FY21 JOHN DOE SAFETY GRANT SAMPLE 2020~1.pdf

GRANT APPLICATION & SUPPORTING DOCUMENTS CHECK OFF SUMMARY

Prepare and submit the grant application and supporting documents as one document according to the following outline. Multiple attachments and zip files cannot be accepted.

INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED UNLESS ALL REQUESTED DOCUMENTS

ARE INCLUDED WITH YOUR SUBMISSION

GRANT APPLICATIONS AND ALL SUPPORTING DOCUMENTS LISTED BELOW MUST ONLY BE SUBMITTED

ELECTRONICALLY TO safety.grant@mass.gov

Grant Application - Submit application as one PDF document. Your application will not be considered if all required information listed in the application is not provided.

Organization Description, Training Goals

Budget Narrative - This should be a detailed written description of your proposed training summary and explain how each line item in the budget summary will be utilized. You must include; number of classes, length of classes, number of participants in each class and training provider.

Budget Summary - Names of Trainers must be included in column one description.

Qualifications of training providers - Resumes or biographical profiles and current certifications and/or licenses of all key training providers must be provided at the time of submission.

Department of Revenue (DOR) Certificate of Good Standing - The fastest and easiest way to obtain a Certificate is to apply online at https://mtc.dor.state.ma.us/mtc. A Certificate of Good Standing less than 6 months old must be provided at the time of submission.

A certificate of Unemployment Insurance Compliance from the Office of Unemployment Insurance. The fastest and easiest way to obtain a DUA Certificate is to apply online at https://uionline.detma.org/Employer/Core/Login.ASPX. Self insured or reimbursable employers can get certificates of compliance from DUA via your UI Online account.

GRANT APPLICATIONS AND ALL SUPPORTING DOCUMENTS LISTED ABOVE MUST BE

SUBMITTED ELECTRONICALLY TO: safety.grant@mass.gov

JOHN DOE SAMPLE

GRANT APPLICATION & CHECK OFF SUMMARY

mailto:electronic.safetygrant@dia.state.ma.us mailto:electronic.safetygrant@dia.state.ma.us

COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF INDUSTRIAL ACCIDENTS

OFFICE OF SAFETY

WORKPLACE SAFETY

TRAINING & EDUCATION GRANT PROGRAM

COMPANY INFORMATION

1. Applicant/Organization Legal Name:

2. Grant Administrator /Title:

3. Applicant Complete Address:

4. Phone Number:

5. Email Address:

6. Federal Employer Identification Number (FEIN): If consortium grant please include FEIN for all parties.

7. How did you originally hear about this grant program?

9.

10.

Has your organization received a Safety Grant contract with the Commonwealth in the past 5 years? If yes please specify.

Type of organization For-Profit Non- Profit

Is your company or training provider SOMWBA certified? If yes please specify.

11. Employee

Demographics

Total

Employees

Total Employees

To Be Trained

12 Hazards to be addressed in application (please check all that apply)

_______OSHA __________ Ergonomics ____CPR/AED

_______ Injury Prevention Fire/Electrical Stress

_______ Asbestos CTD’s Other (explain)

_______ Lead Hazards Toxins

_______ Right to Know/Hazard Communication

13. Location Demographics: Which counties will training take place (please check all that apply)

____ Barnstable Essex Middlesex Suffolk

____ Berkshire Franklin Nantucket Worcester

____ Bristol Hampden Norfolk Statewide

____ Dukes Hampshire Plymouth

14. Total Amount Requested

TELL US ABOUT YOUR ORGANIZATION

Briefly describe the nature of the applicant’s business including a description of products or services provided. Be sure to state how long your organization has been established and the number of employees.

PLEASE REFER TO THE JOHN DOE SAMPLE TEMPLATE FOR GUIDANCE

WHAT ARE YOUR TRAINING GOALS

Identify and describe the injury history of the targeted occupation(s) (if any), or preventative safety issues you intend to address in this proposal. Connect the training requested with the work the employee performs

PLEASE REFER TO THE JOHN DOE SAMPLE TEMPLATE FOR GUIDANCE

BUDGET NARRATIVE

Please provide a brief description of the proposed training plan. This should be a detailed written description of how each line item in the budget summary will be utilized

In order to evaluate the cost effectiveness of the program approximate projected class sizes are required

PLEASE REFER TO THE JOHN DOE SAMPLE TEMPLATE FOR GUIDANCE

**Identify the training topic, number of training sessions, number of participants to be trained per class, the name of trainer providing services, number of instructors to be present for each session, cost per class or per person, length of time per class and training location within your budget narrative.

