FY21 ORIGINAL SAFETY GRANT APPLICATION_CONTRACT DOCUMENTS 8 3 2020.pdf

COMMONWEALTH OF MASSACHUSETTS

Department of Industrial Accidents Workplace Safety Grant Program

Once Congress St., Suite 100 Boston, MA 02114-2017

Rosalin Acosta Secretary of Labor and Workforce Development

Grant Application Announcement Fiscal Year 2021

We will begin accepting applications

June 1, 2020 through December 31, 2020

Companies and organizations are encouraged to apply as soon as possible to have the maximum opportunity for funding

If the number of qualified applicants exceeds funding availability, subsequent applications will continue to be routinely accepted and evaluated

Those that qualify will be placed on a waiting list should funding become available

IMPORTANT: Prior to completing or submitting a Safety Training Grant application, please be sure that you are using the most current version of the application available. Visit http://www.mass.gov/lwd/workers-compensation/safety to download the current application or email safety@dia.state.ma.us http://www.mass.gov/lwd/workers-compensation/safety mailto:safety@dia.state.ma.us mariap Text Box The Department of Industrial Accidents Workplace Safety Grant Program Lafayette City Center 2 Avenue de Lafayette Boston, MA 02111

The prevention of occupational injury and illness is in everyone’s best interest. This Grant entitled, “Workplace Safety Training and Education Grant Program” is issued under the provisions of the

Massachusetts General Law, Chapter 23E, Section 3, and administered by the Department of Industrial

Accidents, Office of Safety. The primary purpose of this Safety Grant is designed to fund programs that reduce the risk of injury and illness to workers and promote safe and healthy conditions in the workplace through training, education, and other preventative programs.

Each fiscal year the grant program awards a maximum of $25,000 to qualifying Massachusetts businesses and organizations operating within the Commonwealth of Massachusetts covered by Massachusetts

Workers’ Compensation Law. (M.G.L. Ch. 152).

Strong preference will be given to first time applicants, consortium applicants, employers and organizations who demonstrate a compelling program design that addresses an injury history, potential injury or provides a proactive approach to injury prevention.

Grants are awarded to employers that best satisfy the Safety Grant Program goals.

PLEASE READ EACH SECTION CAREFULLY BEFORE APPLYING

OVERVIEW

• This is a reimbursement program. Trainings and invoices dated prior to an approved contract date are not eligible for this program.

• The Office of Safety reserves the right to only consider submissions that, in our sole judgment, are complete and responsive to the requirements and include all application components.

• Companies of any size with a workforce in Massachusetts are eligible. All trainees must be payroll employees of participating companies and covered by your workers’ compensation policy.

• Funding is intended for Massachusetts based companies and Massachusetts based training providers only.

• Applications that do not meet the technical requirements (e.g., incomplete application or missing documentation) cannot be processed. Complete contractual documents must be mailed at the time of your grant submission.

• The Office of Safety reserves the right to suspend or revoke the contract for funding at any time and for any reason.

• Applicants must be in full compliance with all obligations to the Department of Unemployment Assistance, Department of Industrial Accidents, and any other obligations to the Commonwealth of Massachusetts. This includes ALL partners within a consortium grant.

Applicants found to be non-compliant will be removed from consideration until all compliance issues have been resolved.

• The Federal Employer Identification Number (FEIN) must be provided for all parties receiving services within this application at the time of submission. (ex. consortium grants)

• Applicants must provide a Massachusetts Department of Revenue Certificate of Good Standing that is less than 6 months old at the time of submission. You can obtain a certificate through Department of Revenue at https://mtc.dor.state.ma.us/mtc. Please refer any questions you may have to the DOR Certificate Unit at 617-887-6367. A certificate from Secretary of State’s Office will not be accepted.

GRANT GUIDELINES

COMPLIANCE GUIDELINES

https://mtc.dor.state.ma.us/mtc

• Applicants must use a Massachusetts based training provider. A resume containing experience, relevant training and current certifications must be included at the time of submission.

• Applicants should negotiate the costs of instruction and related training materials with training providers to ensure that proposed costs are reasonable, necessary, and competitive. The Office of Safety will examine submissions for cost effectiveness and will be the final determiner in assessing appropriate costs and standards for training and training materials.

• Training costs must be submitted on a PER PERSON O R P E R C L A S S BASIS ONLY.

