Form SH 125 Application for a Mold Assessment Contractor License - New York

Form SH125 or the "Application For A Mold Assessment Contractor License" is a form issued by the New York State Department of Labor.

The form was last revised in March 1, 2016 and is available for digital filing. Download an up-to-date Form SH125 in PDF-format down below or look it up on the New York State Department of Labor Forms website.

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Bates #
Lic #
Please do not write in this space.
Approved
Reason (if Disapproved):
Check #
Exp. Dt.
Disapproved
New York State Department of Labor
Division of Safety and Health
License and Certification Unit
Harriman State Office Campus
Building 12, Room 161A
Albany, NY 12240
(518) 457-2735
www.labor.ny.gov
Application for a Mold Assessment Contractor License
Please note: the individual listed on this application will receive an Individual’s Mold Assessor License
Please complete and sign this form with black ink. Please print clearly. See more submittal information on page 4.
_________________________________________________________________________________________________
New ($150 non-refundable application fee)
1. Type of License:
Renewal ($150 non-refundable application fee), License Number: (Renewal Only) ___________
2. Applicant Information (please complete a through o):
Business Information:
a. Legal Name of Company (Must match Department of State Registration):
___________________________________________________________________________________________
b. Business address:
P.O. Box: ___________ Street (include apartment #): ________________________________________________
City, Town, Village: __________________________________________ State: ______ Zip code:____________
c. Federal Employer Identification Number (FEIN): ____________________
d. Phone: (______)________________
e. Email: __________________________________________
Do you operate under a Doing Business As (DBA)?
Yes
No
If “YES”, you must submit a copy of your
f.
Certificate of Doing Business Under Assumed Name (“D/B/A”) for each County in which you do business.
Individual Applicant’s Information:
g. Last Name:_______________________________________ First:______________________ Middle Initial:_____
h. Individual Applicant’s Address:
P.O. Box: ___________ Street (include apartment #): ________________________________________________
City, Town, Village: __________________________________________ State: ______ Zip code:____________
NYS Driver’s License or Identification Number: ____________________
i.
Phone: (______)_________________
k. Email: ___________________________________________
j.
Date of birth: ____/____/_______(MM/DD/YYYY)
l.
m. Height (feet): ____ (inches): ____
n. Eye color: ______________
o. Hair color: ______________
3. Training Requirement:
A copy of my Mold Assessor Training Course Certificate of Completion is enclosed.
SH 125 (03/16)
Page 1 of 3
Bates #
Lic #
Please do not write in this space.
Approved
Reason (if Disapproved):
Check #
Exp. Dt.
Disapproved
New York State Department of Labor
Division of Safety and Health
License and Certification Unit
Harriman State Office Campus
Building 12, Room 161A
Albany, NY 12240
(518) 457-2735
www.labor.ny.gov
Application for a Mold Assessment Contractor License
Please note: the individual listed on this application will receive an Individual’s Mold Assessor License
Please complete and sign this form with black ink. Please print clearly. See more submittal information on page 4.
_________________________________________________________________________________________________
New ($150 non-refundable application fee)
1. Type of License:
Renewal ($150 non-refundable application fee), License Number: (Renewal Only) ___________
2. Applicant Information (please complete a through o):
Business Information:
a. Legal Name of Company (Must match Department of State Registration):
___________________________________________________________________________________________
b. Business address:
P.O. Box: ___________ Street (include apartment #): ________________________________________________
City, Town, Village: __________________________________________ State: ______ Zip code:____________
c. Federal Employer Identification Number (FEIN): ____________________
d. Phone: (______)________________
e. Email: __________________________________________
Do you operate under a Doing Business As (DBA)?
Yes
No
If “YES”, you must submit a copy of your
f.
Certificate of Doing Business Under Assumed Name (“D/B/A”) for each County in which you do business.
Individual Applicant’s Information:
g. Last Name:_______________________________________ First:______________________ Middle Initial:_____
h. Individual Applicant’s Address:
P.O. Box: ___________ Street (include apartment #): ________________________________________________
City, Town, Village: __________________________________________ State: ______ Zip code:____________
NYS Driver’s License or Identification Number: ____________________
i.
Phone: (______)_________________
k. Email: ___________________________________________
j.
Date of birth: ____/____/_______(MM/DD/YYYY)
l.
m. Height (feet): ____ (inches): ____
n. Eye color: ______________
o. Hair color: ______________
3. Training Requirement:
A copy of my Mold Assessor Training Course Certificate of Completion is enclosed.
SH 125 (03/16)
Page 1 of 3
Individual Applicant’s name: Last: _________________________________________ First: _______________________
4. Workers’ Compensation Insurance
I have workers’ compensation coverage or am exempt for the type of mold related work to be performed.
Submit a copy of one of the following forms: C-105.2, U-26.3, SI-12, GSI-105.2 or CE 200 if exempt.
If you have questions about whether your business needs to obtain a New York State Workers' Compensation
Insurance policy, please contact the Workers' Compensation Board, toll free, at (877) 632-4996.
