MA weekly certified payroll report form-fs~28.pdf

PDF 110 KB Posted Jun 24, 2024

Attached to: RFQ FMO24270 Waste Oil AST Replacements
Solicitation number: BD-24-1069-MILDV-10000-104508
Issued by: Middlesex County, Massachusetts

About this file

Written by GovTribe AI · Jun 24, 2024

This document is a Weekly Certified Payroll Report and Workforce Participation Form required for a public works project in Massachusetts. The form collects information on employee hours, wages, and fringe benefits for the project, as well as details on workforce participation goals for minority and female employees. The project is for Waste Oil AST Replacements at three Massachusetts National Guard facilities located in Worcester, Framingham, and Reading. The report must be submitted weekly by the general contractor and any subcontractors, and must be accompanied by a statement of compliance signed by the employer.

The Commonwealth of Massachusetts has set workforce participation goals of 15.3% for minorities and 6.9% for women on this project. The contractor is required to strive to achieve these goals and must report the number of hours worked by employees identified as women, minorities, or non-minorities. The report also includes a section for documenting any apprentice employees and confirming their registration with the Massachusetts Division of Apprentice Standards.

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Project

Hours (A)

Project

Gross

Wages

Su. Mo. Tu. We. Th. Fr. Sa.

All Other

Hours

Total

Gross

Wages

APPRENTICESHIP DOCUMENTATION: Please answer the questions below.

(1) Are any apprentice employees identified above? YES NO

(2) If yes, are all apprentice employees identified above currently registered with the MA DLS Division of Apprentice Standards? YES NO

(3) If yes, is a copy of the apprentice ID card issued by the MA DLS Division of Apprentice Standards included for all apprentice employees identified above? YES NO

(B+C+D+E) (A x F)

General / Prime Contractor's Name: Subcontractor's Name:

Health &

Welfare

Insurance

(C/)

ERISA

Pension

Plan (D)

Supp.

Unemp.

(E/)

Total

Hourly

Prev.

Wage (F)

Check No.

(H)

Employee Name &

Complete Address

Work

Classification

Employee is OSHA 10 certified (?)

Appr.

Rate

Hours Worked Hourly

Base

Wage (B)

Project

Hours

Non-

Minority

Project

Hours

Minority

Project

Hours

Women

Public Works Project Name: Public Works Project Location: Min. Wage Rate Sheet Number:Awarding Authority Name:

Employer Hourly Fringe Benefit Contributions

Title: Contract No: Tax Payer ID #: Work Week Ending:Employer's Signature:

Address: Phone No.:

WEEKLY CERTIFIED PAYROLL REPORT AND WORKFORCE PARTICIPATION FORM

Payroll No.:

CERTIFIED PAYROLL REPORT: Pursuant to MGL c. 149, s. 27B, every contractor and subcontractor is required to submit a true and accurate copy of their certified weekly payroll records to the awarding authority by first-class mail or e-mail. In addition, each weekly payroll must be accompanied by a statement of compliance signed by the employer. Failure to comply may result in the commencement of a criminal action or the issuance of a civil citation.

WORKFORCE PARTICIPATION GOALS: The Commonwealth of Massachusetts has set the following goals for workforce participation for minorities and women. The participation goals for this project shall be

15.3% for minorities and 6.9% for women. The Contractor shall strive to achieve on this project the labor workforce participation goals contained herein. The Contractor shall enter the number of hours worked in each trade by each employee, identified as woman, minority, or non-minority below.

Company Name:

PAGE ________ OF ________

LMoran Highlight

Company NameRow1:

AddressRow1:

Phone NoRow1:

Payroll NoRow1:

Employers SignatureRow1:

TitleRow1:

Contract NoRow1:

Tax Payer ID Row1:

Work Week EndingRow1:

Awarding Authority NameRow1:

Public Works Project NameRow1:

Public Works Project LocationRow1:

Min Wage Rate Sheet NumberRow1:

General Prime Contractors NameRow1:

Subcontractors NameRow1:

Employee Name Complete AddressRow1:

Work ClassificationRow1:

Project Hours Non MinorityRow1:

Project Hours MinorityRow1:

Project Hours WomenRow1:

Employee is OSHA 10 certified Row1:

Appr Rate Row1:

SuRow1:

MoRow1:

TuRow1:

WeRow1:

ThRow1:

FrRow1:

SaRow1:

All Other HoursRow1:

SuRow2:

MoRow2:

TuRow2:

WeRow2:

ThRow2:

FrRow2:

SaRow2:

All Other HoursRow2:

Hourly Base Wage BRow1:

Total Gross WagesRow1:

Health Welfare Insurance CRow1:

undefined:

Total Gross WagesRow2:

Check No HRow1:

Employee Name Complete AddressRow2:

Work ClassificationRow2:

Project Hours Non MinorityRow2:

Project Hours MinorityRow2:

Project Hours WomenRow2:

Employee is OSHA 10 certified Row2:

Appr Rate Row2:

SuRow3:

MoRow3:

TuRow3:

WeRow3:

ThRow3:

FrRow3:

SaRow3:

All Other HoursRow3:

SuRow4:

MoRow4:

TuRow4:

WeRow4:

ThRow4:

FrRow4:

SaRow4:

All Other HoursRow4:

Hourly Base Wage BRow2:

Total Gross WagesRow3:

Health Welfare Insurance CRow2:

undefined_2:

Total Gross WagesRow4:

Check No HRow2:

Employee Name Complete AddressRow3:

Work ClassificationRow3:

Project Hours Non MinorityRow3:

Project Hours MinorityRow3:

Project Hours WomenRow3:

Employee is OSHA 10 certified Row3:

Appr Rate Row3:

SuRow5:

MoRow5:

TuRow5:

WeRow5:

ThRow5:

FrRow5:

SaRow5:

All Other HoursRow5:

SuRow6:

MoRow6:

TuRow6:

WeRow6:

ThRow6:

FrRow6:

SaRow6:

All Other HoursRow6:

Hourly Base Wage BRow3:

Health Welfare Insurance CRow3:

undefined_3:

Total Gross WagesRow5:

Total Gross WagesRow6:

Check No HRow3:

Employee Name Complete AddressRow4:

Work ClassificationRow4:

Project Hours Non MinorityRow4:

Project Hours MinorityRow4:

Project Hours WomenRow4:

Employee is OSHA 10 certified Row4:

Appr Rate Row4:

SuRow7:

MoRow7:

TuRow7:

WeRow7:

ThRow7:

FrRow7:

SaRow7:

All Other HoursRow7:

SuRow8:

MoRow8:

TuRow8:

WeRow8:

ThRow8:

FrRow8:

SaRow8:

All Other HoursRow8:

Hourly Base Wage BRow4:

Total Gross WagesRow7:

Health Welfare Insurance CRow4:

undefined_4:

Total Gross WagesRow8:

Check No HRow4:

Employee Name Complete AddressRow5:

Work ClassificationRow5:

Project Hours Non MinorityRow5:

Project Hours MinorityRow5:

Project Hours WomenRow5:

Employee is OSHA 10 certified Row5:

Appr Rate Row5:

SuRow9:

MoRow9:

TuRow9:

WeRow9:

ThRow9:

FrRow9:

SaRow9:

All Other HoursRow9:

SuRow10:

MoRow10:

TuRow10:

WeRow10:

ThRow10:

FrRow10:

SaRow10:

All Other HoursRow10:

Hourly Base Wage BRow5:

Total Gross WagesRow9:

Health Welfare Insurance CRow5:

undefined_5:

Total Gross WagesRow10:

Check No HRow5:

Employee Name Complete AddressRow6:

Work ClassificationRow6:

Project Hours Non MinorityRow6:

Project Hours MinorityRow6:

Project Hours WomenRow6:

Employee is OSHA 10 certified Row6:

Appr Rate Row6:

SuRow11:

MoRow11:

TuRow11:

WeRow11:

ThRow11:

FrRow11:

SaRow11:

All Other HoursRow11:

SuRow12:

MoRow12:

TuRow12:

WeRow12:

ThRow12:

FrRow12:

SaRow12:

All Other HoursRow12:

Hourly Base Wage BRow6:

Total Gross WagesRow11:

Health Welfare Insurance CRow6:

undefined_6:

Total Gross WagesRow12:

Check No HRow6:

Employee Name Complete AddressRow7:

Work ClassificationRow7:

Project Hours Non MinorityRow7:

Project Hours MinorityRow7:

Project Hours WomenRow7:

Employee is OSHA 10 certified Row7:

Appr Rate Row7:

SuRow13:

MoRow13:

TuRow13:

WeRow13:

ThRow13:

FrRow13:

SaRow13:

All Other HoursRow13:

SuRow14:

MoRow14:

TuRow14:

WeRow14:

ThRow14:

FrRow14:

SaRow14:

All Other HoursRow14:

Hourly Base Wage BRow7:

Total Gross WagesRow13:

Health Welfare Insurance CRow7:

undefined_7:

Total Gross WagesRow14:

Check No HRow7:

PAGE:

OF:

Check Box1: Off

Check Box2: Off

Check Box3: Off

Check Box4: Off

Check Box5: Off

Check Box6: Off

File details come from the government source that posted it. Updated Jun 24, 2024.