HomeMy WebLinkAboutBCOI-23-1768 application og YA.4- TOWN OF YARMOUTH
5 _ 0; Office of the Building Commissioner
$vis � �',�; 1146 Route 28, South Yarmouth, MA 2664
0► : ^ . , '{ 508-398-2231 ext. 1260 Fax 508-398- 836 SEp 0 9 2026
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APPLICATION FOR CERTIFICATE OF INSPECTION Bui IBy
August 24, 2026 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:
Street anilNumber: 5$5
Name of Premises: egec I PsC(L.S cA 51A SCAI1 `1(t 4. Tel: gel 1 I '�22SJ
Y,uL ND-'.k
Purpose for which permit is used: C 42.11 ye-
License(s)or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to 50)0\ `S S i c .i,Ioose Tel: 50$ '17 t tj'L'L1
Address: 5i.6 2$ LSd- y mina. �- my- o'�.-(or13
Owner of Record of Building VV k E £Ps l T y Try
Address tj95 c(Psi P MA o'Lt 13
Present Holder of Certificate Rn14 2aM`ot 1 J
Signature of person to whom Title
Certificate is issued or his agent 12c
Date
Email Address: d cc K1 S(o
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-23-1768
12/31/2026-12/31/2027
g1 UTICA NATIONAL INSURANCE GROUP WC 000001A
gap 18()Genet Street
New Hartford, NY 13413
Issuing Company: Utica Mutual Insurance Company
MEMBER OF UTICA NATIONAL INSURANCE GROUP
WORKERS COMPENSATION AND
EMPLOYERS LIABILITY INSURANCE POLICY
Information Page Policy Number: 5776658
1. The Insured and Mailing Address: Prior Policy Number:
RED FACE JACK'S INC DBA SCALLY'S IRISH ALE HOUSE
585 ROUTE 28 Producer. World Ins Assoc, LLC
100 Wood Ave S,4th Floor
WEST YARMOUTH MA 02673 Iselin, NJ 08830
Entity of Insured: Corporation Producer Number: 78166
Other workplaces not shown above: SIC#: 58121
insured's I.D. Number: 452238664 NCCI Company Number: 15717
Risk I.D.Number
2. The policy period is from 06/19/2026 to 06/19/2027 12:01 AM Standard Time at the insured's mailing address.
3- A. Worker's 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 our 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:
AM States except those listed in Item 3.A., ND,OH,WA,WY
D. This policy includes these endorsements and schedules:
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.
Ail information required below is subject to verification and change by audit
See Extension of Information Page Code Premium Basis Rate Per$100 Estimated Annual
Total est.Annual of
Classifications No. Remuneration Remuneration Premium
Minimum Premium: $ 201 MA Expense Constant $
Employer's Liab Minimum Premium: $ Total Estimated Annual Premium j 4,637
If rndirAte f below,rntenm adjustments of premium shall be made: Deposit Premium $ 4,637
Issuing OMfos: New Hartford,NY 13413 Dets of issue:05-08-2026 Countersigned byC ()JCL_
8 D-WC Ell.OA 2(XJe Copyright 1988 National Courx.il of Crmrponsation Insurance
BILLING NO.209459988