Fillable Commonwealth of Massachusetts Asbestos Analytical Service Application

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Commonwealth of Massachusetts Asbestos Analytical Service Application

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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19 Staniford Street, 2nd Floor
Boston, MA 02114
Phone: 617-626-6960 Fax: 617-626-6965
www.mass.gov/dols
ASBESTOS ANALYTICAL SERVICE APPLICATION
(In accordance with the provisions of M.G.L. c. 149, § 6-6F ½ and 453 CMR 6.00)
FOR OFFICE USE ONLY Initial application Renewal application Duplicate application issue
License number ___________________________ Date___________________Reviewer_________________________________________
Please complete each section below by printing or typing the information, attaching all required documentation, and signing the application.
Section 1: Applicant information
Company Name____________________________________________________________________________________________________
Phone______________________________________________________________ Fax__________________________________________
Email address_____________________________________________________________________________________________________
Business Location (Street)____________________________________________________________________________________________
City/Town_________________________________________________State_______________________________ Zip__________________
Mailing address (if different)__________________________________________________________________________________________
City/Town_________________________________________________ State ______________________________ Zip_________________
Federal Identification Number_________________________________________________________________________________________
Section 2: Attachments to be submitted with the application:
1. (A) If applicant is a Sole Proprietorships or Partnership: A copy of the Business Certificate as filed in the City or
Town Clerk’s Office of the city or town where the applicant is located.
(B) If applicant is a Corporation or LLC:
Organized in MA in existence for less than one (1) year, provide a copy of the short form Certificate of Legal
Existence, issued by the Secretary of the Commonwealth’s Office.*
Organized in MA in existence for more than (1) year, provide a Certificate of Good Standing, issued by the
Secretary of the Commonwealth’s Office.*
Foreign Corporation (a corporation transacting business in the Commonwealth of MA and organized under
laws of a different state), provide a copy of the Foreign Corporation Certificate and a Certificate of Good
Standing issued by the Secretary of the Commonwealth’s Office.*
*Secretary of the Commonwealth’s Office: One Ashburton Place, Boston, MA 02108-1512; Tel.: 1-800-392-6090;
www.sec.state.ma.us/cor/coridx.htm. Do not send the Certificate of Good Standing issued by the Massachusetts
Department of Revenue.
(C) Not applicable. I am an Individual, Public Entity or Other, as noted in Section I above.
(D) If applicant receives samples by mail ONLY. Please include a letter stating that.
2. A list of all names, acronyms or other identifiers by which the applicant does or has done business, and the address(es)
and telephone number(s) of the business.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
3. The type(s) of approval/certification listed at 453 CMR 6.08(1)(a) through (d) for which the applicant is applying.
Class A Certificate Class B Certificate Class C Certificate Class D Certificate
4. If the applicant has employees, evidence that Asbestos Analytical Work to be performed by the applicant is covered under
a current workers' compensation policy or self-insurance program must be provided with the application. Certificate of
Insurance must include the assigned policy number, the WC code 4511 or other indication that any asbestos operations
are covered under the policy, and list the Department of Labor Standards with the proper address as the certificate holder.
If the applicant has no employees, a notarized statement to that effect must be submitted with the application.
5. A list of all occupational safety and health-related citations or notices of violation, including notices of noncompliance,
notices of responsibility, notices of intent to assess an administrative penalty, orders, consent orders, and court judgments,
received by the Responsible Persons (including all corporate officers, partners, and other managing agents) of the
applicant in the two years prior to the date of application, and the issuing agency or department and final disposition of
such citation or notice.
6. A list of the names and addresses of all persons designated as Asbestos Laboratory Supervisors of the Asbestos
Analytical Service pursuant to 453 CMR 6.08(4)(a).
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. A copy of the laboratory standard operating procedures manual for asbestos analysis used by the applicant, which shall