• Greater weight will be given to all-inclusive programs, those that incorporate the cost of all training materials and certifications where practical.

• You must meet attendance projections per class as outlined in your budget narrative. If your classes will not be at full capacity, you must notify the Office of Safety before training takes place.

• Vendors, safety training companies and other providers are prohibited from charging a fee or receiving additional compensation for safety training services or materials specifically provided by this grant. Training providers are prohibited from subcontracting training services to another provider.

• State funds will not be distributed until all contractual documents are signed by all parties and have an executed state contract. Training or invoices dated prior to an approved contract are not compensable.

• Reimbursements are made based on approved budget summaries at the time of contract execution.

• Timetable for funding is determined by the fiscal year, therefore, all training programs must be completed on or before June 30, 2021.

• All training costs/invoices associated with this grant must be received by the Department of Industrial Accidents on or before July 15, 2021.

APPLICANT GUIDELINES

ACCOUNT & FINANCE GUIDELINES

Employee wages, stipends or fringe benefits

Online training programs

Programs that re-train employees previously trained by DIA Office of Safety grants on the same topic

Office space, conference room rentals, utilities, communications, equipment (TVs, DVD players, computers, projectors, etc.) overhead expenses

Travel expenses (hotel, airfare, meals, car rental, tolls, mileage etc.) are not compensable

Training/education of a target audience which does not directly address the avoidance and prevention of unsafe and unhealthy working conditions and practices

Applications from agencies of the Commonwealth or applications that propose to train employees of the Commonwealth

Costs incurred prior to contract approval

Other exclusions may apply; we encourage you to contact the Office of Safety to discuss your proposal

FOR GENERAL INQUIRIES, PLEASE CONTACT

Maria Pesantes 857-321-7376 maria.pesantes@mass.gov

Deven Awalt 857-321-7404 deven.awalt@mass.gov

EXCLUSIONS

mailto:maria.pesantes@MassMail.State.MA.US mailto:maria.pesantes@MassMail.State.MA.US

Applicant Organization Name Please use the organizations full legal name as registered with the Secretary of State Office of the Commonwealth of Massachusetts.

Grant Administrator This person does not necessarily have to be the senior-most person at your facility, but is the most important contact that will be associated with your grant. The grant administrator must be an employee that is familiar with the application. The Grant Administrator will be the sole person responsible for the coordination of the grant to include; training schedules, invoices, sign in sheets, budget modifications, trainer changes and responds to phone calls and/or e-mails regarding the grant application. The Grant Administrator must ensure that the work is carried out in accordance with the Office of Safety standards, policies and procedures to ensure smooth implementation.

** The Office of Safety must be notified as soon as possible if the grant administrator has changed.

Complete Address, Phone & E-mail All fields should be completed referencing the Grant Administrators information, as the grant administrator will be the point of contact for all correspondence with the Office of Safety and the Executive Office of Labor and Workforce Development Contracts and Procurement Unit as they relate to the grant application and contractual documents.

Federal Employee ID Number This number refers to the FEIN issued by the Internal Revenue Service.

** The Federal Employer Identification Number (FEIN) must be provided for all parties receiving services within this application at the time of submission (ex. consortium grants).

Type of Organization For-Profit or Non-Profit Check whichever box applies.

SOMWBA Certified Certification is the process by which the Supplier Diversity Office (SDO) an agency within the Commonwealth of Massachusetts formerly known as the State Office for Minority and Women Business Assistance (SOMWBA) reviews and investigates applicants who seek to participate in affirmative business opportunities to determine that they meet the requirements of state and federal statutes and regulations.

Employee Demographics Total number of current employees within your organization and number of employees being trained for this grant.

Hazards to be addressed Check all hazards that apply.

Location Demographics Check all county locations training will take place.

Total Amount of Requested Total dollar amount requested.

YOUR APPLICATION CANNOT BE CONSIDERED IF ALL REQUIRED ANSWERS AND REQUESTED

INFORMATION LISTED IN THE APPLICATION ARE NOT PROVIDED

GRANT INSTRUCTIONS

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 BELOW ARE INCLUDED WITH YOUR SUBMISSION

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 - A Resume containing experience, relevant training and current certifications of all Massachusetts 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.

