Fillable Commonwealth of Massachusetts Plumbing Business License Application

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Commonwealth of Massachusetts Plumbing Business License Application

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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The
Commonwealth of Massachusetts
DIVISION OF PROFESSIONAL LICENSURE
BOARD OF STATE EXAMINERS OF PLUMBERS AND GAS FITTERS
1000 Washington Street, Suite 710 – Boston, Massachusetts 02118-6100
PLUMBING BUSINESS LICENSE APPLICATION
$225.00 Application Fee by check only – Payable to “Commonwealth of Massachusetts”
MUST BE FILLED OUT BY THE MASTER PLUMBER OF RECORD
PLEASE PRINT CLEARLY
I would like to:
Apply for a New Plumbing Business License
Change the Master Plumber for an existing Business License
Application Date:_____________
Master Plumber Name _______________________________________ _________________________ _____
Last Name First Name MI
Address: _____________________________________ ___________________________ ______ _________
Street City/Town State Zip Code
License Information: ______________________ __________________ _______________________
Master Number Date of Issue Serial Number on License
Full Name of Business
:___________________________________________________________________________________________
Address of Business: _________________________________________________________________________
____________________________________ __________ __________ _
_____________________________
City/Town State Zip Code Business Federal Tax ID Number (FIEN)
Business Phone: _____________ Cell Phone: ______________ email: __________________________________
Please note: EMAIL is the primary means of contact for routine correspondences during the application process.
Social Security Number (Mandatory): ________________________________ Date of Birth: ________________
Pursuant to G.L. c.62C, s. 47A, the Division of Professional Licensure is required to obtain your social security number and forward it to the
Department of Revenue. The Department of Revenue will use your social security number to ascertain whether you are in compliance with the
tax laws of the Commonwealth.
What is the legal structure of this company?
Corporation: LLC:
For Corporations: How many years has this company been incorporated? __________
If the company is doing business under another name (DBA) please provide the name:
___________________________________________________________________________________________
Name of Business (DBA)
PHONE: 617 727-9952 FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
Page 1
In the section below, please provide the names, addresses and titles of all of the managers,
officers, directors, partners and/or members of this plumbing business.
Last Name: ____________________________ First Name: ________________ Ml:_____ Lic.#: ______________
______ ___________________________________________ ____________________ _____ __________
Number Street City/Town State Zip Code
Last Name: ____________________________ First Name: ________________ Ml:_____ Lic.#: ______________
______ ___________________________________________ ____________________ _____ __________
Number Street City/Town State Zip Code
Last Name: ____________________________ First Name: ________________ Ml:_____ Lic.#: ______________
______ ___________________________________________ ____________________ _____ __________
Number Street City/Town State Zip Code
Last Name: ____________________________ First Name: ________________ Ml:_____ Lic.#: ______________
______ ___________________________________________ ____________________ _____ __________
Number Street City/Town State Zip Code
List all professional licenses/certifications you have held in the United States, or any country or jurisdiction, and the
state/jurisdiction from which the license/certification was originally issued.
Type of License: Jurisdiction: License Number:
Type of License: Jurisdiction: License Number:
Has any disciplinary action been taken against you by a licensing/certification board located in the United States or
any country or foreign jurisdiction? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Are you the subject of pending disciplinary actions by a licensing/certification board located in the United States or
any country or foreign jurisdiction? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Have you ever voluntarily surrendered or resigned a professional license to a licensing/certification board in the
United States or any country or foreign jurisdiction? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
PHONE: 617 727-9952 FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
Page 2
Have you ever applied for and been denied a professional license in the United States or any country or foreign
jurisdiction? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Have you ever been convicted of, or admitted to, a felony or misdemeanor in the United States or any country or
foreign jurisdiction? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Have you ever been charged with a criminal violation which led to a disposition of “continued without a
finding”(“CWOF”) or admission to sufficient facts? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
I certify, under the pains and penalties of perjury, that the information I have provided pursuant to this application
for licensure is truthful and accurate. I understand that the failure to provide accurate information may be grounds
for the Massachusetts Board of Examiners of Plumbers and Gas Fitters to deny me the right to sit as a candidate or
to suspend or revoke a license issued to me in accordance with Massachusetts Law. I further attest that, pursuant
to G.L. c.62C, §49A, to the best of my knowledge and belief, I have filed all Massachusetts tax returns and paid all
Massachusetts taxes required by law.