minimally include:
1. A listing of all Responsible Persons and employees of the applicant who will be performing asbestos analysis.
2. Legible copies of certificates of training or other training records for all persons listed at 453 CMR 6.08(2)(b)1.,
indicating that each such person has fulfilled the applicable asbestos analytical training required by 453 CMR
6.08(4)(d).
3. Copies of all applicable analytical protocols and procedures referenced at 453 CMR 6.08(4)(f).
4. An inventory of the analytical equipment used by the applicant, with a description of associated equipment
calibration and maintenance procedures and schedules.
5. A description of chain of custody procedures, including handling, storage and disposal procedures for asbestos
samples.
6. A description of the quality control procedures and programs utilized by the applicant.
8. Results indicating proficiency in the two most recent rounds of the applicable quality control program(s) required by 453
CMR 6.08(4)(e). Documentation shall be in the form of legible copies of official correspondence or certificates from the
provider of the applicable quality control program. Applicants from within the Commonwealth seeking certification as Class
B or Class C Asbestos Analytical Services may submit the single most recent quality control round result, but their receipt
of certification and approval pursuant to 453 CMR 6.08(2) may be contingent upon the results of a laboratory inspection at
the discretion of the Director.
9. A money order or certified bank check payable to the Commonwealth of Massachusetts in the amount of the
entire annual fee of $750.00. If the Director denies, revokes, suspends or refuses to renew a certificate for reasons
specified in 453 CMR 6.04, the fee payment is not refundable.
Section 3: Payment of tax obligations and Statement of Compliance
I, _________________________________________(print name) ________________________________________ (print title)
hereby certify that my business has complied with all laws of the Commonwealth of Massachusetts relating to: taxes, reporting of
employees and contractors, and withholding and remitting of child support (M.G.L. c. 62C, § 49A(a)); unemployment insurance
contributions (M.G.L. c. 151A, § 19A); workers’ compensation insurance (M.G.L. c. 152, § 25A and 25C(6)); and classification of
employees (M.G.L. c. 149, § 148B). I understand that compliance with these laws may be verified by multiple government entities
and that false attestation of compliance may be considered just cause for denial of application and other penalties.
I further state, that all employees to be engaged in Asbestos Work are certified, or will be certified prior to any work being
performed by them, pursuant to the requirements of 453 CMR 6.00.
I further state, that I have read and understand the Commonwealth of Massachusetts Regulations for The Removal, Containment
or Encapsulation of Asbestos, 453 CMR 6.00, and that all information contained herein, including any supplements attached hereto,
is true and correct to the best of my knowledge and belief.
Signed under the penalties of perjury.
Signature____________________________________________________________________ Date ________________________________
A certificate as a provider of Asbestos Analytical Services is valid for a period of one year. The Director may renew an Asbestos
Analytical Service certificate upon written application for renewal by the certificate holder. Renewal applications should be
submitted to the Department of Labor Standards no later than 30 calendar days before the expiration of the current certificate.
The submission of a renewal application later than 30 days before the expiration of the current certificate may result in renewal
after the expiration of the current certificate. Said application for renewal shall include submission of the items referenced at 453
CMR 6.08(2)(a) through (e). The Director may waive the requirement for resubmission of the information specified at 453 CMR
6.08(2)(b) where there has been no substantive change in the information submitted with a previous application, and the applicant
attests to such.
Please forward your completed application to:
Department of Labor Standards
19 Staniford Street, 2nd Floor
Boston, MA 02114
(FOR OFFICIAL DLS USE ONLY)
Items approved by:
Date:
Fee received
Worker’s Compensation
Notarized tax statement
Art of org/annual report/DBA
Copies of all violations
Services approved
DUA/FSC
Class A Certificate
Class B Certificate
Class C Certificate
Class D Certificate
Application complete – ok to issue
Asbestos Analytical Services Application rev. 8-06-17
Page 3 of 3
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Commonwealth of Massachusetts Asbestos Analytical Service Application

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Completed 22 May 2020

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