**A certificate from Secretary of State’s Office will not be accepted

GRANT APPLICATIONS AND ALL SUPPORTING DOCUMENTS LISTED ABOVE MUST

BE SUBMITTED ELECTRONICALLY TO: safety.grant@mass.gov

GRANT APPLICATION CHECK OFF SUMMARY

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

________________ASSDSDSDFSDFS_______________________________________________________

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 Mailing 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 your 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 MAILING ADDRESS:

PHONE:

E-MAIL ADDRESS:

FOR EACH TRAINING TOPIC/DESCRIPTION, PLEASE CHOOSE (ONE) CONTRACT EXPENDITURE

EITHER CHARGE PER PERSON OR PER CLASS FOR EACH TOPIC

PLEASE REFER TO THE JOHN DOE SAMPLE TEMPLATE FOR GUIDANCE

DESCRIPTION C O N T R A C T E X P E N D I T U R E

P E R P E R S O N

OR

C O N T R A C T E X P E N D I T U R E P E R C L A S S

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.

10.

Maximum Obligation up to $25,000

CONTRACT INSTRUCTIONS

CONTRACT FORMS MUST BE DOWNLOADED,

COMPLETED AND MAILED

There are several contractual documents that you must complete and sign (ALL signatures and dates must be original and in ink – NO STAMPS). Whether contracting through a corporation, other organization, or as an individual - please make sure to be consistent with the listing of information (as some information is required on multiple forms). There are also instructions for each form.

Please Note: Some of our forms have been revised. If you need assistance please call the Contracts & Procurements unit at 617-626-5913.

STANDARD CONTRACT FORM(SCF)

Please complete the top-left and bottom-left sections of this form. Please make sure you use the complete legal name and the legal address of the entity applying for the grant on this and all contractual documents. If you are unsure of your Vendor Code and Address ID, you may leave them blank. Please make sure that the individual signing this form is an authorized signatory; authorized signatory must be identified on Contractor Authorized Signatory Listing Form.

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND

CERTIFICATION (SUBSTITUTE W-9)

Please complete the attached Request for Taxpayer Identification Number and Certification (Substitute W-9). Please make sure that you use the complete legal name and the legal address of the entity applying for this grant on this and all contractual documents. If you are already registered as a vendor with the Commonwealth of Massachusetts Office of the State Comptroller, and want to make an address change, you will need to also include a letter requesting the change. The letter should specify your request and include your Vendor Code and new address; if you are changing your legal and/or remittance address (as opposed to simply requesting an additional remittance address), you should also specify the Address Code and the address that is being replaced.

If any of the information on this form changes after submission (i.e., name, address, or tax identification number), please call the Contracts & Procurements unit (617-626-5913) to obtain assistance in updating this information.

dlentini Cross-Out dlentini Cross-Out

CONTRACTOR AUTHORIZED SIGNATORY LISTING (CASL)

Please complete the Contractor Authorized Signatory Listing form; please make sure that the individual(s) who are authorized to sign the contractual documents for this grant name(s) and title(s) are listed in the middle of the page. The individual who certifies the authorization must hold one of the following titles; President, CEO, CFO, Corporate Clerk, or Legal Counsel.

This form is used to verify that the person signing the contractual documents is specifically authorized to execute and bind the organization into a contractual relationship with the Commonwealth of Massachusetts, Executive Office of Labor and Workforce Development, Department of Industrial Accidents, Office of Safety. The information provide on this form will be confirmed by the Executive Office of Labor and Workforce Development by comparing the names and titles provided on the form against what is on record with the Commonwealth of Massachusetts Secretary of States Corporate Division.

ELECTRONIC FUNDS TRANSFER SIGN UP FORM EFT)

Please complete this form in its entirety, sign, date, and return with the Contract.

The “Vendor” will be considered to be the same as the “Contractor”, and the pertinent information (Tax Identification Number, Name, Address, etc.) should be the same as on other contract forms.

CERTIFICATE OF GOOD STANDING)

You will need to obtain this form from the Department of Revenue, not from the Secretary of State’s Office. You may do this via the DOR website (https://wfb.dor.state.ma.us/webfile/Certificate/Public/WebForms/Welcome.asp.For questions, call 617-887-MDOR or 800-392-6089 (toll-free in Massachusetts).

