Fill - Free fillable REQUIREMENTS TO APPLY OR RENEW A DRAINLAYER'S LICENSE (City of Worcester) PDF form

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REQUIREMENTS TO APPLY OR RENEW A DRAINLAYER'S LICENSE

1. ALL APPLICATIONS SHOULD INCLUDE THE ITEMS LISTED BELOW. INCOMPLETE

APPLICATIONS SHALL BE RETURNED.

A. APPLICATION FEES: (CHECK MADE OUT TO THE CITY OF WORCESTER)

NEW APPLICANTS…………… $200.00

RENEWAL OF LICENSES……. $100.00

B. ORIGINAL CERTIFICATE OF INSURANCE:

THE CERTIFICATE OF INSURANCE MUST READ THE SAME AS THE DRAINLAYER'S

LICENSE. WITH THE INDIVIDUAL APPLICANT'S NAME AS WELL AS THE COMPANY

HE IS WORKING FOR. FOR EXAMPLE: “JOHN SMITH OF SMITH'S CONST. CO., INC.”

CERTIFICATE MUST NAME CITY OF WORCESTER AS CERTIFICATE HOLDER.

MINIMUM COVERAGE AS FOLLOWS:

GENERAL LIABILITY:

Includes: Each Occurrence $1,000,000

Comprehensive Form Aggregate $2,000,000

Premises/Operations

Underground Explosion Collapse

Hazard

Products/Completed Operations

Independent Contractors

Broad From Property Damage

Personal Injury

AUTOMOBILE LIABILITY:

Includes: Bodily Injury & $1,000,000

All Owned Vehicles Property Damage

Hired Vehicles Combined

Non-owned Vehicles

All Owned Vehicles

WORKERS COMPENSATION & EMPLOYERS LIABILITY:

As required by State of Massachusetts

Bodily Injury Each Accident $ 500,000

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REQUIREMENTS FOR DRAINLAYER'S LICENSE cont.

C. $5,000 CASH BOND - Check made out to the City of Worcester providing a (2) year

guarantee of workmanship.

D. CERTIFICATE OF COMPLIANCE - Ordinance governing revenue collection.

E. STATEMENT OF COMPLIANCE - Workers Compensation Act

F. STATEMENT OF COMPLIANCE - Department of Revenue

2. DRAINLAYER EXAM & INTERVIEW (DOES NOT APPLY FOR RENEWALS):

UTHE DRAINLAYER'S EXAMU SHALL BE BASED ON THE PERMIT MANUAL AND

CONSTRUCTION METHODS REGARDING SANITARY AND SURFACE CONNECTIONS.

THE UINTERVIEW WILL BE A BRIEF DISCUSSION OF THE APPLICANT'S EXPERIENCES

AS A DRAINLAYER. THE APPLICANT IS REQUIRED TO BRING COPIES OF ANY

DRAINLAYER LICENSE AND LETTERS OF RECOMMENDATION FROM ANY CITIES OR

TOWNS DOCUMENTING HIS EXPERIENCE.

3. LICENSE:

A LICENSE SHALL BE ISSUED ONCE ALL THE REQUIREMENTS ARE MET AND

DEEMED ACCEPTABLE BY THE COMMISSIONER OF PUBLIC WORKS. LICENSE ARE

ISSUED ON AN ANNUAL BASIS AND EXPIRE ON DECEMBER 31ST.

LICENSES ARE RENEWABLE ON A CONSECUTIVE ANNUAL BASIS.

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DRAINLAYERS LICENSE APPLICATION

Applicant ____________________________________________ Mobile # ___________________

Address ________________________________________________________________________

City/Town ______________________________________ State _______ Zip Code ____________

Company _______________________________________________________________________

Address ________________________________________________________________________

City/Town ______________________________________ State _______ Zip Code ____________

Tel # __________________________________________ Fax # ___________________________

E-Mail Address __________________________________ FID # _____________________

Company Type (check all that apply) Drainlayer:______ Paver:______

Excavator: ______ General Contractor: ______

(Your Company will be listed on the City’s web site under Licensed Contractors for all types checked)

Insurer ________________________________________ Policy Expiration ___________________

Address________________________________________________________________________

City/Town _______________________________________ State _______ Zip Code ___________

Brief Description of Company:_______________________________________________________

_______________________________________________________________________________

Approximate # of Employees: ______________ Number of Years in Business: ________________

Explain briefly reason for applying for license(s) (If renewing license write renewal) _____________

_______________________________________________________________________________

Have you or your company ever had a drainlayer's license in the City of Worcester?____________

If yes, in what name and when? _____________________________________________________

_______________________________________________________________________________

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DRAINLAYERS LICENSE APPLICATION cont.

