Fill - Free fillable TOWN OF RAMAPO RAMAPO TOWN HALL 237 ROUTE PDF form

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 ____________________________

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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)

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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)

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_____________________________________________________________

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 #

LICENSE

PLATE

NUMBER

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?

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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)

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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)

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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)

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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

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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

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