Fillable Department of Labor Standards - Asbestos Training Provider Application

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Department of Labor Standards - Asbestos Training Provider Application

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Asbestos Training Provider Application rev. 06/2014
Page 1 of 3
ASBESTOS TRAINING PROVIDER APPLICATION
(In accordance with the provisions of M.G.L. c. 149, § 6-6F ½ and 453 CMR 6.00)
Initial Application License #
Renewal Application Date
Duplicate ApplicationIssue Reviewer
Please complete each section by printing or typing the information, attaching all required documentation and signing the
application. Please note that incomplete applications, including missing attachments, will significantly delay application processing.
Section I: APPLICANT INFORMATION
Applicant or Business Name
Telephone Number (_____)_____________________________________FAX
E-mail address:______________________________________ Website Address:
Applicant or Business Location (Street)
City/Town ____________________________________________ State _______________ Zip
Mailing Address (if different from above)
City/Town ____________________________________________ State _______________ Zip
Federal Identification Number OR Social Security Number
Section II: REQUIRED INFORMATION & ATTACHMENTS Provide information below and attach the following:
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:
o 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.*
o 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.*
o 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.
2. Training course(s) set forth in 453 CMR 6.10 which you intend to offer:
Worker Initial Supervisor Initial Project Designer Initial
Worker Refresher Supervisor Refresher Project Designer Refresher
Worker Spanish Initial Inspector Initial Management Planner Initial
Worker Spanish Refresher Inspector Refresher Management Planner Refresher
Project Monitor Initial Project Monitor Refresher Associated Project Worker Initial
19 STANIFORD STREET 2
ND
FLOOR BOSTON, MA 02114
PHONE: 617-626-6960
FAX: 617-626-6965
WWW.MASS.GOV/DOLS
Asbestos Training Provider Application rev. 06/2014
Page 2 of 3
3. If the applicant has employees, evidence that the Asbestos Training 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. Certificates
of Insurance must include the assigned policy number, or other indication that asbestos training operations are covered
under the policy, and list the Department of Labor Standards with current address as the certificate holder. If the applicant
has no employees, a notarized statement to that effect must be submitted with the application.
4. 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 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.
5. A sample agenda for each training course which the applicant intends to offer, which shows topics covered and the amount
of time to be given to each topic.
6. A copy of the training manual and all printed material to be distributed in each course.
7. A description of the teaching methods to be employed, including audio-visual aids.
8. A description of the hands-on training to be provided (where required), including protocols for instruction, training
methods, numbers of students to be accommodated, and ratio of students to instructors.
9. A description of the equipment that will be used in both classroom lectures and in hands-on training.
10. A list of the names and qualifications of the persons who will provide the training in each course, including their education,
training, and experience.
11. An example of the written examination to be given in each course.
12. A list of the tuition or other fees required.
13. A copy of the certificate of completion to be given to participants. The certificate should conform to the requirements to
453 CMR 6.09 § 3(c), and include the exact location of the training.
14. A list of all states and federal agencies which have certified, accredited or given other forms of approval to the applicant to
provide asbestos training, including the name, address and telephone number of the person, department, or agency giving
such approval, and copies of all such written approvals received.
15. A statement made under the penalties of perjury by a Responsible Person of the applicant that the applicant will comply
with the applicable requirements of 453 CMR 6.00.
16. A money order or certified bank check payable to the Commonwealth of Massachusetts in the amount of the entire annual
fee of $1,750.00. 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.
Asbestos Training Provider Application rev. 06/2014
Page 3 of 3
Section III: PAYMENT OF TAX OBLIGATIONS & 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 an Asbestos Training Provider is valid for a period of one year. The Director may renew an Asbestos Training Provider
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 6.09(1)(a) through (c). The Director
may waive the requirement for resubmission of information specified at 453 CMR 6.09(1)(a) 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
Licensing Unit
19 Staniford Street, 2nd
Floor
Boston, MA 02114
_____________________________________________________________________________________________________________________________
(FOR OFFICIAL DLS USE ONLY)
ITEMS APPROVED BY:
DATE:
FEE RECEIVED
WORKERS COMPENSATION
ART OF ORG/ANNUAL REPORT/DBA
MANUALS/UPDATES SUBMITTED
COPIES OF ALL VIOLATIONS
SERVICES APPROVED
Worker Initial
Supervisor Initial
Worker Refresher
Supervisor Refresher
Worker Spanish Refresher
Project Designer Initial
Project Monitor Refresher
Project Designer Refresher
Management Planner Initial
Management Planner Refresher
Inspector Initial
Inspector Refresher
DUA/FSC
APPL. COMPLETE - OK TO ISSUE
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Completed 17 May 2020

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