BUDGET SUMMARY

APPLICANT:

GRANT ADMINISTRATOR NAME:

COMPLETE ADDRESS:

PHONE:

E-MAIL ADDRESS:

CHOOSE EITHER PER PERSON OR PER CLASS FOR EACH TOPIC

PLEASE REFER TO THE JOHN DOE SAMPLE TEMPLATE FOR GUIDANCE

DESCRIPTION CONT RA CT EXPEN DITU R E

PER PERSON

OR

CONT RA CT E XPEN DITU R E

PER CL ASS

COST

TRAINING TOPICS

NAME OF TRAINERS

(example OSHA/Jim Sullivan)

TOTAL # OF

PERSONS

AND COST PER

PERSON

TOTAL # OF

CLASSES

AND COST PER

CLASS

TOTAL COST

1.

2.

3.

4.

5.

6.

7.

8.

9.

Admin. Cost up to 7%

Maximum Obligation up to $25,000 mariap Cross-Out mariap Text Box

Will Turner

10 YORKEY WAY

BOSTON MA 02111

617-555-1212

WILLTURNER@FIVESTAROSHATRAINING.COM

Employment

Work Experience:

May 2008 to Present, Five Star Safety Training. Certified Safety & Health Official (CSHO) and OSHA

Authorized Outreach Trainer in both Construction and General Industry, MSHA certified, and is recognized for developing and maintaining a “world class” safety culture in the water, wastewater, construction, transportation, mining, and municipal solid waste service industries. David is skilled in training both internal and external customers committed to a team effort of safety and who have a zero tolerance for accident, injuries, and safety failures regardless of their individual position.

November 2005 to January 2008, OSHA Safety Compliance and Teaching, 2097 Fallon Blvd., Palm Bay, FL

32907. Teacher / Inspector (self-employed). Taught 10- and 30-hour OSHA Construction Outreach

Programs. Conducted on-site training and certification for Permit-Required Confined-Space Entrant /

Attendant, Powered Industrial Truck Operator, Rough Terrain Aerial Platform, and NESC safety guidelines for electrical transmission and distribution systems. As a consultant, I set up an OSHA-compliant record system.

Education

B.S. Occupational Health & Safety, West Clayton University, Humble, TX, 06/22/08.

OSHA - 500 Train the Trainer Construction Safety Training Outreach Program, #07-MA-0633, 12/21/2011.

OSHA - 501 Train the Trainer General Industry Outreach Training Program, #07-MA-0633, 07/16/20017.

OSHA Safety Program Management Certificate, Mid-America OSHA Education Center, June 8, 2008

ISO 14001, DOT, OSHA 18001, Environmental, Health and Safety Training, #10914100887.

OSHA - 30-Hour Construction Industry Outreach Training Program, #600179131.

OSHA- 30-Hour General Industry Outreach Training Program, Certificate #953468.

OSHA - 10-Hour Construction Industry Outreach Training Program, #001535598.

OSHA - 24-Hour Hazwoper Training Program, Certificate #771826.

mailto:WILLTURNER@FIVESTAROSHATRAINING.COM

WILL TURNER

mariap

10 / 10 / 2022

Jack Sparrow Owner/Operator Community Forklift Academy

Biography:

Jack Sparrow has owned Community Forklift Acacdemy since 2006 after years of working in the safety industry at Hanscom Air Force Base. He came to us with 25+ years experience as an engineering equipment operator.

To date, he has provided Forklift training to nearly 1,000 customers. His experience as a Safety and Occupational Health Specialist allows him to answer the multitude of inquiries he receives from safety officers looking to enrich their safety programs.