Signature of Applicant _______________________________________ Date ______________________
PHONE: 617 727-9952 FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
Page 3
FOR ALL LLC’S
**** This page should be filled out only for an LLC LICENCE ****
YOU MUST INCLUDE THIS CHECKLIST WITH YOUR APPLICATION
I have included with this application a signed and stamped copy of the Certificate of
Organization from the Secretary of State for the Commonwealth of Massachusetts
The installation of “PLUMBING WORK” is clearly stated as one of the disciplines in the
Certificate of Organization from the Secretary of State for the Commonwealth of
Massachusetts.
As the applicant and the Master Plumber of record, I am listed as a Manager of the LLC.
I have included the “CORI Authorization Form”
I have included the $ 225.00 non-refundable application / license fee payable to the
“Commonwealth of Massachusetts”
FOR CHANGES TO AN EXISTING LLC WHILE RETAINING THE CURRENT LICENSE
NUMBER
If the former Master Plumber has been terminated or resigned: I have included with
this application a notarized letter showing that the former Master Plumber of record has
resigned, been terminated or is otherwise disassociated from this LLC and the reason
you wish to keep the existing LLC License Number.
If the former Master Plumber has passed away: I have included a copy of the death
certificate for the former Master Plumber of record.
I have included the current LLC license issued to the former Master Plumber of record in
this application.
I have included a copy of the certificate of change of manager showing my appointment
as a manager of this LLC with in this application.
I have included with this application the original and new Certificate of Organization from
the Secretary of State for the Commonwealth of Massachusetts.
I certify, under pains and penalties of perjury that the information on this form is true and
accurate.
Signature of Master Plumber Date of Birth (mm/dd/yyyy) Date
Mail your completed application to:
Board of Examiners of Plumbers and Gas Fitters
1000 Washington Street – Suite 710
Boston, MA, 02118-6100
PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/pl
Page 4
FOR ALL CORPORATIONS
**** This page should be filled out only for a CORPORATION LICENCE ****
YOU MUST INCLUDE THIS CHECKLIST WITH YOUR APPLICATION
I have included with this application a signed and stamped copy of the Articles of
Organization from the Secretary of State for the Commonwealth of Massachusetts
The installation of “PLUMBING WORK” is clearly stated as one of the disciplines in the
Articles of Organization from the Secretary of State for the Commonwealth of
Massachusetts.
As the applicant and the Master Plumber of record, I am listed as an Officer of the
Corporation. (Directors are not acceptable)
I have included the “CORI Authorization Form”
I have included the $ 225.00 non-refundable application / license fee payable to the
“Commonwealth of Massachusetts”
FOR CHANGES TO AN EXISTING CORPORATION WHILE RETAINING THE
CURRENT LICENSE NUMBER
If the former Master Plumber has been terminated or resigned: I have included with
this application a notarized letter showing that the former Master Plumber of record has
resigned, been terminated or is otherwise disassociated from this Corporation and the
reason you wish to keep the existing Corporation License Number.
If the former Master Plumber has passed away: I have included a copy of the death
certificate for the former Master Plumber of record.
I have included the current Corporation license issued to the former Master Plumber of
record in this application.
I have included a copy of the amended Articles of Organization showing my appointment
as an officer of this Corporation with in this application.
I certify, under pains and penalties of perjury that the information on this form is true and
accurate.
