Fillable Department of Labor Standards - Lead Training Provider Application

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Department of Labor Standards - Lead Training Provider Application

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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LEAD TRAINING PROVIDER APPLICATION
(In accordance with the provisions of M.G.L. c. 111, §. 189A-199B and 454 CMR
22.00)
Initial Application License Number
Renewal Application Date
Duplicate Application Issue 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
Email 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 AND ATTACHMENTS
Pr
o
v
i
de
info
r
mation
be
lo
w
and at
t
ach
the
follo
w
i
ng:
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:
ᴏ Organized in Massachusetts in existence for less than one (1) year, provide a copy of the short for
Certificate of
Legal Existence, issued by the Secretary of the Commonwealth’s Office.*
ᴏ 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.*
ᴏ 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.
19 STANIFORD STREET • 2nd FLOOR • BOSTON, MA 02114
PHONE: 617-626-6960 • FAX: 617-626-6965
WWW.MASS.GOV/DOLS
2. Check the Training course(s) set forth in 454 CMR 22.00 which you intend to offer. Deleading Worker (Initial and
Refresher) and Lead-Safe Renovation (Initial, Refresher, and Moderate Risk) may be offered in languages other than
English. List language you intend to teach the courses in if other than English:
Course
Check if offering
course
Language(s)
Deleader Worker Initial
Deleader Worker Refresher
Deleader Supervisor Initial
ENGLISH ONLY
Deleader Supervisor Refresher
ENGLISH ONLY
Lead-Safe Renovator- Supervisor Initial
Lead-Safe Renovator- Supervisor Refresher
Lead-Safe Renovator – Moderate-Risk Deleading Option
3. When applying for approval to offer a course in a language other than English, a signed statement from a qualified,
independent translator that the course was compared to the English language version and found to be accurate.
4.
List all names under which applicant conducts or intends to conduct training:
5. A course outline showing topics covered and the amount of time given to each topic.
6. A copy of the course manual, including all printed material to be distributed in the course.
7. A description of teaching methods to be employed, including a description of audio-visual aids to be used.
8. A description of the hands-on facility to be utilized, including protocols for instruction, the number of students to be
accommodated, and the number of instructors.
9. A description of the equipment that will be used in classroom lectures and in hands-on training.
10. A list of names and qualifications of the persons who will provide the training in each course, including verifiable
documentation of their education, training and experience.
11. An example of the written examination to be given in each course for which approval is sought.
12. A list of tuition or other fees required.
13. A copy of the certification given to course participants upon completion of the course.
14. A list of student to instructor ratios to be maintained in hands-on and classroom training sessions.
15. A list of all states and federal agencies which have certified, accredited, or given other forms of approval to the applicant to
provide lead training, including the name, address, and phone number of the person, department, or agency giving such
approval, and copies of all such written approvals received.
16. A certificate of insurance or a letter of binder from an insurance carrier indicating that the lead training activity to be performed
by the applicant is covered by a current workers' compensation policy or self-insurance program acceptable to the
Commonwealth or a notarized statement that the training provider has no employees.
17. Copies of all notices of violation or other citations issued against the applicant or business by any government agency
concerning lead related work you performed in the two (2) years prior to the date of application. Copies must clearly
indicate the issuing agency or department, the date of issue, and nature of the notice or citation. Attach a brief statement
outlining the final disposition of each notice or citation.
18. A money order or certified bank check, payable to the Commonwealth of Massachusetts in the amount of the entire
annual fee of $1,775.00 for initial or renewal license, or $45.00 for a duplicate license.
In accordance with 801 CMR 4.02, the $1,775 fee is waived for Lead Training Providers seeking approval to offer only Lead-
Safe Renovator-Supervisor training courses (initial or refresher) who are a State, federally recognized Indian Tribe, local
government or non-profit organization; a $75 surcharge still applies.
If the Director denies, revokes, suspends or refuses to renew a license for reasons specified in 454 CMR 22.15, the
application fee payment is not refundable.
Section III: PAYMENT OF TAX OBLIGATIONS & STATEMENT OF COMPLIANCE
I, , _, hereby
PRINT NAME PRINT TITLE
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 I have read and understand the Commonwealth of Massachusetts Deleading Regulations, 454 CMR
22.00, as most recently amended and that the applicant will comply with the requirements in accordance with Section
22.07.
I further state that this application is prepared in conformity with 454 CMR 22.00 and that all information contained herein,
including any supplements attached hereto, is true and correct to the best of my knowledge and belief, and I understand
that any false answer(s) will be considered just cause for denial of application or revocation of license. I further understand
that information contained within this application can and will be verified using resources available to DLS.
Signed under the penalties of perjury.
S
IGNA
T
UR
E DATE
Training Provider Licenses shall be valid for a period of one year from the date of issuance. The Director may renew a
Training Provider License, provided the current license holder submits 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. Said renewal application shall include: (a) A completed application form.
(b) Written confirmation or disclosure of any changes in the information originally submitted pursuant to 454 CMR
22.07(1)(a) thru (k). (c) A money order or certified bank check, payable to the Commonwealth of Massachusetts, in the
amount of the entire annual fee of $1,775.00. If the Director denies the license for reasons specified in 454 CMR
22.04(2), the payment is not refundable.
Please forward your completed application
to:
Department of Labor Standards
Licensing Unit
19 Staniford Street, 2
nd
Floor
Boston, MA 02114
FOR OFFICIAL USE ONLY
DATE:
FEE RECEIVED
WORKERS COMPENSATION
ART OF ORG/ANNUAL REPORT
COPIES OF ALL VIOLATIONS
SERVICES APPROVED
Deleader Supervisor Initial
Deleader Supervisor Refresher
Deleader-Worker Initial
Deleader-Worker Refresher
Lead-Safe Renovator-Supervisor
Initial
Lead-Safe Renovator-Supervisor Refresher
Lead-Safe Renovator-Supervisor
– Moderate Risk Deleading
LANGUAGES OTHER THAN
ENGLISH APPROVED
ONLINE COURSES APPROVED
APPL. COMPLETE - OK TO ISSUE
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Department of Labor Standards - Lead Training Provider Application

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Completed 16 May 2020

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