COMMBUYS REGISTRATION

While you may previously have been registered as a seller in Comm-PASS, no vendor registration was transferred to COMMBUYS, so you must now register as a seller in COMMBUYS. To assist you in the registration process, The Operational Services Division (OSD) has provided a series of COMMBUYS job aids and on-line learning videos for use as you transition to COMMBUYS.

COMMBUYS registration is easy! It takes just two simple steps:

1. Go to the COMMBUYS landing page at www.COMMBUYS.com.

2. Select the first link titled REGISTER and complete registration.

There is no cost.

3. You must register and select the United Nations Standard Products and Services Code (UNSPSC) 84-10-16.

dlentini Cross-Out

DO’s & DON’T’s

DO

Do read the instructions

Do include all original documents that are listed on the contractual check-off summary

Do use the proper legal name of the company throughout the documents. (List the dba where indicated.)*

Do use the legal address on all documents. (A remittance address can be included on the W-9.)*

Do print and sign the Signatory’s name consistently throughout the documents.

(If the Signatory signs with her/his middle name on one form, s/he should continue to do so on all the forms.)

Do use only one FEIN number on the Contract documents.

Do obtain the Certificate of Good Standing from the Department of Revenue, not from the Secretary of State’s Office.)

Do submit a current Certificate of Good Standing. (current means the CGS must have an issued date that is within 6 months from the contract signature date.)

Do ensure that your Unemployment Insurance, Universal Health Insurance and Fair Share Contribution taxes are up to date and that your Workers Compensation Policy is current. (Non-compliance will cause delays in the process.)

Do ensure that your current Board of Directors is listed with the Secretary of State’s Office. *

Do list the Signatory on the Contractor Authorized Signatory Listing Form.

(Include the Signatory’s name and title on the listing as an Authorized Signatory.)

Do use the Massachusetts Substitute W-9 Form, not the Form W-9 from the Department of Treasury Internal Revenue Service.

∗ We verify legal name, legal address and incumbency of officers / directors via the Secretary of State website (http://www.sec.state.ma.us/)

DON’T

Don’t start services prior to the execution of your Contract. (Payment will not be made for services that are not covered)

Don’t enter the start and end dates on the Contract. (The Agency enters the authorized dates.)

Don’t use white out or correction tape. It invalidates the form.

Don’t submit a blank Electronic Funds Transfer (EFT) form with the information attached. (The form requires contact information and a signature)

Don’t substitute forms in the Contract Package. (The forms are continuously updated; alternate/outdated forms are invalid)

Don't change the company / organization name/address/bank account without notifying the Department Contract Manager. (It will delay Contract execution and / or payments)

Don't change/add/delete language to the forms. (Changes will invalidate the document) http://www.sec.state.ma.us/ mariap Text Box include (2) copies of your certificate of good standing. (1) with your contractual documents to be mailed and (1) with your electronic grant application submission.

Prepare and submit original contractual documents according to the following outline.

ALL signatures and dates must be in original ink

INCOMPLETE CONTRACTUAL DOCUMENTS WILL HOLD UP PROCESSING AND YOU MAY BE

CONTACTED BY OUR ACCOUNTING AND FINANCE DEPARTMENT

Commonwealth of Massachusetts Standard Contract Form

Request for Taxpayer Information Number and Certification (W9) Form

Contractor Authorized Signatory Listing (CASL)

Electronic Funds Transfer Payments (EFT)

Certificate of Good Standing from the Department of Revenue (DOR) - The fastest and easiest way to obtain a Certificate is online through MassTaxConnect https:// mtc.dor.state.ma.us/mtc and click on the tab (I Want To). 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.

COMMBUYS Registration; since your business may have an active contract with our department, it is necessary for you to register your business with COMMBUYS. COMMBUYS is the Commonwealth’s state-of-the-art electronic Market Center supporting online commerce between government purchasers and businesses. Register with COMMBUYS online at https:// www.commbuys.com . If you have questions or need assistance with registration, please refer any questions you may have to the COMMBUYS Helpdesk at 1-888-627-8283. If you are already registered with COMMBUYS please skip this step.

