REFUSE LICENSE APPLICATION (2/2016)
1
TOWN OF RAMAPO
RAMAPO TOWN HALL
237 ROUTE 59
SUFFERN, NEW YORK 10901
845-357-5100
DIRECTOR OF PUBLIC WORKS
REFUSE LICENSE APPLICATION
TO: DIRECTOR OF PUBLIC WORKS
TOWN OF RAMAPO
THE UNDERSIGNED HEREBY APPLIES FOR REFUSE REMOVAL LICENSE,
PURSUANT TO THE APPLICABLE PROVISIONS OF THE TOWN CODE OF THE TOWN
OF RAMAPO, AND FOR THIS PURPOSE, SUBMITS THE FOLLOWING STATEMENTS
AND ANSWERS, SWORN TO UNDER OATH.
1. NAME OF APPLICANT:_______________________________________
2. INDICATE BY CHECKING THE APPROPRIATE BOX AS TO THE STATUS
OF APPLICANT:
INDIVIDUAL OPERATING UNDER OWN NAME ( )
INDIVIDUAL OPERATING UNDER ASSUMED
BUSINESS OR TRADE NAME ( )
PARTNERSHIP ( )
CORPORATION ( )
STATE OF INCORPORATION
DATE OF INCORPORATION
CERTIFICATE DOING BUSINESS FILED AT
DATE FILED
# OF SHAREHOLDERS ______ # OF PARTNERS ________
[IF APPLICANT IS OPERATING UNDER AN ASSUMED NAME, OR IS A PARTNERSHIP,
ATTACH TO APPLICATION A COPY OF CERTIFICATE FILED IN COUNTY CLERK'S
OFFICE. IF APPLICANT IS A CORPORATION, SUBMIT CERTIFIED COPY OF
CERTIFICATE OF INCORPORATION DATED NO EARLIER THAN THIRTY DAYS FROM
DATE OF APPLICATION. (OUT OF STATE CORPORATIONS MUST ALSO SUBMIT COPY
OF AUTHORITY TO DO BUSINESS IN New York STATE.]
3. ADDRESS AND PHONE NUMBER OF APPLICANT:
Street
City State Zip
GARAGE ADDRESS ________________________________________
Street
________________________________________
City State Zip
EMERGENCY PHONE NUMBER
FAX NUMBER ____________________________
REFUSE LICENSE APPLICATION (2/2016)
2
EMAIL _________________________________
PLEASE CHECK IF BUSINESS LOCATION IS OWNED BY
APPLICANT:_____OR RENTED ______. IF RENTED, ATTACH A COPY OF
LEASE AGREEMENT.
4. NAMES, ADDRESSES AND TITLES OF PRINCIPALS OF APPLICANT:
[INDICATE ALL NAMES INCLUDING ALIASES AND NICKNAMES BY
WHICH A PARTY MAY HAVE BEEN KNOWN.]
[IF APPLICANT IS A PARTNERSHIP, LIST DETAILS AS TO ALL
PARTNERS; IF APPLICANT IS A CORPORATION, LIST DETAILS AS
TO ALL CORPORATE OFFICERS AND ADD SHAREHOLDERS.]
NAME:
TITLE:
DATE OF BIRTH:
RESIDENCE ADDRESS:
Street
City State Zip
NAME:
TITLE:
DATE OF BIRTH:
RESIDENCE ADDRESS:
Street
City State Zip
NAME:
TITLE:
DATE OF BIRTH:
RESIDENCE ADDRESS:
Street
City State Zip
NAME:
TITLE:
DATE OF BIRTH:
RESIDENCE ADDRESS:
Street
REFUSE LICENSE APPLICATION (2/2016)
3
City State Zip
[IF THE SPACE PROVIDED IN THIS APPLICATION FORM IS
INSUFFICIENT TO GIVE ALL THE REQUIRED INFORMATION IN ORDER
TO FULLY ANSWER ANY QUESTIONS, A SUPPLEMENTAL SHEET SHOULD
BE ATTACHED TO THIS LICENSE APPLICATION FORM WHEREIN SUCH
INFORMATION MUST BE PROVIDED.]