Credentials and Qualifications:

• Class 'A' COL with all endorsements

• Transportation Worker Identification Credential (TWIC card)

• OSHA 500 General Construction Industry Safety & Health Standards 30 Hr course

• Fluor Health, Safety & Environmental HSE Leadership Train The Trainer

• USAF, Crane Inspection-Certification

• Northeast Tractor Trailer School

• USAF, Supervisor safety training

• USAF, Operational Risk Management Level1

• OSHA Compliance Course

• Management Skills for New Supervisors mariap Text Box Community Forklift Academy 10 Ballard Road Watertown, MA 01843 855-285-8978

MASSACHUSETTS DEPT. OF REVENUE

P.O. BOX 7066

BOSTON, MA 02204

MARK E. NUNNELLY, COMMISSIONER

CHARLENE HANNAFORD, ACTING DEPUTY COMMISSIONER

CERTIFICATE OF GOOD STANDING AND/OR TAX COMPLIANCE

The Commissioner of Revenue certifies as of the above date, that the above named individual or entity is in compliance with its tax obligations payable under M.G.L. c. 62C, including corporation excise, sales and use taxes, sales tax on meals, withholding taxes, room occupancy excise and personal income taxes, with the following exceptions.

This Certificate certifies that individual taxpayers are in compliance with income tax obligations and any sales and use taxes, sales tax on meals, withholding taxes, and/or room occupancy taxes related to a sole proprietorship. Persons deemed responsible for the payment of these taxes on behalf of a corporation, partnership or other business entity may not use our automated process to obtain a Certificate.

This Certificate does not certify that the entity's standing as to taxes such as unemployment insurance administered by agencies other than the Department of Revenue, or taxes under any other provisions of law. Taxpayers required to collect or remit the following taxes must submit a separate request to certify compliance: Alcoholic Beverage Excise, Cigarette Excise, Sales Tax on Boats, International Fuels Tax Agreement, Smokeless Tobacco or Ferry Embarkation.

THIS IS NOT A WAIVER OF LIEN ISSUED UNDER GENERAL LAWS, CHAPTER 62C,

SECTION 52.

Very truly yours

Charlene Hannaford, Acting Deputy Commissioner

Highlight

Pages from FY18 JOHN DOE SAFETY GRANT APPLICATION.PDF.pdf

Pages from FY18 JOHN DOE SAFETY GRANT APPLICATION.pdf

OSHA CARD.pdf

Pages from FY18 SS SERVICE CORP.pdf secretary of state certificate.pdf

Road Side Safety

Each year there are thousands of injuries related to our industry from operating large construction vehicles, equipment operation and repair, asphalt fumes and staying safe from the traveling public. While some accidents involve the operator, over half involve people on the ground, passerby, spotters, co-workers, laborers and shovel hands.

Recently we experienced a paving related accident. A member from our paving crew was injured while conducting maintenance on a vehicle. It is not clear exactly how the accident occurred, what is clear is that the situation might have been avoided by reinforcing day to day safety protocols.

It is our intention, with this grant to reinforce best practices within our field by providing comprehensive preventative safety training and techniques in order to address the hazards of our industry.

Identify the training topic number of training sessions number of participants to be trained per class the name of trainer providing services number of instructors to be present for each session cost per class or per person length of time per class and training location within your budget narrative:

This budget summary is broken down into 3 line items, each consisting of all inclusive course costs.

Budget line #1 is for (3) OSHA 10 training classes for 80 employees. Each class will be 10 hours and will be split between (2) 5 hour days. There will be a minimum of 20 employees in each class with one instructor Will Turner from Five Star Safety. The cost will be $200 per person for 80 employees for $16,000. This cost includes the OSHA 10 cards. Training topics include; Take Care When Getting On and Off Equipment, Loading/Unloading Equipment Properly, Secure Work Zone/Paving Area and PPE. Training will take place at Brighton Asphalt & Cement Services.

Budget Line #2 is for (8) Forklift Training classes. We will train 40 of our machine operators. Each class will be 3 hours in length. There will be a minimum of 5 employees with one instructor Jack Sparrow from Community Forklift Academy. The cost will be $500 per class for 8 classes for $4000. Training will take place onsite at Community Forklift Academy.

Total Cost $20,000

$200

$16,000

$500

TOTAL COST2:

$4,000

$20,000