ORIGINAL CONTRACTUAL DOCUMENTS MUST BE DOWNLOADED AND SUBMITTED VIA US

POST OR SIMILAR SERVICE TO:

Department of Industrial Accidents Office of Safety

Lafayette City Center 2 Avenue de Lafayette

Boston, MA 02111

If you have questions or need assistance with the contractual portion only, please refer all questions to Diane Lentini at 617-626-5913 or email diane.lentini@detma.org

CONTRACTUAL DOCUMENTS CHECK OFF SUMMARY

https://mtc.dor.state.ma.us/mtc https://mtc.dor.state.ma.us/mtc https://mtc.dor.state.ma.us/mtc https://www.commbuys.com/

COMMONWEALTH OF MASSACHUSETTS ~ STANDARD CONTRACT FORM

(Updated: 10/25/2019) Page 1 of 1

This form is jointly issued and published by the Office of the Comptroller (CTR), the Executive Office for Administration and Finance (ANF), and the Operational Services Division (OSD) as the default contract for all Commonwealth Departments when another form is not prescribed by regulation or policy. The Commonwealth deems void any changes made on or by attachment (in the form of addendum, engagement letters, contract forms or invoice terms) to the terms in this published form or to the Standard Contract Form Instructions, Contractor Certifications and Commonwealth Terms and Conditions which are incorporated by reference herein. Additional non-conflicting terms may be added by Attachment.

Contractors are required to access published forms at CTR Forms: https://www.macomptroller.org/forms. Forms are also posted at OSD Forms: https://www.mass.gov/lists/osd-forms.

CONTRACTOR LEGAL NAME (and d/b/a): COMMONWEALTH DEPARTMENT NAME: Ex. Office of Labor Workforce

Development/ Dept. of Industrial Accidents MMARS Department Code: EOL

Legal Address: (W-9, W-4): Business Mailing Address: 2 Avenue Lafayette, Boston, MA 02111 Contract Manager: Phone: Billing Address (if different): accounts.payable@detma.org E-Mail: Fax: Contract Manager: KATHY MANSON Phone: 617-727-4900 Contractor Vendor Code: VC E-Mail: Kathy.Manson@massmail.state.ma.us Fax:

Vendor Code Address ID (e.g. “AD001”): AD .

(Note: The Address ID must be set up for EFT payments.)

MMARS Doc ID(s): CT EOL 0999 21SAFETY7003050000*

RFR/Procurement / Other ID Number: 20-1043-DAOO1-32500-52023 Safety Grant 2021

__X_ NEW CONTRACT

PROCUREMENT OR EXCEPTION TYPE: (Check one option only) __ Statewide Contract (OSD or an OSD-designated Department) __ Collective Purchase (Attach OSD approval, scope, budget) _X_ Department Procurement (includes all Grants - 815 CMR 2.00) (Solicitation

Notice or RFR, and Response or other procurement supporting documentation) __ Emergency Contract (Attach justification for emergency, scope, budget) __ Contract Employee (Attach Employment Status Form, scope, budget) __ Other Procurement Exception (Attach authorizing language, legislation with specific exemption or earmark, and exception justification, scope and budget)

___ CONTRACT AMENDMENT

Enter Current Contract End Date Prior to Amendment: , 20 .

Enter Amendment Amount: $ . (or “no change”) AMENDMENT TYPE: (Check one option only. Attach details of amendment changes.)

__ Amendment to Date, Scope or Budget (Attach updated scope and budget) __ Interim Contract (Attach justification for Interim Contract and updated scope/budget) __ Contract Employee (Attach any updates to scope or budget) __ Other Procurement Exception (Attach authorizing language/justification and updated scope and budget) The Standard Contract Form Instructions, Contractor Certifications and the following Commonwealth Terms and Conditions document is incorporated by reference into this Contract and are legally binding: (Check ONE option): __ Commonwealth Terms and Conditions __ Commonwealth Terms and Conditions For Human and Social Services COMPENSATION: (Check ONE option): The Department certifies that payments for authorized performance accepted in accordance with the terms of this Contract will be supported in the state accounting system by sufficient appropriations or other non-appropriated funds, subject to intercept for Commonwealth owed debts under 815 CMR 9.00.

X__ Rate Contract. (No Maximum Obligation) Attach details of all rates, units, calculations, conditions or terms and any changes if rates or terms are being amended.)

__ Maximum Obligation Contract. Enter total maximum obligation for total duration of this contract (or new total if Contract is being amended). $ .

