Application for Registered Motor Vehicle Repair Shop

Registration fee is $450.00 for a three year period, Mail to: Division of Standards, One Ashburton Place, Rm 1115, Boston, MA 02108

In addition to the registration fee of $450.00 dollars, a surety bond, or letter of credit, in the amount of $10,000 must accompany this application in accordance with the requirements of Massachusetts General Laws, Chapter 100 Section 2A.

Type of Shop: Auto Body _____ Glass Shop _____

Is this a RENEWAL? Yes ____ No ____

Business Name ________________________________________________________

Phone No.:________________________ Email Address:_______________________

Business Address_______________________ City ______________ Zip:__________

Federal ID or Social Security No.:_________________ Sales Tax No.:_____________

Name & License No. of Appraiser in your Employ:______________________________

Hazardous Wage ID Number _____________________________________________

Liability Insurer: ______________________ Policy No._________________________

If applicant is a firm, partnership, association or corporation, the following must be completed:

Name:___________________ Address:____________________ Title:______________

Name:___________________ Address:____________________ Title:______________

Name:___________________ Address:____________________ Title:______________

Name of Person in Charge: ____________________________________________________

The name and residences of other persons having a direct or indirect financial interest in the business to be conducted under this registrations are as follows:

Name:___________________ Address:________________________ Title:______________

Name:___________________ Address:________________________ Title:______________

Name:___________________ Address:________________________ Title:______________

Have you or any person listed above been charged with, indicted for or convicted of any felony during the last 5 years? ____ if so give details _____________________________________

________________________________________________________________________

Have you or any person listed above been a party in any proceedings pending in any court involving fraud, deceit or misrepresentation? ______ If so, explain fully. __________________ ________________________________________________________________________

Have you or any person listed above, or any motor vehicle repair shop in which you or any person listed above had a direct or indirect financial interest, had a previous application for registration denied or a certificate or registration suspended, revoked, or suspended? _______ If so, explain fully _____________________________________________________________________

Are the public areas of this facility which you are applying for registration accessible to persons with disabilities? Yes ___ No ____.

Letter of Recommendation: ( Not required for Renewals )

We, the undersigned, recommend the applicant names herein, ______________________, for Registration as Motor Vehicle Repair Shop in the Commonwealth of Massachusetts.

Name

Address

City/Town

Official Designation

_________________

_________________

_________________

_________________

_________________

_________________

_________________

_________________

Letters of recommendation must be signed by two individuals who are either Registered Motor Vehicle Repair Shops, elected public officials or members of the Massachusetts Bar.

Pursuant to Massachusetts General Laws Chapter 100A, I certify under the penalties of purjury that I have filed all state tax returns and paid all state taxes required under law, that I have complied with all local permit and license requirements, and that all the statements contained in this application, to the best of my knowledge and belief, are true.

___________________________________
Signature of Applicant

_________________
Date

If applicant is a firm, partnership, association or corporation:

___________________________________
Signature of Authorized Officer

_________________
Date


___________________________________
Name and Title of Authorized Officer

 

Applicant will not fill out the following

NO. ______________________

Name_____________________

No.______________ St.______

City/Town_________________

Registration Issued:__________

Registration No._____________
__________________________

Surety Bond No._____________

Date Filed__________________

Remarks___________________

__________________________

__________________________

 


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