Fillable Department of Labor Standards - Contractor Application Attachment Checklist

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Department of Labor Standards - Contractor Application Attachment Checklist

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CONTRACTOR APPLICATION ATTACHMENT CHECKLIST
Please answer all questions on the application to the best of your ability. Do not leave blanks, if the question is not applicable write N/A.
Information can be obtained on our website at www.mass.gov/dols.
Please use this check off sheet to ensure that you have included all your attachments with your contractor application.
If you have employees:
Did you remember to submit:
Certificate of Good Standing/Business Certificate/DBA/Foreign Corporation Certificate
Training Certificate
Workers’ Compensation Sheet with the proper codes on the description box (5474 Lead, 5472, and 5473 Asbestos)
and the Department of Labor Standards, 19 Staniford Street. 2nd, Floor Boston MA 02114 listed as the certificate holder.
Medical Monitoring and Respiratory Protection Programs (or a letter stating they have not changed if it is a renewal)
Certified Check or Money Order
Copies of Violations (if any)
If you do NOT have employees:
Did you remember to submit:
Certificate of Good Standing/Business Certificate/DBA/Foreign Corporation Certificate Training Certificate
A notarized statement stating you have no employees
Certified Check or Money Order
Copies of Violations (if any)
Please mail your completed application, fee, and the required documents to:
Department of Labor Standards, 19 Staniford St., 2nd Floor, Boston, MA 02114
19 Staniford Street, 2nd Floor
Boston, MA 02114
Phone: 617-626-6960 Fax: 617-626-6965
www.mass.gov/dols
ASBESTOS CONTRACTOR 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.
Please note that incomplete applications, including missing attachments, will significantly delay application processing.
Section 1: Applicant information
Applicant or Business Name____________________________________ Phone ________________________ Fax____________________
Email__________________________________________________________ Web address_______________________________________
Applicant or Business Location (Street)________________________________________________________________________________
City/Town________________________________________________ State_______________________________ Zip__________________
Mailing address (if different)__________________________________________________________________________________________
City/Town_________________________________________________ State ______________________________ Zip_________________
Federal Identification Number or Social Security 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 Massachusetts 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 Massachusetts 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 Massachusetts 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; Phone: 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. List all names, acronyms or other identifiers by which the applicant does or has done business, the address(es), and phone number(s) of
the business. Use additional paper if necessary.
Name/Acronym
Address
Phone Number
3. List all states in which the applicant holds a current license, certification, accreditation, or other approval for Asbestos Abatement
Work. Use additional paper if necessary.
State
Name/Type of License, Certification, Accreditation, or other approval
4. List the names and addresses of all Asbestos Abatement Firms or entities in which the Responsible Person(s) (including all
corporate officers, partners, and other managing agents) of the applicant has or has had a financial interest, or management
responsibility. Use additional paper if necessary.
Name of entity
5. Does the applicant have employee(s)?
Yes • IF APPLICANT HAS EMPLOYEES, attach (A), (B), and (C) listed below to this completed application:
a. A list of employees in applicant’s present workforce and a list of employees who have worked for the applicant for any period
of time during the preceding 12 months.
b. A respiratory protection AND worker health and safety program evidencing compliance with 29 CFR 1910.134,
453 CMR 6.15(4) or 29 CFR and OSHA medical monitoring requirements. If the applicant does not have a written program,
please contact (617) 626-6960 to request model programs.
c. A copy of applicant’s workers’ compensation insurance policy Certificate of Insurance or evidence of self-insurance program,
if the applicant has any employee(s). The Certificate of Insurance must include the assigned policy number, the WC code
5472/5473 or other indication that Asbestos operations are covered under the policy and effective dates and show the
Department of Labor Standards, 19 Staniford, Street., 2nd Floor, Boston, MA 02114 as the certificate holder.
No • IF APPLICANT HAS NO EMPLOYEES, attach (D) ONLY
d. Attach a NOTARIZED STATEMENT which clearly states, “(Applicant or Business name) has no employees engaged in
asbestos abatement.” Applicant must sign and date the statement and statement must be notarized. Note that if the business
acquires an employee(s) at a future date, it must have a respiratory protection and worker health and safety protection
program as noted in 5B above.
6. 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.
7. RESPONSIBLE PERSON(S) AND TRAINING (including all corporate officers, partners, and other managing agents) - Please
list of the names, license numbers and addresses of all Responsible Persons and managers of the applicant who have primary
responsibility for, and control over Asbestos Work of the applicant.
Name
License number
Address
8. Asbestos training certificates or legible copies thereof, indicating that a Responsible Person or manager of the applicant listed
pursuant to 453 CMR 6.05(1)(a)9 has successfully completed the applicable initial and refresher training requirements for
Asbestos Supervisors specified by 453 CMR 6.10(2), 6.10(4)(c), and/or 453 CMR 6.10(5).
Name
Course Title
Name, Address of Training Provider
Date of Course
Completion
9. A list of the names and addresses of all Responsible Persons (including all corporate officers, partners, and other managing
agents) and managers of the applicant who have primary responsibility for, and control over, Asbestos Work of the applicant.
Name
Address
10. A money order or certified bank check payable to the Commonwealth of Massachusetts in the amount of the entire
annual fee of $2,050. If the Director denies, revokes, suspends, or refuses to renew the License for reasons specified in 453
CMR 6.04, the fee payment is not refundable.
Section III: Payment of tax obligations and statement of compliance
I, ________________________________(Print name) do hereby certify, that I have complied with all laws of the Commonwealth relating
to taxes, reporting of employees and contractors, and withholding and remitting of child support (M.G.L. c. 62C, § 49A(a)), 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______________________________________________
An Asbestos Contractor License is valid for a period of one year. The Director may renew an Asbestos License issued pursuant to this section,
provided the current license holder mails in or submits in-person, a renewal application at least 30, but not more than 60, calendar days before
the expiration of the current license. Applications received later than 30 calendar days before the expiration of the current license will be
processed in the normal course of business, which may result in the license being renewed after its expiration date.
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------------------------------------------------------------------------
Signed under the penalties of perjury,
Signature____________________________________________________________________ Date ________________________________
Applicants for certification shall apply in person at one of the DLS offices listed below:
Attachment
Approved by
Date
Attachment
Approved by
Date
Business Certification
or Corporation
Certification
Respiratory Protection
List of employees or
notarized statement
Medical Monitoring
WC Certificate of
Insurance
Application fee
Training Certificates
Application OK to
Issue
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Department of Labor Standards - Contractor Application Attachment Checklist

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Completed 16 May 2020

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