Application for a Mold Remediation Contractor License (SH126)

SH 126 (05/23) Page 1 of 3

Please do not write in this space

 Cross Check Clear  Cross Check Issue

 Approved  Disapproved

Reason (if Disapproved):

Bates # Lic. #

Check # Exp. Date:

Division of Safety and Health

License and Certificate Unit

Harriman State Office Campus

Building 12, Room 161A

Albany, NY 12226

(518) 457-2735

license&certificat[email protected]y.gov

Application for a

Mold Remediation Contractor

License

Note: Application for Mold Remediation Contractor no longer includes an individual license to work as a Mold

Remediation Contractor. Individuals wishing to apply for or renew their individual Mold Remediation

Contractor License should now use the Mold Supervisor License Application, SH127.2.

pply Online: You can now apply for this license using the Management System for Protecting Workers’

Rights (MPWR). This completely online system speeds up the application process and makes information

about applications readily available. Using MPWR, an applicant can:

• Submit their information, upload the required documentation, and pay online in one easy step.

• Receive real-time updates about the status or issues with respect to their application when they opt-in t

eceive electronic communications.

• Select their preferred language.

To appl

y online, go to https://dol.ny.gov/mpwr and login with your personal ny.gov account and if this is your

first time applying online, click on “New Request” and select the application you want. If you do not have a

personal ny.gov account select the option to “Create Account.” If you experience problems creating the

NY.Gov ID account, or if you are unable to sign into your NY.Gov ID account, please call 1-800-833-3000 for

assistance.

pply on Paper: Use this paper form to apply for your business’s Mold Remediation Contractor License. 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.

ote: By signing this form, you are granting permission to the commissioner of Labor to provide access to

your Unemployment Insurance benefit file. Please see page 4 of this form for how to submit your application,

fees and required documents.

Type of License you are applying for: (check one)

 Initial Mold Remediation Contractor License ($500 non-refundable application fee)

 Renewal Mold Remediation Contractor License, Current Mold License number:

($500 non-refundable application fee)

Business Information

Business Legal Name: (Must match Department of State Registration)

o you operate under a Doing Business As (DBA)?

 Yes  No If “YES”, you must submit a copy of

your Certificate of Doing Business Under Assumed Name (DBA) for each County in which you do business.

Type of Business Organization:

 Sole Proprietorship  Limited Liability Corporation  Corporation

 Limited Liability Partnership  Partnership  Government

www.dol.ny.gov

SH 126 (05/23) Page 2 of 3

FEIN: Primary Phone: Email:

Business Physical Location

Address: City: State: Zip:

Business Mailing Address (if different)

Address: City: State: Zip:

Designated Supervisor: All businesses must employ a licensed Mold Abatement Supervisor. Provide the name

and DMV ID number of the licensed Mold Supervisor employed by your business.

First Name: Last Name:

ndividual Mold Supervisor License Number (If Currently Licensed):

DMV ID Number:

ertification of Child Support Obligations (Not required for Corporations or LLCs)

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

ote: 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.

cknowledgement

This statement must be signed by the applicant or a representative of the applicant who is authorized to sign

on behalf of the business 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 swear that each of my employees will have his or her own valid Mold Abatement License to work

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

pplicant Signature: Date:

Print Name: Title:

SH 126 (05/23) Page 3 of 3

How to Submit your Mold Remediation Contractor License Application

Onli

ne Application: To apply online, go to https://dol.ny.gov/mpwr and login with your personal ny.gov

account and if this is your first time applying online, click on “New Request” and select the application you

want. If you do not have a personal ny.gov account select the option to “Create Account.” If you experience

problems creating the NY.Gov ID account, or if you are unable to sign into your NY.Gov ID account,

please call 1-800-833-3000 for assistance.

Paper Appl

ication: To apply using the paper form, please complete and sign this form with black ink. Please

type or print clearly.

Fee: You must include with your application a $500.00 non-refundable application fee. Make your check or

money order payable to the: “Commissioner of Labor.” Do not send cash.

Required Documents: For a Mold Remediation Contractor License, include

Proof of Business Legal Name

• Proof of Business Legal Name from the government entity it was registered with (not required

for Sole Proprietor or Partnership organizations).

• A copy

of your DBA for each County in which you do business (if applicable).

Copies

of your proofs of insurance:

• Workers’ Compensation Insurance coverage: Submit a copy of one of the following forms: C-

105.2, U26.3, SI-12, SI-105.2P, SIG-105.2, CE-200.

• Dis

ability and Paid Family Leave Benefits Insurance coverage: Submit a copy of one of the

following forms: DB-120.1, DB-155, CE-200 If you have any questions visit the New York State

Workers’ Compensation Insurance Board website at www.wcb.ny.gov.

• Liabil

ity insurance coverage, you must submit proof that you have $50,000 minimum

Occurrence Coverage in liability insurance for claims resulting from your licensed activities and

operations (Acord 25 Form). Include NYS DOL, State Office Campus, Building 12 Room 161A,

Albany NY 12226 listed as a Certificate Holder. See New York State Labor Law Article 32, and

§ 932 (3) (d) for more information.

Send to: 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 12226.

(Keep a copy for your records)

For more information visit https://www.dol.ny.gov/mold-program.