Also, was the license suspended, revoked or not renewed? Explain reason and when:

_______________________________________________________________________________

Does applicant have a drainlayer’s license in any other city or town? If yes, list city(s) or town(s) and

bring a copy(s) of license(s) on the day of the exam. ______________________________________

_______________________________________________________________________________

Has your company worked in the city before? _____ If yes, explain what type of work and when:

_______________________________________________________________________________

________________________________________________________________ _______________

_______________________________________________________________________________

This is to certify that I am familiar with the rules, regulations and revised ordinances of the City of

Worcester and attest that I will work in conformance with said rules, regulations and ordinances. I

hereby agree to defend, indemnify and hold harmless the City of Worcester from any and all liability,

causes of action, costs or expenses in connection with or growing out of any injury, death, loss or

damage to any person or property arising out of or in connection with any activity or business

conducted under the proposed license.

Applicant's Signature ______________________________________ Date ____________________

DO NOT WRITE BELOW

Exam or Renewal Date _______________ Exam Results Pass _____ Fail ______ Renewal ______

Drainlayer License # _____ _____ Date Issued ___ ____ Date Expires: December 31,__________

Fee Paid: ____________ _____________________ Check No ____________________________

Authorized Signature:______________________________________________________________

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CERTIFICATION OF COMPLIANCE WITH WORCESTER REVISED

ORDINANCES GOVERNING REVENUE COLLECTION

Pursuant to M.G.L.C. 40 Section 57 and Worcester Revised ordinance, Chapter 11, Article 28,

Section A, I hereby certify under the pain and penalties of perjury, that the undersigned applicant and

all parties having an ownership interest therein, have complied with the Laws of the Commonwealth

of Massachusetts and the City of Worcester regarding payment of all local taxes, fees, assessments,

betterments, or any other municipal charges of any kind.

1. IF A PROPRIETORSHIP

Name of Owner:__________________________________________________________

Home Address:___________________________________________________________

City/Town _________________________________State_______ Zip Code__________

Company Name __________________________________________________________

Business Address:________________________________________________________

City/Town _________________________________State_______ Zip Code__________

Business Phone:________________________ Home Phone:______________________

2. IF A PARTNERSHIP (Full Names and Addresses of all Partners)

NAME ADDRESS

_______________________________ _______________________________________

Company Name __________________________________________________________

Business Address:________________________________________________________

City/Town _________________________________State_______ Zip Code__________

Business Phone:__________________________________________________________

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CERT. OF COMPLIANCE - REVENUE COLLECTION cont.

3. IF A CORPORATION State of Incorporation:___________

Full Legal Name of Corp:____________________________________________________

Principal Place of Business:__________________________________________________

Other Places of Business in Mass:____________________________________________

Officers of Corporation:

NAME ADDRESS

_______________________________ _______________________________________

4. IF A TRUST

Name of Trust:___________________________________________________________

Business Address:________________________________________________________

NAME OF TRUSTEE ADDRESS

_______________________________ ______________________________________

_______________________________ _______________________________________

NAME OF BENEFICIARIES ADDRESS

_______________________________ _______________________________________

ALL: Dated this__________Day of_____________________________________20__________

By Name: _______________________________ Title:_________________________________

Business Address: ______________________________________________________________

Federal I.D. No.__________________________________________________

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APPLICATION FOR DRAINLAYERS LICENSE

STATEMENT OF COMPLIANCE WITH WORKERS COMPENSATION ACT

Massachusetts General Laws, Chapter 152, requires employer to provide Workers’ Compensation

Insurance for employees. Applicants must demonstrate compliance with Chapter 152 or provide a

statement of inapplicability.

Please check the appropriate statements, provide additional information where necessary, and sign

below:

Applicant is in compliance with the Massachusetts General Laws relative to

providing workers’ compensation insurance for employees. A Certificate of

Insurance or a license as a self-insurer is attached.

Applicant is not required to provide worker’s compensation insurance for the

following reasons:

I certify that the above statement is true and correct under the pains and penalties of perjury

this________ day of ____________20_____.

________________________________

CORPORATE NAME OR DBA

_________________________________

SIGNATURE

_________________________________

TITLE

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CERTIFICATE OF COMPLIANCE

MASSACHUSETTS DEPARTMENT OF REVENUE

I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax

returns and paid all state taxes as required under law

_____________________________ __________________________

*Signature of Individual By: Corporate Officer

_____________________________

Federal Identification Number

This license will not be issued unless this certification clause is signed by the applicant.

Your FID will be furnished to the Massachusetts Department of Revenue to determine whether you

have met tax filing or tax payment obligations. Licensees who fail to correct their non-filing or

delinquency will be subject to license suspension or revocation. This request is made under the

authority of Massachusetts General Law, Chapter 62C, Section 49A.

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