PROMPT PAYMENT DISCOUNTS (PPD): Commonwealth payments are issued through EFT 45 days from invoice receipt. Contractors requesting accelerated payments must identify a PPD as follows: Payment issued within 10 days __% PPD; Payment issued within 15 days __ % PPD; Payment issued within 20 days __ % PPD; Payment issued within 30 days __% PPD. If PPD percentages are left blank, identify reason: __agree to standard 45 day cycle __ statutory/legal or Ready Payments (M.G.L. c. 29, § 23A); __ only initial payment (subsequent payments scheduled to support standard EFT 45 day payment cycle. See Prompt Pay Discounts Policy.) NA BRIEF DESCRIPTION OF CONTRACT PERFORMANCE or REASON FOR AMENDMENT: (Enter the Contract title, purpose, fiscal year(s) and a detailed description of the scope of performance or what is being amended for a Contract Amendment. Attach all supporting documentation and justifications.)

SAFETY GRANT

ANTICIPATED START DATE: (Complete ONE option only) The Department and Contractor certify for this Contract, or Contract Amendment, that Contract obligations:

_X_ 1. may be incurred as of the Effective Date (latest signature date below) and no obligations have been incurred prior to the Effective Date.

__ 2. may be incurred as of , 20 , a date LATER than the Effective Date below and no obligations have been incurred prior to the Effective Date.

__ 3. were incurred as of , 20 , a date PRIOR to the Effective Date below, and the parties agree that payments for any obligations incurred prior to the Effective Date are authorized to be made either as settlement payments or as authorized reimbursement payments, and that the details and circumstances of all obligations under this Contract are attached and incorporated into this Contract. Acceptance of payments forever releases the Commonwealth from further claims related to these obligations.

CONTRACT END DATE: Contract performance shall terminate as of June 30 , 2021 , with no new obligations being incurred after this date unless the Contract is properly amended, provided that the terms of this Contract and performance expectations and obligations shall survive its termination for the purpose of resolving any claim or dispute, for completing any negotiated terms and warranties, to allow any close out or transition performance, reporting, invoicing or final payments, or during any lapse between amendments.

CERTIFICATIONS: Notwithstanding verbal or other representations by the parties, the “Effective Date” of this Contract or Amendment shall be the latest date that this Contract or Amendment has been executed by an authorized signatory of the Contractor, the Department, or a later Contract or Amendment Start Date specified above, subject to any required approvals. The Contractor certifies that they have accessed and reviewed all documents incorporated by reference as electronically published and the Contractor makes all certifications required under the Standard Contract Form Instructions and Contractor Certifications under the pains and penalties of perjury, and further agrees to provide any required documentation upon request to support compliance, and agrees that all terms governing performance of this Contract and doing business in Massachusetts are attached or incorporated by reference herein according to the following hierarchy of document precedence, this Standard Contract Form, the Standard Contract Form Instructions, Contractor Certifications, the applicable Commonwealth Terms and Conditions, the Request for Response (RFR) or other solicitation, the Contractor’s Response, and additional negotiated terms, provided that additional negotiated terms will take precedence over the relevant terms in the RFR and the Contractor’s Response only if made using the process outlined in 801 CMR 21.07, incorporated herein, provided that any amended RFR or Response terms result in best value, lower costs, or a more cost effective Contract.

AUTHORIZING SIGNATURE FOR THE CONTRACTOR:

X: . Date: .

(Signature and Date Must Be Handwritten At Time of Signature)

Print Name: .

Print Title: .

AUTHORIZING SIGNATURE FOR THE COMMONWEALTH:

X: . Date: .

(Signature and Date Must Be Handwritten At Time of Signature)

Print Name: .

Print Title: .

http://www.macomptroller.info/comptroller/docs/forms/contracts/standard-contract-frm.doc http://www.macomptroller.info/comptroller/docs/forms/contracts/2007-19-exec-order-481-cert.doc http://www.macomptroller.info/comptroller/docs/forms/contracts/CommonwealthTermsAndConditions.pdf https://www.macomptroller.org/forms https://www.mass.gov/lists/osd-forms mailto:accounts.payable@detma.org mailto:Kathy.Manson@massmail.state.ma.us https://www.mass.gov/law-library/815-cmr https://www.mass.gov/law-library/815-cmr https://malegislature.gov/Laws/GeneralLaws/PartI/TitleIII/Chapter29/Section23A https://www.mass.gov/law-library/801-cmr

Form MA- W-9 (Rev. March 2020)

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Services

(IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am an U.S. person (including an U.S. resident alien).

