Fillable La App Ap Fs (Commonwealth of Massachusetts)

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La App Ap Fs (Commonwealth of Massachusetts)

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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19 Staniford Street, 2nd Floor
Boston, MA 02114
Phone: 617-626-6960 Fax: 617-626-6965
www.mass.gov/dols
ASBESTOS PROJECT MONITOR APPLICATION
(In accordance with the provisions of M.G.L. c. 149, § 6-6F ½ and 453 CMR 6.00)
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
Check here if you would like your phone number and email address made available to the public.
Name____________________________________ Social Security Number________________________ Date of birth__________________
Address______________________________________________________________ Phone______________________________________
City/Town________________________________________________ State_______________________________ Zip__________________
Email address_____________________________________________________________________________________________________
Mailing address (if different)__________________________________________________________________________________________
City/Town_________________________________________________ State ______________________________ Zip_________________
Section 2: Education beyond high school (Attach additional sheets, if necessary)
Name and address of institution attended________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Degree/Certificate received___________________________________________________ Date of degree____________________________
Field(s) of concentration
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Section 3: Employment experience
Document a minimum of six months employment experience in the asbestos abatement field; or two months field experience under the direct
supervision of a certified Asbestos Project Monitor, as prescribed in 453 CMR 6.07(2)(d)1.
Name and address of employer______________________________________________________________________________________
Phone___________________________________ Current Position/Title______________________________________________________
Duties and Responsibilities
_________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Dates employed: From______________________________________________________ to______________________________________
Supervisor’s name and position/title ____________________________________________________________________________________
If claiming two months field experience under the direct supervision of a certified Asbestos Project Monitor; please include the name(s),
Massachusetts certification number(s), and the expiration date(s) of the individual(s).
_________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Section 3: Attachments to be submitted with the application:
a. A form of photo identification acceptable to DLS that positively establishes the identity and age of the applicant.
b. Original Asbestos training certificates, and legible copies thereof, indicating successful completion of the applicable initial and refresher
training requirements specified by 453 CMR 6.10(2), 6.10(4)(d), and/or 453 CMR 6.10(5). Original training certificates will be returned after
review of the application.
c. Two years of college or an Associate’s Degree or Technical Degree.
d. Document a minimum of six months employment experience in the asbestos abatement field; or two months field experience under the
direct supervision of a certified Asbestos Project Monitor, as prescribed in 453 CMR 6.07(2)(d)1.
e. 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 judgements, received by 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.
f. A money order or certified bank check payable to the Commonwealth of Massachusetts in the amount of the entire annual fee of $625.00.
A person applying for certification as an Asbestos Inspector and as an Asbestos Management Planner at the same time need pay only one
$625.00 fee. If the Commissioner denies, revokes, suspends or refuses to renew a certificate for reasons specified in 453 CMR 6.04, the
fee payment is not refundable.
Section 4: 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 ________________________________
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 6-7-18
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La App Ap Fs (Commonwealth of Massachusetts)

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Completed 27 July 2020

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