Application For Employment Agency License Or Placement Agency Registration

19 STANIFORD STREET, 2ND FLOOR BOSTON, MA 02114 (617) 626-6970 (617) 626-6965 FAX www.mass.gov/dols APPLICATION FOR EMPLOYMENT AGENCY LICENSE OR PLACEMENT AGENCY REGISTRATION AND DETERMINATION OF APPLICABILITY OF THE TEMPORARY WORKERS RIGHT TO KNOW LAW The Employment, Placement, and Staffing Agencies Program within the Massachusetts Department of Labor Standards (DLS) licenses employment agencies and registers placement agencies in accordance with M.G.L. c. 140, §§ 46A-46R and 454 CMR 24.00. Depending upon the nature of your business and the manner in which you place, find, recruit, refer, or assign workers to jobs, employment, interviews, or assignments, your agency will either require a license or registration. Said license or registration must be renewed annually. In addition, the Temporary Workers Right to Know Law ("TWRKL") at M.G.L. c. 149, § 159C, contains obligations and prohibitions which apply to "staffing agencies" as defined by the law. Depending on the nature of your business, the TWRKL may apply to your business. SECTION I AGENCY NAME PARENT OR AFFILIATE COMPANY NAME (if applicable) STREET ADDRESS BLDG/SUITE # CITY / TOWN STATE ZIP CODE TELEPHONE NUMBER FAX NUMBER E-MAIL ADDRESS WEBSITE ADDRESS RESIDENCE COMMERCIAL BUILDING AGENCY IS LOCATED IN A : AGENCY MAILING ADDRESS (if different) SECTION II 1. THIS AGENCY IS A: SOLE PROPRIETORSHIP PARTNERSHIP, LP, OR LLP CORPORATION OR LLC FEDERAL TAX ID # _____________________________________________ · · · If sole proprietorship, provide the following for the Owner; If partnership, LP, or LLP, provide the following for the Partner (1 of 2); If corporation, provide the following for the President: Initial EPSA Application Rev. 2014--12-19 Page 1 of 12 American LegalNet, Inc. www.FormsWorkFlow.com FIRST NAME LAST NAME TITLE SOCIAL SECURITY NUMBER (LAST 6 DIGITS ONLY) HOME TELEPHONE NUMBER FORMER BUSINESS OR OCCUPATION HOME MAILING ADDRESS · · If partnership, LP, or LLP, provide the following for the Partner (2 of 2); If corporation or LLC, provide the following for the Treasurer: FIRST NAME LAST NAME TITLE SOCIAL SECURITY NUMBER (LAST 6 DIGITS ONLY) HOME TELEPHONE NUMBER FORMER BUSINESS OR OCCUPATION HOME MAILING ADDRESS 2. All sole proprietorships, partnerships, LPs, LLPs, corporations, and LLCs: Provide the following information for the AGENCY MANAGER: FIRST NAME LAST NAME TITLE FORMER BUSINESS OR OCCUPATION 3. All sole proprietorships, partnerships, LPs, LLPs, corporations, and LLCs: List all types of placement occupations / jobs / engagements to which your agency will provide or refer workers: PART-TIME PART-TIME PART-TIME PART-TIME FULL-TIME FULL-TIME FULL-TIME FULL-TIME PERMANENT PERMANENT PERMANENT PERMANENT TEMPORARY TEMPORARY TEMPORARY TEMPORARY 4. How many placement counselors will your agency utilize? 1-4 5 or more SECTION III Please answer the following: 1. Will your business procure or provide temporary or part time employment to any individual(s) who will then work under the supervision or direction of a work site employer? YES NO If the answer to #1 is YES, then your business is a staffing agency under M.G.L. c. 149, §159C and 454 CMR 24.00 and the TWRKL applies to your business. Please continue to question 2. Initial EPSA Application Rev. 2014--12-19 Page 2 of 12 American LegalNet, Inc. www.FormsWorkFlow.com 2. Will your business charge fees to job applicants or workers for procuring or attempting to procure, permanent or temporary employment or engagements? YES NO If the answer to question # 2 is YES, please skip remaining question in Section III and complete SECTION IV AND SECTION V of this application. Your business must be licensed as an employment agency. If the answer question # 2 is NO, please answer question # 3: 3. Will your business provide domestic employees, that is, any worker who is paid directly by a household, family, or individual to perform work of a domestic nature, including, but not limited to, housekeeping, home management, nanny services, child monitoring, caretaking, laundering, cooking, home companion services, house sitting, and butler services for members of households or their guests in or about private homes. YES NO The term "domestic employee" does NOT include a person who performs services of a domestic nature as an employee of the business that places him. If your business solely consists of employing workers to perform these domestic services at your direction, your business is not an employment or placement agency and does not need to be licensed or registered and you do not need to complete this application. Call 617-626-6970 with questions. The term "domestic employee" does NOT include a licensed medical professional, such as a medical doctor, registered or licensed practical nurse, or similarly trained and licensed individual who performs services relating to the delivery of specialized medical care. If your business places or assigns persons in these occupations, answer NO to question # 3. If the answer question # 3 is YES, please complete SECTION IV AND SECTION V of this application. Your business must be licensed as an employment agency. If the answer to question # 3 is NO, skip SECTION IV, and go directly to SECTION V of this application. Your business must be registered as a placement agency. SECTION IV This section is to be completed by employment agency license applicants only. Placement agency registration applicants go directly to Section V. 1. Has any individual listed in SECTION II ever been convicted of any crime or offense other than a traffic infraction? NO YES 2. Has any individual listed in SECTION II ever had a license to conduct business be denied, canceled, suspended, revoked, or surrendered? NO YES (If yes, provide details below. Attach additional sheets if necessary.) NAME OF PERSON WHOSE LICENSE WAS AFFECTED DATE OF ACTION NAME AND NATURE OF LICENSED BUSINESS CITY / TOWN & STATE NAME OF PUBLIC AGENCY THAT TOOK ACTION Initial EPSA Application Rev. 2014--12-19 Page 3 of 12 American LegalNet, Inc. www.FormsWorkFlow.com 3. Will your business engage in the placement of domestic employees, that is, placing any worker who is not your employee and is paid directly by a household, family, or individual to perform work of a domestic nature, including, but not limited to, housekeeping, home management, nanny services, child monitoring, caretaking, laundering, cooking, home companion services, house sitting, and butler services for members of households or thei