Fillable Ds Accessible Fs 5 (Commonwealth of Massachusetts)

Fill Online, Printable, Fillable, Blank Ds Accessible Fs 5 (Commonwealth of Massachusetts) Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Ds Accessible Fs 5 (Commonwealth of Massachusetts)

On average this form takes 10 minutes to complete

The Ds Accessible Fs 5 (Commonwealth of Massachusetts) form is 2 pages long and contains:

  • 2 signatures
  • 7 check-boxes
  • 30 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
19 Staniford Street, 2nd Floor
Boston, MA 02114
Phone: 617-626-6960 Fax: 617-626-6965
www.mass.gov/dols
DELEADER SUPERVISOR APPLICATION
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
Name____________________________________ Social Security Number________________________ Date of birth__________________
Address______________________________________________________________ Phone______________________________________
City/Town________________________________________________ State_______________________________ Zip__________________
Email address_____________________________________________________________________________________________________
Mailing address (if different)__________________________________________________________________________________________
City/Town_________________________________________________ State ______________________________ Zip_________________
Employer_________________________________________________________________________________________________________
Section 2: Attachments to be submitted with the application:
a Original lead training certificates, or legible copies thereof, indicating successful completion of the applicable initial and refresher training
requirements specified by 454 CMR 22.08(2), 22.08(4 )(c), and/or 454 CMR 22.08(4)(f). Original training certificates will be returned after
review of the application
b. For an initial application, proof that the applicant has successfully passed the DLS Third Party Exam.
c. A form of photo identification acceptable to DLS that positively establishes the identity and age of the applicant.
d. A signed physician’s statement, as set forth at 454 CMR 22.09(4)(f).
e. The results of all blood lead and zpp monitoring conducted on the applicant in the three-month period prior to application, including at least
one blood lead and one zpp result.
f. A money order or certified bank check, payable to the Commonwealth of Massachusetts, in the amount of the entire annual fee of $150.00
for initial or renewal license, or $45.00 for a duplicate license. If the Director denies, revokes, suspends or refuses to renew a license for
reasons specified in 454 CMR 22.15, the payment is not refundable.
Section 3: Payment of tax obligations and Statement of Compliance
I, ________________________________(Print name) do hereby certify, that I have complied with all laws of the Commonwealth (PRINT
NAME) 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 Deleading and Lead-Safe Renovation Regulations, 454 CMR 22.00. 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,
Signature____________________________________________________________________ Date ________________________________
_________________________________________________________________________________________________________________
Applicants for certification shall apply in person at one of the DLS offices listed below:
Monday-Walk-in service: 9am to 3pm 19 Staniford St., 2nd Floor, Boston, MA 02114617-626-6960
Tuesday-Walk-in service: 1st Tuesday of the month, 9am to 3pm 1 Federal St., Building 101, 3rd Floor, Springfield 01105413-781-2676
Wednesday-Walk-in service: 9am to 3pm 4 Summer St., Room 212, Haverhill, MA 01830978-372-9797
Thursday-Walk-in service: 2nd Thursday of the month, 9am to 3pm 1213 Purchase St., New Bedford, MA 02740 (Enter through Maxfield St.)508-984-7718
Friday- Walk-in service: 3rd Friday of the month, 9am to 3pm 167 Lyman St., Westborough, MA 01581508-616-0461
Rev 09/2016
click to sign
signature
click to edit
REPORTING PHYSICIAN’S STATEMENT
Pursuant to the Department of Labor Standards’ Deleading and Lead-safe Renovation Regulations, 454 CMR 22.09(4), a Deleading
Contractor, Lead-Safe Renovation Contractor, or other employer conducting Class 1 Deleading Work or Moderate-Risk Deleading Work
or Renovation Work shall ensure that employees are provided with medical examinations, the specific requirements for which are set forth
therein. Within two working days after receipt of the information set forth in 454 CMR 22.09(4)(e), the Deleading Contractor, Lead-Safe
Renovation Contractor, or other employer, as applicable, must obtain and furnish to the employee who underwent the medical examination,
a copy of a written medical opinion from the examining physician. See CMR 454 22.09(4)(f). DLS provides this form to be completed by the
examining physician for ease of use. Applicants should submit this form, or a letter from the physician containing the same information,
in lieu of the results of the medical examination.
1. The patient (name)__________________________________ has does not have (check one) a medical condition which would
place his/her health at increased risk of impairment from exposure to lead.
2. List any further recommended special protective measures or limitations on the patient’s activities which concern potential exposure to
lead:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
3. The patient (name) _________________________________ is is not (check one) physically fit to use a respirator without
restrictions. If the patient is not physically fit to use a respirator without restrictions, please describe recommended restrictions:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
4. Blood sample results
1
Date of blood draw
2
__________________________________
a. Blood lead level _______________________________________________________________________________________
b. Zinc Protoporphyrin ___________________________________________________________________________________
Date of Medical Examination_______________________________________________________________________________________
Physician’s Signature________________________________________________________ Date_______________________________
Print Physician’s Name __________________________________________________________________________________________
Physician’s Address and Phone Number____________________________________________________________________________
_________________
1
Blood lead and ZPP analysis must be performed on the same blood sample.
2
Deleader-Supervisors and Deleader-Workers shall follow the blood lead and ZPP monitoring schedule set forth at 454 CMR 22.09(S)(a)1.
3
Blood lead and ZPP monitoring for Lead-safe Renovator Supervisors and workers on Renovation projects must be done in accordance with the schedule
set forth by the OSHA Lead in Construction Standard at 29 CFR 1926.62(j).
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Ds Accessible Fs 5 (Commonwealth of Massachusetts)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document