5. Disability Insurance
I have disability insurance coverage or am exempt. Submit a copy of your Certificate of Disability Insurance
(form DB-120.1) or Certificate of Disability Self Insurance (form # DB-155) or proof of exemption form (CE-200)
with your application.
Please call the Workers’ Compensation Board, toll-free, at (877) 632-4996 if you have any questions.
6. Liability Insurance:
A copy of my Certificate of Liability Insurance is enclosed. You must submit proof that you have $50,000 in
liability insurance coverage for claims resulting from your licensed activities and operations.
7. Certification of Child Support Obligations
Are you under an obligation to pay child support?
Yes
No
If you answered Yes, complete items 1 - 4.
1. I am making payments in accordance with a plan agreed upon by the parties.
Yes
No
2. I am four months or more behind in the payment of child support.
Yes
No
3. My child support obligation is the subject of a pending court proceeding.
Yes
No
4
I am receiving public assistance or supplemental security income.
Yes
No
If you are four months or more behind in child support or have failed to comply with a summons, subpoena
or warrant relating to a paternity or child support proceeding, you may be subject to suspension of your
business, professional and/or driver licenses.
8. Applicant Verification Statement:
This statement must be signed by the applicant or a representative of the applicant who is authorized to sign on behalf
of the company or organization named in this application.
A. I understand that:
This application is subject to verification and I agree to provide any additional documentation as needed.
Outside sources may be contacted to verify information contained in this application. I give permission to the
outside sources for the disclosure of any information needed to process this application.
In order to complete this form, I must provide personal information. The authority to collect this information is
found in the New York State Labor Law. This information will be maintained and used to process this
application. Failure to provide this personal information may result in the inability to process my application.
The Department of Motor Vehicles will issue this license to the mailing address I maintain with the
Department of Labor.
B. I swear that:
Each of my employees will have his/her own valid Mold Assessor’s License to work on any mold project
when their duties involve the inspection or assessment of property for mold. I will comply with the requirements
of Article 32 of the New York State Labor Law and all the rules and regulations promulgated pursuant to Article
32 of the New York State Labor Law.
The information contained in this application is accurate, true, and complete to the best of my knowledge and
I am aware that there are penalties for making false statements.
Applicant Signature: _____________________________________________________ Date: ___________________
Print Name: ______________________________________________ Title: ___________________________________
Page 2 of 3
To submit this application you need to:
Use black ink to complete items 1 though 7. Please print clearly.
Mail the original, signed application to the New York State Department of Labor, Division of Safety and
Health, License and Certification Unit, State Office Campus, Building 12, Room 161A, Albany, NY 12240.
Keep a copy for your records.
You must include with your application:
1)
Your non-refundable application fee of $150, see page 1, item 1.
Make your check or money order payable to the Commissioner of Labor. Do not send cash.
2)
A copy of your Mold Assessor Training Course Certificate of Completion form.
This must be from a New York State Department of Labor approved training provider.
3)
A copy of your DBA for each County in which you do business (if applicable) see page 1, item 2b.
4)
Copies of your proofs of insurance:
I.
Worker’s Compensation coverage,
a. C-105.2:
Certificate of Workers’ Compensation Insurance
b. SI-12:
Certificate of Workers’ Compensation Self-Insurance
c. GSI-105.2: Certificate of Participation in Workers’ Compensation Group Self-
Insurance
d. U-26.3:
State Insurance Fund’s version of the C-105.2
e. CE-200:
Certificate of Attestation of Exemption
II. Disability Insurance coverage,
III. Liability insurance coverage, You must submit proof that you have $50,000 in liability
insurance coverage for claims resulting from your licensed activities and operations. See New
York State Labor Law Article 32, and § 932(3)(d) for more information.
For more information please go to
http://labor.ny.gov/mold
General information:
Any business that engages in mold assessment on a project, advertises that it is a mold
Who needs a Mold
assessment business, or holds itself out as a mold assessment business.
Assessor License?
Any individual engaged in mold assessment.
Mold assessment is defined as any inspection or assessment of property for the purpose
to discover mold, conditions that facilitate mold, and/or any conditions that indicate they
are likely to encourage mold.
What are the
An applicant for a Mold Assessor License must:
qualifications?
be eighteen (18) years of age or older,
satisfactorily complete a Mold Assessor Training Course from a Department of
Labor approved training provider,
pay the statutorily required application fee of $150, and
submit proof of:
Workers’ Compensation coverage, if required
o
Disability insurance coverage, if required
o
Liability insurance coverage of at least $50,000 providing coverage for
o
claims from the licensed activities and operations performed according
to New York State Labor Law Article 32.
How do I obtain an
You may obtain a Mold Assessor License application online at www.labor.ny.gov/mold
.
application?
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Download Form SH 125 Application for a Mold Assessment Contractor License - New York

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