5. IN ADDITION TO THE COMPLETED APPLICATION FORM, THE
APPLICANT MUST PROVIDE THE TOWN WITH PROOF OF NECESSARY
INSURANCE COVERAGE AS SET FORTH IN THE ATTACHED
"INSURANCE COVERAGE."
[INSURANCE CERTIFICATES MUST BE SUBMITTED WITH THE
APPLICATION. IF APPLICANT IS UNDER CONTRACT WITH THE TOWN
OF RAMAPO FOR REFUSE COLLECTION, THE CERTIFICATE MUST
INDICATE THEREON THAT TOWN OF RAMAPO IS A “NAMED INSURED.”
IT SHOULD BE UNDERSTOOD THAT IF THIS IS NOT COMPLIED WITH,
THE APPLICATION CANNOT BE PROCESSED.
6. PLEASE PROVIDE A BRIEF NOTE ON APPLICANT’S EXPERIENCE IN THE
FIELD OF REFUSE COLLECTION AND HOW LONG HAS THE APPLICANT
BEEN ENGAGED IN THE REFUSE REMOVAL BUSINESS AND THE TYPES OF
BUSINESSES SERVICED BY THE APPLICANT OVER THE PAST FIVE
YEARS?
______________________________
______________________________________________________
______________________________________________________
7. LIST ALL MUNICIPALITIES IN WHICH APPLICANT HAS BEEN LICENSED
FOR REFUSE REMOVAL DURING THE PAST FIVE YEARS.
8. LIST ALL MUNICIPALITIES IN WHICH APPLICANT OR ANY OF ITS
PRINCIPALS, OFFICERS, DIRECTORS, SHAREHOLDERS OR AFFILIATE(S)
WAS DENIED A LICENSE FOR REFUSE REMOVAL OR DENIED A RENEWAL
LICENSE FOR REFUSE REMOVAL DURING THE PAST TEN YEARS.
_______________________________________________________
_______________________________________________________
_______________________________________________________
[IF EXPLANATION FOR DENIAL WERE PROVIDED TO APPLICANT
SUPPLY EXPLANATION IN A SUPPLEMENTAL SHEET TO BE ATTACHED
TO THIS APPLICATION]
9. HAS ANY REFUSE LICENSE HELD BY APPLICANT OR ANY OF ITS
PRINCIPALS, OFFICERS, DIRECTORS, SHAREHOLDERS OR AFFILIATE(S)
IN ANY OTHER JURISIDCTION EVER BEEN SUSPENDED OR REVOKED? YES
_______ NO ______. IF YES, IDENTIFY THE JURISDICTION AND
FULLY STATE THE CIRCUMSTANCES AND PRESENT STATUS OF LICENSE.
ATTACH SUPPLEMENTAL SHEETS, IF NECESSARY. ALSO ATTACH A
COPY OF DETERMINATION, DECISION OR SETTLEMENT.
_____________________________________________________________
_____________________________________________________________
REFUSE LICENSE APPLICATION (2/2016)
4
_____________________________________________________________
10. DESCRIBE THE SCOPE OF OPERATION IN THE TOWN OF RAMAPO
INTENDED BY APPLICANT:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
11. HOW MANY PEOPLE ARE EMPLOYED BY APPLICANT?
12. VEHICLES OWNED BY APPLICANT:
[LIST BELOW ALL VEHICLES OWNED BY APPLICANT. SAID LISTING
SHALL INCLUDE MAKE AND YEAR OF VEHICLE TYPE, VEHICLE
IDENTIFICATION NUMBER, LICENSE PLATE NUMBER AND STATE OF
REGISTRATION THAT WILL BE OPERATED IN THE TOWN.]
MAKE & YEAR
OF VEHICLE
TYPE
VEHICLE ID #
STATE OF
REGISTRATION
[ADDITIONAL ON SEPARATE SHEET]
13. HAVE YOU BEEN ENGAGED IN A REFUSE REMOVAL BUSINESS IN THE
TOWN OF RAMAPO DURING THE PAST CALENDAR YEAR?
YES ( )
NO ( )
IF YES, PROVIDE A LIST OF ALL CUSTOMERS SERVICED IN THE TOWN
DURING SAID PERIOD.