4. I am currently a Commonwealth of Massachusetts’s state employee: (check one): No____ Yes _____ If yes, in compliance with the State Ethics

Commission requirements.

Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.

Sign Here Authorized Signature ► Date ►

Purpose of Form A person who is required to file an information return with the IRS must get your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or debt, or contributions you made to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to give your correct TIN to the person requesting it (the requester) and , when applicable, to:

1. Certify the TIN you are giving is correct (or you are waiting for a number to be issued).

2. Certify you are not subject to backup withholding If you are a foreign person, use the appropriate Form W-8. See Pub 515, Withholding of Tax on Nonresident Aliens and Foreign Corporations.

What is backup withholding? Persons making certain payments to you must withhold a designated percentage, currently 28% and pay to the IRS of such payments under certain conditions. This is called “backup withholding.”

Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

If you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return, payments you receive will not be subject to backup withholding. Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester, or

2. You do not certify your TIN when required

(see the Part II instructions on page 2 for details), or

3. The IRS tells the requester that you furnished an incorrect TIN, or

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See the Part II instructions on page 2.

Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information.

Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties.

Form W-9 (Massachusetts Substitute W-9 Form) Rev. March 2020

Request for Taxpayer Identification Number and Certification

Completed form should be given to the requesting department or the department you are currently doing business with.

Name (as shown on your income tax return). Name is required on this line, do not leave this line blank.

Business name/disregarded entity name, if different from above.

Check the appropriate box: □ Individual/Sole proprietor □ C Corporation □ S Corporation □ Partnership □ Trust/ Estate □ Other ►-----------------

Legal Address: number, street, and apt. or suite no. Remittance Address: if different from legal address number, street, apt. or suite no

City, state and ZIP code City, state and ZIP code

Phone: Fax: Email address:

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instruction on page 2. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 2.

Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter.

Vendors:

Dunn and Bradstreet Universal Numbering System (DUNS))

Social security number

OR Employer identification number

DUNS

Part II Certification xuanl Typewritten Text xuanl Typewritten Text xuanl Typewritten Text xuanl Typewritten Text or single-member LLC

Form MA- W-9 (Rev. March 2020)

Specific Instructions Name. If you are an individual, you must generally enter the name shown on your social security card. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.

If the account is in joint names, list first and then circle the name of the person or entity whose number you enter in Part I of the form.

Sole proprietor. Enter your individual name as shown on your social security card on the “Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “Business name” line.

Limited liability company (LLC). If you are a single-member LLC (including a foreign LLC with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section 301.7701-3, enter the owner’s name on the “Name” line. Enter the LLC’s name on the “Business name” line.

Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8.

Other entities. Enter your business name as shown on required Federal tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “Business name” line.

Part I - Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box.

If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN.

However, the IRS prefers that you use your

SSN.

If you are an LLC that is disregarded as an entity separate from its owner (see Limited liability company (LLC) above), and are owned by an individual, enter your SSN (or “pre-LLC” EIN, if desired). If the owner of a disregarded LLC is a corporation, partnership, etc., enter the owner’s EIN.

Note: See the chart on this page for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office. Get Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can get Forms W-7 and SS-4 from the IRS by calling 1-800-TAX-FORM (1-800-829- 3676) or from the IRS’s Internet Web Site www.irs.gov.

If you do not have a TIN, write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments.

The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note: Writing “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Part II - Certification

To establish to the paying agent that your TIN is correct or you are a U.S. person, or resident alien, sign Form W-9.

For a joint account, only the person whole TIN is shown in Part I should sign (when required).

Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to give your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA or MSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their tax laws

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold a designated percentage, currently 28% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.

What Name and Number to Give the Requester

For this type of account: Give name and SSN of:

1. Individual

2. Two or more individuals (joint account)

3. Custodian account of a minor (Uniform Gift to Minors Act)

4. a. The usual revocable savings trust (grantor is also trustee)

b. So-called trust account that is not a legal or valid trust under state law

5. Sole proprietorship

The individual The actual owner of the account or, if combined funds, the first individual on the account 1

The minor 2

The grantor-trustee 1

The actual owner 1

The owner 3

For this type of account: Give name and EIN of:

6. Sole proprietorship

7. A valid trust, estate, or pension trust

8. Corporate

9. Association, club, religious, charitable, educational, or other tax-exempt organization

10. Partnership

11. A broker or registered nominee

12. Account with the

Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

The owner 3

Legal entity 4

The corporation The organization

The partnership The broker or nominee

The public entity

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2 Circle the minor’s name and furnish the minor’s SSN.