Signature of Master Plumber Date of Birth (mm/dd/yyyy) Date
Mail your completed application to:
Board of Examiners of Plumbers and Gas Fitters
1000 Washington Street – Suite 710
Boston, MA, 02118-6100
PHONE: 617 727-9952 FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
Page 5
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
The Division of Professional Licensure by itself and on behalf of boards of registration pursuant to
M.G.L. c. 13, §9 [hereinafter, “Division of Professional Licensure”] is registered under the provisions of
M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified
prospective license applicants and current licensees.
As a license applicant or current licensee, I understand that a CORI check will be submitted for my
personal information to the Department of Criminal Justice Information Services (“DCJIS”). I hereby
acknowledge and provide permission to the Division of Professional Licensure to submit a CORI check
for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I
may withdraw this authorization at any time by providing the Division of Professional Licensure written
notice of my intent to withdraw consent to a CORI check.
FOR LICENSING PURPOSES ONLY:
The Division of Professional Licensure may conduct subsequent CORI checks within one year of the
date this Form was signed by me. If subsequent CORI checks are necessary, the Division of
Professional Licensure will provide me with written notice of the subsequent CORI checks.
By signing below, I provide my consent to a CORI check and acknowledge that the information provided
on Page 2 of this Acknowledgement Form is true and accurate.
_________________________________ _________________________________
Signature Date
Please provide the name of the board of registration and license type for which you are applying or currently hold:
_________________________________ _________________________________
Board of Registration License Type
NOTE: DPL CANNOT ACCEPT THIS TWO-PAGE CORI ACKNOWLEDGMENT FORM UNLESS IT IS
EITHER (1) SIGNED IN PERSON AT THE BOARD'S OFFICES IN THE PRESENCE OF A DPL
EMPLOYEE WHO HAS VERIFIED THE APPLICANT'S IDENTITY THROUGH ACCEPTABLE
IDENTIFICATION, OR (2) SIGNED IN THE PRESENCE OF A NOTARY PUBLIC WHO HAS LIKEWISE
VERIFIED IDENTITY AND THEN MAILED OR OTHERWISE DELIVERED TO THE BOARD'S OFFICES
AT THE ADDRESS SET FORTH ABOVE.
Page 1 of 2
SUBJECT INFORMATION: (An asterisk (*) denotes a required field)
___________________________________________________________________________________
*Last Name *First Name Middle Name Suffix
___________________________________________________________________________________
*Maiden Name (or other name(s) by which you have been known)
___________________ ____________________________
*Date of Birth Place of Birth
*Last Six Digits of Your Social Security Number: ______ - _____________
Sex: ______ Height: ____ ft. ____ in. Eye Color: ___________
Driver’s License or ID Number: ___________________ State of Issue: ________________________
Current and Former Addresses:
___________________________________________________________________________________
Street Number & Name City/Town State Zip
___________________________________________________________________________________
Street Number & Name City/Town State Zip
SECTION A: VERIFICATION BY DPL EMPLOYEE: I hereby certify that I verified the identity of the
above-referenced subject by reviewing the following form(s) of government-issued identification:
1
Passport State-issued driver’s license Military identification State-issued identification card
VERIFIED BY:
Name of Verifying DPL Employee (Please Print)
Signature of Verifying DPL Employee (Please Print) Date
SECTION B: VERIFICATION BY NOTARY:
On this ______ day of _____________, 20____, before me, the undersigned notary public, personally
appeared _________________________________ (name of document signer), and proved to me
through satisfactory evidence of identification, which was the following:
1
Passport State-issued driver’s license Military identification State-issued identification card
to be the person whose name is signed on the preceding or attached document, and acknowledged to
me that (he) (she) signed it voluntarily for its stated purpose.
Notary Public: Notary Commission Expires On:
1
If a subject does not have an acceptable government-issued identification, his or her identity shall be verified by the other
forms of identification documentation as determined by DCJIS. 803 CMR 2.09 (2).
Page 2 of 2
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Commonwealth of Massachusetts Plumbing Business License Application

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Completed 8 May 2020

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