CUSTOMERS:
_____________________________________________________
14. DURING THE PAST FIVE YEARS HAS THE APPLICANT, OR ANY OF ITS
PRINCIPALS EVER HAD, OR PRESENTLY HAVE, AN OWNERSHIP INTEREST
OR FINANCIAL INTEREST IN ANY OTHER REFUSE COLLECTION FIRM:
YES ( )
NO ( )
IF YES, GIVE DETAILS ON A SEPARATE SHEET.
15. HAS THE APPLICANT, OR ANY OF ITS PRINCIPALS, OFFICERS,
DIRECTORS, SHAREHOLDERS OR AFFILIATE(S), BEEN CONVICTED OF A
CRIME, OR CURRENTLY HAVE PENDING AGAINST HIM/HER CRIMINAL
CHARGES?
REFUSE LICENSE APPLICATION (2/2016)
5
YES ( )
NO ( )
[IF THE ANSWER IS YES, GIVE DETAILED EXPLANATION BELOW INDICATING
NATURE OF CRIME, COURT (JURISDICTION) IN WHICH MATTER WAS DISPOSED OF,
OR CURRENTLY PENDING, DATE OF CONVICTION, DATE OF ARREST IF CHARGES ARE
PENDING, AND ALSO ANY SENTENCE IMPOSED FOR CONVICTIONS. ATTACH
CERTFICATE OF CONVICTION FOR ALL COMPLETED CASES, IF CASE IS PENDING
PROVIDE NAME AND TELEPHONE NUMBER OF PROSECUTING AGENCY.]
16. DOES THE APPLICANT HAVE ANY OUTSTANDING FINES AND/OR
PENALTIES DUE THE TOWN OF RAMAPO? IF YES - AMOUNT
$ .
17. APPLICANTS ARE ADVISED THAT EMPLOYEE WHO ARE AUTHORIZED BY
LICENSEE TO OPERATED MOTOR VEHICLES MUST HAVE AND ATTACH
COPIES OF A VALID OPERATOR’S LICENSE FOR THE TYPE OF VEHICLE
BEING OPERATED. LISTED BELOW ARE CURRENT AGENTS OR
EMPLOYEES OF APPLICANT WHO ARE AUTHORIZED TO OPERATE
VEHICLES OWNED OR LEASED BY LICENSEE:
NAME LICENSE ID# EXPIRATION DATE
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
[FOR ANY NEW HIRES, A COPY OF THE EMPLOYEE’S OPERATOR LICENSE MUST BE FILED
WITH THE TOWN WITHIN THIRTY DAYS FROM THE DATE OF HIRE. FAILURE TO COMPLY
WITH THIS MAY BE GROUNDS FOR REFUSAL, SUSPENSION OR REVOCATION OF LICENSE]
18. THE UNDERSIGNED INDIVIDUAL OR AGENT OF CORPORATE APPLICANT OR
PARTNERSHIP APPLICANT UNDERSTANDS THAT SHOULD ANY OF THE
FACTS STATED IN THIS APPLICATION CHANGE OR IF APPLICANT OR
ANY OFFICER, DIRECTOR, STOCKHOLDER OR PARTNER OR ANY NON-
INDIVIDUAL APPLICANT SHOULD BE THE SUBJECT OF ANY CRIME OR
OTHER DISCIPLINARY ACTION AS A RESULT OF ENGAGING IN THE
REFUSE LICENSE APPLICATION (2/2016)
6
SOLID WASTE BUSINESS IN ANY JURISDICTION, SUCH FACT OR
CIRCUMSTANCE SHALL BE REPORTED TO THE DIRECTOR OF PUBLIC
WORKS OR THEIR DULY AUTHORIZED REPRESENTATIVE WITHIN TEN
(10) DAYS FROM THE DATE OF OCCURRENCE.
19. THE UNDERSIGNED INDIVIDUAL, AGENT OF CORPORATE APPLICANT OR
PARTNERSHIP APPLICANT IS AWARE OF CHAPTER 235OF THE TOWN OF
RAMAPO CODE AS IT RELATES TO THE SOLID WASTE MANAGEMENT
BUSINESS IN THE TOWN OF RAMAPO AND THE APPLICANT AGREES TO
COMPLY WITH ALL THE PROVISIONS THEREIN.