3 You must show your individual name, but you may also enter your business or “DBA” name. You may use either your SSN or EIN (if you have one).

4. List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.)

Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

If you have questions on completing this form, please contact the Office of the State Comptroller.

(617) 973-2468.

Upon completion of this form, please send it to the Commonwealth of Massachusetts Department you are doing business with.

Executive Office of Labor and Workforce Development

CONTRACTOR LEGAL NAME:

CONTRACTOR VENDOR/CUSTOMER CODE:

DBA (if applicable):

EOLWD CASL revised 07-11 Page 1 of 1

Issued May 2004

INSTRUCTIONS: All Contractors (other than a sole-proprietor or an individual contractor) must provide a listing of individuals who are authorized as legal representatives of the Contractor who are authorized to sign contracts and other legally binding documents on the Contractor’s behalf. In addition to this listing, additional proof of authority to sign contracts on behalf of the Contractor, and/or proof of authenticity of signature is required by Contractor’s submission of a completed Contractor Authorized Signature Verification Form (CASV).

NOTICE: Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by the Contractor challenging the existence of a valid Contract due to an alleged lack of authority to execute the document by the signatory.

For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors.

PRINT AUTHORIZED SIGNATORY’S NAME TITLE

I certify that I am the President, Chief Executive Officer, Chief Fiscal Officer, Corporate Clerk, Legal Counsel or other authorized officer of the Contractor. I hereby certify that the names of the individuals identified on this listing are current as of the date of execution below and that these individuals are authorized to sign contracts and other legally binding documents related to contracts with the Commonwealth of Massachusetts on behalf of the Contractor. I understand and agree that the Contractor has a duty to ensure that this listing is immediately updated and communicated to any state department with which the Contractor does business whenever the authorized signatories are no longer authorized to sign contracts with the Commonwealth or whenever new signatories are designated.

Signature: Date:

Print Name: Title:

Telephone: Fax: Email:

Executive Office of Labor and Workforce Development

CONTRACTOR LEGAL NAME:

CONTRACTOR VENDOR/CUSTOMER CODE:

DBA (if applicable):

EOLWD CASL revised 07-11 Page 1 of 1

Issued May 2004

[Listing cannot be accepted unless all of the information is completed. The Contractor must also complete and submit a Contractor Authorized Signature Verification Form (CASV), as appropriate.]

COMMONWEALTH OF MASSACHUSETTS

OFFICE OF THE COMPTROLLER

Electronic Funds Transfer Sign Up Form

This form should be sent to a department with whom you do business.

Request type must be checked: Initial Request Changing Existing Account Closing Account

I , hereby certify that the account/s indicated on this form is under my direct control and access; therefore, I authorize the State Treasurer as fiscal agent for the State of Massachusetts to initiate, change or cancel credit entries to that account/s as indicated on this form. For ACH debits consistent with the International ACH Transaction (IAT) rules check one:

I affirm that payments authorized hereunder are not to an account that is subject to being transferred to a foreign bank account.

I affirm that payments authorized hereunder are to an account that is subject to being transferred to a foreign bank account.

This authority is to remain in full force and effect until the Office of Comptroller has received written notification, from either me or an authorized officer of organization of the account's termination in such time and in such a manner as to afford CTR a reasonable opportunity to act upon it.

VENDOR BANK INFORMATION

Vendor Bank Name:

Vendor Bank Transit Number (ABA):

Vendor Bank Account Number:

Account Type:

Filling out this field is a requirement for changing account number Vendor Bank Old Account Number:

Account Type:

VENDOR INFORMATION

Vendor Tax Identification Number (TIN):

Vendor/Business Name:

Vendor Contact Name:

E-mail:

Telephone:

Address:

City:

State:

Zip:

This authorization will remain in effect until either canceled in writing or an updated form changing information is sent to the Department you currently do business with.

AUTHORIZED SIGNATURE:

Print Name:

Title:

Date:

Form forwarded to Commonwealth Department:

Attached voided check here: