 1 -C el: 5D8 347a-Li 3;
Address: ii ri i 1k,w St T nv'} P D.?-b rj
Owner of Record of Building Co fe,
(e.i 4-/sictocio Co L mn u I y S coin of ilyyfrei 1 cr._
Address a !7 kJ! I/bu> S-i'
Present Holder of Certificate ,t. as c,bou.e
410 Aft i:+ 01 Scoo+ Exec u7iue1CC,d
Signatu' ice.er.into whom Title
Certificate is issued or his agent 3 151a-10Dae
Email Address: avny, Z 6 Sco lvC Df j
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 withingq ten(10)days of anychange in the above information.
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Certificate of Inspection#_BCOI-24-46_
04/24/2026-04/24/2027
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800)876-2765 NCCI NO 26158
POLICY NO. VWC-100-6014316-2025A
PRIOR NO. VWC-100-6014316-2024A
ITEM
1. The Insured: Cape Cod&Islands Council Inc Boy Scouts of America
DBA:
Mailing address: 247 Willow Street FEIN:**-***1816
Yarmouthport,MA 02675
Legal Entity Type: Corporation
Other workplaces not shown above: See Location
2. The policy period is from 03/31/2025 to 03/31/2026 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 $ 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease $ 1,000,000 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 000060471
INTER SEE CLASS CODE SCHEDULE
Minimum Premium $320 Total Estimated Annual Premium $1,456
GOV GOV Deposit Premium $1,501
STATE CLASS
MA 9015 State Assessments/Surcharges
$965.00 x 4.6800% $45
This policy,including all endorsements,is hereby countersigned by 03/11/2025
Authorized ignature Date
Service Office: The Hilb Group of New England LLC
54 Third Avenue 973 lyannough Road
Burlington MA 01803 Hyannis,MA 02601
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.