Application for a Mold Remediation Contractor License

www.labor.ny.gov license&certifcate@labor.ny.gov

Division of Safety and Health License and Certificate Unit Harriman State Office Campus Building 12, Room 161A Albany NY 12240 (518) 457-2735

Use this form to apply for both your company and personal Mold Remediation Contractor License. Note: If approved, only one Mold Remediation Contractor License per company will be issued. To license another individual please use the Application for a Mold Abatement Worker or Supervisor License, SH 127, available on our website.

You must provide personal information to complete this form. The authority to collect this information is found in the New York State (NYS) Labor Law. This information will be maintained and used to process the application you are filing with the Division of Safety and Health, License and Certificate Unit. Failure to provide this information may result in our inability to process your application.

Note: By signing this form, you are granting permission to the commissioner of Labor to provide access to your Unemployment Insurance benefit file.

Please see pages 2 and 3 for how to submit your application, fees and required documents.

non-refundable application fee),

Note: If approved, this person will receive a Mold Remediation Contractor license. All other employees of the business need a Mold Abatement Worker or Supervisor License. The SH 127 application for this is available on our website.

Note: 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.

• This statement must be signed by the person listed in the Business Representative’s Information section or a representative of the business who is authorized to sign on behalf of the company or organization named in this application.
• I swear the information on this form is correct to the best of my knowledge.
• I am aware there are penalties for making false statements.
• I understand that this application is subject to verification o I agree to provide any additional documentation as needed.
• I understand 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.
• I approve the Department of Labor (DOL) and the Department of Motor Vehicles (DMV) to produce an identification (ID) card for me using my DMV photo. o I understand my DMV photo will be used for all future license and certificate ID cards o I understand the DOL will send my ID card to the mailing address given above.
• I swear that each of my employees will have his or her own valid Mold Abatement License to work on any mold remediation project when their duties involve one or more of the following: o The removal, cleaning, sanitizing, or surface disinfection of mold containment o Waste handling of mold and materials used to remove mold from surfaces o Materials used to remove mold from surfaces
• I swear that I will comply with the requirements of Article 32 of the New York State Labor Law

• Please complete and sign this form with black ink. Please type or print clearly. • You must include with your application: o A $500.00 non-refundable application fee.

Make your check or money order payable to the ‘Commissioner of Labor.’ Do not send cash.

• Include all required documents: o A copy of your Mold Remediation Contractor Training Course Certificate of Completion. This must be from a New York State Department of Labor approved training provider. o A copy of your DBA for each County in which you do business (if applicable

o 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 - Submit a copy of your a. Certificate of Disability Insurance (form DB-120.1) b. Certificate of Disability Self Insurance (form # DB-155) c. proof of exemption form (CE-200) If you have any questions. please call the Workers’ Compensation Board, toll-free, at (877) 632-4996 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(3d) for more information.
• Mail the original, signed application to the New York State Department of Labor, Division of Safety and Health, License and Certificate Unit, State Office Campus, Building 12, Room 161A, Albany, NY 12240.
• Keep a copy for your records.

Mold Abatement Note: Any individual engaged in mold abatement must have a Mold Abatement Worker or Supervisor license or a Mold Remediation Contractor license.

• Mold abatement is defined as the act of removal, cleaning, sanitizing, or surface disinfection of mold, mold containment, and waste handling of mold and materials used to remove mold from surfaces by an individual.
• For individuals who will serve as site or project supervisors, a Mold Abatement Worker Supervisor’s license is required.
• You must be eighteen (18) years of age or older to qualify.

Mold Remediation Note: Any business or individual engaged in mold remediation must have a Mold Remediation

• Mold remediation is defined as the business of removal, cleaning, sanitizing, or surface disinfection of mold, mold containment, and waste handling of mold and materials used to remove mold form surfaces by a business enterprise including, but not limited to, sole proprietorships.
• Companies or individual that do mold remediation work must have a Mold Remediation Contractor’s License and individuals who perform mold remediation must have either a Mold Remediation Contractor’s License, Mold Abatement worker Supervisor License or a Mold Abatement Worker License depending on their individual job duties
• Any business that engages in mold assessment on a project, advertises that it is a mold assessment business, or holds itself out as a mold assessment business.
• Any individual engaged in mold assessment.
• You must be eighteen (18) years of age or older to qualify.

. For more information visit www.labor.ny.gov/mold