20. THE UNDERSIGNED INDIVIDUAL OR AGENT OF CORPORATE APPLICANT OR
PARTNERSHIP APPLICANT ACKNOWLEDGED THAT HE/SHE WILL BEAR IN
FULL, ANY COST INCURRED BY THE TOWN OF RAMAPO FOR THE
STENOGRAPHIC SERVICES PROVIDED AND REQUIRED AT ANY HEARING
INVOLVING THIS APPLICATION, ANY SUPPLEMENT, VIOLATION AND/OR
RENEWAL.
21. THE UNDERSIGNED ACKNOWLEDGES THERE IS AN APPLICATION FEE OF
$150.00 AND A TRUCK FEE OF $100.00 FOR EACH TRUCK WHICH MUST
ACCOMPANY THIS APPLICATION TO BE CONSIDERED COMPLETE FOR
REVIEW.
SIGNATURE AND VERIFICATION
[NO APPLICATION WILL BE PROCESSED UNLESS THE APPLICANT SIGNS THE
APPLICATION FORMS AND VERIFIES UNDER OATH BEFORE A NOTARY PUBLIC AS TO
THE TRUTH OF THE STATEMENTS CONTAINED THEREIN. IN THE CASE OF A
PARTNERSHIP, ALL PARTNERS MUST SIGN AND IN THE CASE OF A CORPORATE
APPLICANT, WE REQUIRE VERIFIED SIGNATURES OF ALL OFFICERS AND
SHAREHOLDERS LISTED IN ITEM NO.4 OF THIS APPLICATION.]
[IT SHOULD BE UNDERSTOOD BY ALL THOSE SIGNING THIS APPLICATION FORM
THAT IN ORDER TO VERIFY INFORMATION SUPPLIED THEREIN, IT MAY BE
NECESSARY FOR THE DIRECTOR OF PUBLIC WORKS OR THEIR DULY AUTHORIZED
REPRESENTATIVE TO SEARCH RECORDS ON FILE WITH FEDERAL, STATE AND LOCAL
LAW ENFORCEMENT AGENCIES. IN ADDITION, IN SOME CASES IT MAY BE
NECESSARY FOR A SIGNATORY TO BE SUBJECTED TO FINGERPRINTING AND A
FINGERPRINTING SEARCH. THE SIGNATORIES BY THEIR SIGNING OF THIS
APPLICATION DO HEREBY AUTHORIZE SUCH A SEARCH OF SAID LAW ENFORCEMENT
AGENCY RECORDS TO BE MADE.]
INDIVIDUAL VERIFICATION
STATE OF NEW YORK
ss:
COUNTY OF
I, ,RESIDING AT
, BEING DULY SWORN,
DEPOSE AND SAY: I HAVE READ THE FOREGOING APPLICATION, AND KNOW
THE CONTENTS THEREOF: THAT THE SAME IS TRUE TO THE KNOWLEDGE OF
APPLICANT, EXCEPT AS TO THE MATTERS STATED TO BE SET FORTH ON
INFORMATION AND BELIEF, AND AS TO THOSE MATTERS, I BELIEVE IT TO
BE TRUE.
SIGNED
SWORN TO BEFORE ME THIS
DAY OF , 20 .
NOTARY
REFUSE LICENSE APPLICATION (2/2016)
7
INDIVIDUAL VERIFICATION
STATE OF NEW YORK
ss:
COUNTY OF
I, , RESIDING AT
, BEING DULY SWORN,
DEPOSE AND SAY: I HAVE READ THE FOREGOING APPLICATION, AND KNOW
THE CONTENTS THEREOF: THAT THE SAME IS TRUE TO THE KNOWLEDGE OF
APPLICANT, EXCEPT AS TO THE MATTERS STATED TO BE SET FORTH ON
INFORMATION AND BELIEF, AND AS TO THOSE MATTERS, I BELIEVE IT TO
BE TRUE.
SIGNED
SWORN TO BEFORE ME THIS
DAY OF , 20 .
NOTARY
REFUSE LICENSE APPLICATION (2/2016)
8
INDIVIDUAL VERIFICATION
STATE OF NEW YORK
ss:
COUNTY OF
I, , RESIDING AT
, BEING DULY SWORN,
DEPOSE AND SAY: I HAVE READ THE FOREGOING APPLICATION, AND KNOW
THE CONTENTS THEREOF: THAT THE SAME IS TRUE TO THE KNOWLEDGE OF
APPLICANT, EXCEPT AS TO THE MATTERS STATED TO BE SET FORTH ON
INFORMATION AND BELIEF, AND AS TO THOSE MATTERS, I BELIEVE IT TO
BE TRUE.
SIGNED
SWORN TO BEFORE ME THIS
DAY OF , 20 .
NOTARY
INDIVIDUAL VERIFICATION
STATE OF NEW YORK
ss:
COUNTY OF
I, , RESIDING AT
BEING DULY SWORN,
DEPOSE AND SAY: I HAVE READ THE FOREGOING APPLICATION, AND KNOW
THE CONTENTS THEREOF: THAT THE SAME IS TRUE TO THE KNOWLEDGE OF
APPLICANT, EXCEPT AS TO THE MATTERS STATED TO BE SET FORTH ON
INFORMATION AND BELIEF, AND AS TO THOSE MATTERS, I BELIEVE IT TO
BE TRUE.
SIGNED
SWORN TO BEFORE ME THIS
DAY OF , 20 .
NOTARY
CORPORATE VERIFICATION
STATE OF NEW YORK
ss:
COUNTY OF
I, , RESIDING AT ,
, BEING DULY
SWORN, DEPOSE AND SAY: THAT I AM THE
OF THE AFORESAID APPLICANT CORPORATION: THAT THE
FOREGOING APPLICATION IS TRUE TO APPLICANT'S KNOWLEDGE, EXCEPT AS
TO MATTERS WHICH ARE STATED UPON INFORMATION AND BELIEF, AND THAT
AS TO THOSE MATTERS APPLICANT BELIEVES IT TO BE TRUE.
SIGNED
SWORN TO BEFORE ME THIS
DAY OF , 20 .
NOTARY
REFUSE LICENSE APPLICATION (2/2016)
9
CORPORATE VERIFICATION
STATE OF NEW YORK
ss:
COUNTY OF
I, , RESIDING AT ,
, BEING DULY
SWORN, DEPOSE AND SAY: THAT I AM THE
OF THE AFORESAID APPLICANT CORPORATION: THAT THE
FOREGOING APPLICATION IS TRUE TO APPLICANT'S KNOWLEDGE, EXCEPT AS
TO MATTERS WHICH ARE STATED UPON INFORMATION AND BELIEF, AND THAT
AS TO THOSE MATTERS APPLICANT BELIEVES IT TO BE TRUE.
SIGNED
SWORN TO BEFORE ME THIS
DAY OF , 20 .
NOTARY
CORPORATE VERIFICATION
STATE OF NEW YORK
ss:
COUNTY OF
I, , RESIDING AT ,
, BEING DULY
SWORN, DEPOSE AND SAY: THAT I AM THE
OF THE AFORESAID APPLICANT CORPORATION: THAT THE
FOREGOING APPLICATION IS TRUE TO APPLICANT'S KNOWLEDGE, EXCEPT AS
TO MATTERS WHICH ARE STATED UPON INFORMATION AND BELIEF, AND THAT
AS TO THOSE MATTERS APPLICANT BELIEVES IT TO BE TRUE.
SIGNED
SWORN TO BEFORE ME THIS
DAY OF , 20 .
NOTARY
REFUSE LICENSE APPLICATION (2/2016)
10
INSURANCE COVERAGE
AS A CONTRACTOR PROVIDING REFUSE COLLECTION WITHIN THE TOWN OF
RAMAPO, THE APPLICANT SHALL PROVIDE THE TOWN OF RAMAPO WITH THE
CERTIFICATES OF INSURANCE WITH THE MINIMUM REQUIREMENTS OUTLINED
BELOW PRIOR TO THE COMMENCEMENT OF ANY WORK
COMMERCIAL GENERAL LIABILITY (OCCURANCE FORM)
General Aggregate (other than Prod/Comp Ops Liability) $2,000,000
Products/Completed Operations Aggregate $1,000,000
Personal & Advertising Injury Liability $1,000,000
Each Occurrence $1,000,000
Fire Damage (Any one fire) $1,000,000
Medical Exp. (Any one person) $1,000,000
The Town of Ramapo, named as Additional Insured using ISO
form CG2010 and including Completed Operations using form
CG2037 or copies of the equivalent.
Additional Insured Status must be on a primary and non-
contributory basis.
The General Aggregate must apply on a per project basis and
per location basis.
Waiver of Subrogation in favor of the Town of Ramapo, form
#CG2404 or equivalent.
AUTOMOBILE LIABILITY
Commercial Auto Liability Insurance covering the use of all Owned,
Non Owned, and hired Vehicles with combined Bodily Injury and
Property Damage Limit of at least $1,000,000
No Fault liability as required by statute
WORKERS COMPENSATION AND EMPLOYER’S LIABILITY
Workers Compensation- NY Statutory Coverage
Employer’s Liability
Bodily Injury by Accident $500,000 each accident
Bodily Injury by Disease $500,000 policy limit
Bodily Injury by Disease $500,000 each employee
All States Endorsement
NY State Disability Benefits Please provide a DB 120.1 form
UMBRELLA LIABILITY
Each Occurrence and Aggregate $2,000,000
The Umbrella must be excess over the General Liability,
Automobile and Employers Liability.
The above coverage must be place with an insurance company with an
A.M. Best rating of A-:VII or better.
ALL INSURANCE CERTIFICATES MUST CLEARLY INDICATE THAT THE TOWN
WOULD BE GIVEN WRITTEN NOTICE OF AT LEAST 30 DAYS PRIOR TO
CANCELLATION. NO DEDUCTIBLES ARE ALLOWED FOR ANY OF THE
COVERAGES. AUTOMOBILE LIABILITY INSURANCE CERTIFICATES MUST
CLEARLY INDICATE THAT THE VEHICLES FOR WHICH LICENSES ARE
REFUSE LICENSE APPLICATION (2/2016)
11
REQUIRED, ARE IN FACT COVERED BY SAID INSURANCE POLICY AND,
THEREFORE, WE REQUIRE SAID CERTIFICATES TO INDICATE THE YEAR,
TYPE AND VEHICLE IDENTIFICATION NUMBER OF THE VEHICLES COVERED BY
THE AUTOMOBILE LIABILITY POLICY.
TOWN OF RAMAPO HOLD HARMLESS AGREEMENT
The Applicant and all its employees and agents agrees to protect,
defend, Indemnify and hold the Town of Ramapo, and its officers,
employees and agents and save it harmless from and against any and
all losses, penalties, damages, settlements, costs, charges and
professional fees or other expenses or liabilities of every kind
and character arising out of or relating to any and all claims,
liens, demands, obligations, actions directly or indirectly out of
this agreement and/or the performance thereof. Without death,
damage to property, defects in materials or Workmanship, or any
other violation of any applicable statute, ordinance,
administrative order, rule or regulation or decree of any Court,
shall be included in the indemnity hereunder, with the exception
of claims, if any, caused by the sole negligence of the Town of
Ramapo.
The Applicant agrees to name the Town of Ramapo as Additional
Insured on its liability insurance policies by way of police
endorsements and provide the Town with Certificates of Insurance
as may be required or evidence of insurance as may be required by
the Town. With respect to the insurance for which the Town of
Ramapo is designated as a Named Insured, this insurance will be
primary to the Town of Ramapo.
____________________________________
Signature of Contractor/Applicant
____________________________________
PRINT NAME
____________________________________
DATE OF BIRTH
STATE OF NEW YORK )
)
COUNTY OF ROCKLAND )
On the ____ day of __________________, in the year ______, before
me, the undersigned, personally appeared _________________________
Personally known to me or proved to me on the basis of
satisfactory evidence to be the individual whose name is
subscribed to within instrument and acknowledged to me that ______
Executed the same in ________ capacity, and that by ______
signature on the instrument, the individual, or the person upon
behalf of which the individual acted, executed the instrument.
______________________________________
NOTARY PUBLIC
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome