OCCUPATIONAL HEALTH AND SAFETY REGULATIONS 2017 June 2017 WORKSAFE VICTORIA APPLICATION FOR A LICENCE TO OPERATE AS AN ASBESTOS REMOVALIST Please refer to General Information and Instructions at the end of this form for guidance on completing and submitting this application. 1. Application Type (tick application type) I wish to apply for: A new Licence to Operate as an Asbestos Removalist (for first time applicants only). Complete licence type below: Renewal of my Licence to Operate as an Asbestos Removalist Licence No: Date of Expiry Amendment to my Licence to Operate as an Asbestos Removalist Licence No: Date of Expiry Replacement of my Licence to Operate as an Asbestos Removalist Licence No: Date of Expiry Indicate Licence type: CLASS A FRIABLE AND NON-FRIABLE (Removal of all forms of asbestos-containing material) CLASS A SPECIFIC FRIABLE (Removal of specific* types of friable asbestos-containing material) Specify Types(s) of Asbestos Containing Material CLASS B NON FRIABLE (Removal of all non-friable asbestos-containing material) CLASS B SPECIFIC NON FRIABLE (Removal of specific* types of non-friable asbestos-containing material Eg. telecommunication pits and pipes, asbestos cement pipes, gaskets.) Specify Types(s) of Asbestos Containing Material * type of asbestos-containing material means a description of asbestos-containing material or product e.g. asbestos-containing cement sheeting, cement pipes, vinyl tiles, sprayed insulation, telecommunications pits and pipes, pipe lagging, millboard and gaskets. Friable Asbestos means:- asbestos-containing materials that when dry may be crumbled, pulverised or reduced to powder by hand pressure; or as a result of a work process becomes such that it may be crumbled, pulverised or reduced to powder by hand pressure. Non Friable Asbestos means:- asbestos-containing materials that have been compounded from asbestos mixed with cement or other hard bonding materials. 2. Details of Applicant a. Complete if the applicant is not a Natural Person (e.g. Corporate Body, Body Politic, Partnership) [Please also complete the Identification Form - Non Individual] Full Legal Name of Organisation ACN Number or Equivalent ABN Number Trading As Postal Address Principal Business Address Contact Person Telephone Facsimile Email
2. Details of Applicant (cont.) 2b. Complete only if applying as a Natural Person (e.g. Sole trader) [Please also complete the Identification Form - Natural Person] Family Name Given Names ABN Number Trading As (if applicable) Residential Address Postal Address Telephone (BH) Telephone (AH) Mobile Facsimile Email 3. Licensing History a. Has the applicant (and in the case of a body corporate, any officer of the applicant body corporate), ever previously been issued a licence as an asbestos removalist in Victoria or in any other Australian State or Territory? (tick appropriate box) No If, please indicate: State of Issue Licence Number Issue Date Expiry Date b. Has the applicant (and in the case of a body corporate, any officer of the applicant body corporate), ever previously had a licence or approval under any relevant occupational health and safety legislation, suspended or cancelled? No If, please provide details on a separate sheet. 4. Convictions Has the applicant (and in the case of a body corporate, any officer of the applicant body corporate), ever been found guilty of any offence under any relevant occupational health and safety legislation for asbestos removal? No If yes, provide details on a separate sheet of every finding, including when and where it occurred, details of the offence in respect of which it occurred and a brief description of the circumstances of the offence. Has the applicant (and in the case of a body corporate, any officer of the applicant body corporate), ever been found guilty of any offence under the Environment Protection Act 1970 or the Environment Protection (Industrial Waste Resource) Regulations 2009 in relation to the transport or disposal of asbestos? No If yes, provide details on a separate sheet of every finding, including when and where it occurred, details of the offence in respect of which it occurred and a brief description of the circumstances of the offence.
5. Certification for Asbestos Occupational Health and Safety Management System (Class A Only) Provide A COPY of Certification for an Asbestos Occupational Health and Safety Management System which is: current, and is directly associated with asbestos removal, and is accredited/approved by JAS-ANZ or as determined by the Authority. Certification must remain current for the term of the Licence as an Asbestos Removalist. Provide details of the person who will be responsible for ensuring that certification remains current. Name Position Contact Number Facsimile Number Note: If the new applicant does not hold current certification for an asbestos occupational health and safety management system, then the applicant must provide evidence of satisfactory review of the asbestos occupational health and safety management system documents, within the last six months, by an occupational health and safety auditor. 6. Personal Protective Equipment & Laundering 6.1 Describe the types of Respiratory Protection to be worn by employees, (including brand and model details, filter type, compliance with Australian Standards) 6.2 Provide details of vacuum cleaner fitted with a HEPA (Dust Class H) filter. 6.3 Does the applicant and/or employees use (tick appropriate box) Non-Disposable Clothing Disposable Clothing Both Describe the Type of Clothing 6.4 (a) If non-disposable clothing is used, does the applicant: (i) Launder their own employees contaminated clothes? (tick appropriate box) No (ii) Forward their contaminated clothing to a laundry? (tick appropriate box) No 6.4 (b) If the contaminated clothing is forwarded to a laundry, is the laundry informed that the clothing may be contaminated with asbestos? (tick appropriate box) No 6.4 (c) What is/are the name(s) and address(es) of the laundry(s)? 7. Training of Employees Do you have any employees? No Provide evidence of training undertaken in asbestos removal for each employee (including site supervisors who must also provide evidence of site supervisor training) involved in or expected to be involved in asbestos removal activities. Evidence of base training must be provided, and in addition refresher training (where applicable) less than 24 months old for Class B removal and less than 12 months old for Class A removal. If a nominated site supervisor has completed the registered training organisation (RTO) recognised asbestos removal course, they must also complete the RTO recognised site supervisor course. For renewal applications, provide details of training conducted during the current licence period. Proof of training MUST be in the form of course certificates, letters from training providers or other suitable training institutions. Training details must include the following: Course name Date(s) of course completion Type/Scope of course eg. Friable and non-friable asbestos removal Non-friable asbestos removal only Other: Removal of specific type of asbestos removal (eg. Water pipes, telecommunications pits and pipes, gasket removal.)
8a. Site Supervisors Experience (required for both new and renewal applications) Provide the name and details for each site supervisor including details of their experience in asbestos removal work activities. If there is an additional site supervisor provide details on the following page. Note: Site supervisors must have at least two years experience in asbestos removal work. Provide details of at least six asbestos removal projects (if six projects have not been provided, advise reason in writing). Projects for non-specific Class A applicant should include a minimum of four friable asbestos removal jobs. Projects for non-specific applicant should, as far as possible, show removal of a range of different asbestos containing material and in different quantities. Provide contact name and phone numbers of the client for each project. Projects shown below should not be more than two years old. Nominated Site Supervisor s Name Years of Experience in Asbestos Removal Project Name and Removal Address Client Contact Person and Telephone Number Project dates (Start/Finish) Supervisor s direct employer Friable or Non-friable (indicate type of Asbestos-containing material, for example ac sheeting, lagging, vinyl titles, ac pipes, gaskets) 1. 2. 3. 4. 5. 6. Quantity of Asbestos Removed (m 2 or m 3 )
8b. Additional Site Supervisors Experience (required for both new and renewal applications) Note: Site supervisors must have at least two years experience in asbestos removal work. Provide details of at least six asbestos removal projects (if six projects have not been provided, advise reason in writing). Projects for non-specific Class A applicant should include a minimum of four friable asbestos removal jobs. Projects for non-specific applicant should, as far as possible, show removal of a range of different asbestos containing material and in different quantities. Provide contact name and phone numbers of the client for each project. Projects shown below should not be more than two years old. Nominated Site Supervisor s Name Years of Experience in Asbestos Removal Project Name and Removal Address Client Contact Person and Telephone Number Project dates (Start/Finish) Supervisor s direct employer Friable or Non-friable (indicate type of Asbestos-containing material, for example ac sheeting, lagging, vinyl titles, ac pipes, gaskets) 1. 2. 3. 4. 5. 6. Quantity of Asbestos Removed (m 2 or m 3 )
Declaration by Applicant I declare that, to the best of my knowledge, the information provided in this application and supporting this application is true and correct in every particular. I declare that where I provide personal information to WorkSafe Victoria (WorkSafe) about any other individual, I am authorised to provide that information, the information has been collected in accordance with the Privacy and Data Protection Act 2014 (Vic) and the individual has been or will be made aware of WorkSafe s identity and how to contact it and of the other matters of which an individual is required to be made aware when personal information is collected about them. Applicant s Signature Date Witnessed by (signature) - witness must be at least 18 years of age Print Name of Witness Telephone WARNING: Withholding relevant information or providing information that is false or misleading is a basis for WorkSafe refusing to approve an application. Use this checklist to ensure that your application is complete: Completed, signed and witnessed application form; Evidence of training attached; Copy of current Certificate of Asbestos Occupational Health and Safety Management System; or Evidence of satisfactory review, for proposed Certification of Asbestos Occupational Health and Safety Management System; Completed Identification form (either Non-Individual or Natural Person); Payment details provided or enclosed. NOTE: Unsigned or incomplete applications or applications not accompanied by the required documentation and fee cannot be processed and may be returned. Licence Application Fee Licence fees are set using fee units. A fee unit is a dollar amount set under the Monetary Units Act 2004 each financial year that is used to calculate certain statutory fees. You can check the current application fee, and the current value of a fee unit, at worksafe.vic.gov.au. Period within which the application is lodged Class A Licence Fee Class B Licence Fee 18 June 2017 30 June 2018 44.9 fee units 40.5 fee units 1 July 2018 30 June 2019 52.6 fee units 46.5 fee units 1 July 2019 30 June 2020 60.3 fee units 52.5 fee units 1 July 2020 30 June 2021 68.0 fee units 58.5 fee units On or after 1 July 2021 75.7 fee units 64.5 fee units Please send payment with this Application The Victorian WorkCover Authority ABN is 90 296 467 627 Paying by mail I wish to pay by: Cheque OR Money order Make cheque/money order payable to the Victorian WorkCover Authority. Paying by credit I wish to pay by credit card. Please charge payment of $ to my: MasterCard Visa Card No. Expiry date Cardholder Name Signature
General Information and Instructions Note: Part 4.4, Division 7 of the Occupational Health and Safety Regulations 2017 allows an employer or self-employed person to remove a limited amount of asbestos containing material that is present at a workplace, building, structure, ship or plant without the need to hold an Asbestos Removal Licence. This exclusion only applies to: Non-friable asbestos containing material; The area to be removed is less than 10 square metres in total; and The removal is not undertaken for more than 1 hour in any 7 day period. And in the removal of asbestos-contaminated dust (ACD) if: the asbestos removal work does not exceed 10 minutes in total; and the removal is not undertaken for more than 1 hour in any period of 7 days; or the removal of ACD if an independent person has determined that the airborne asbestos fibre levels are likely to be less than one half of the asbestos exposure standard. This permitted limited asbestos removal must be conducted in accordance with these Regulations. 1. WorkSafe cannot process applications from a person whose identity has not been verified. If you have not previously done so, you must complete and submit an Identification Form Natural Person / Identification Form Non-Individual with this application. 2. If the application is for a Class A Asbestos Licence, you must attach a copy of your current Certification for an Asbestos Occupational Health & Safety Management System. 3. As part of the application assessment, a WorkSafe Inspector may visit your workplace to conduct an interview / audit of your systems of work. 4. A request to nominate an additional site supervisor for an existing licence must be made by the licence holder using the form Asbestos Removal Licence Nomination of Additional Site Supervisor 5. A request to remove a nominated site supervisor from an existing licence can be made in writing, by the licence holder, to the Manager, Licensing Branch, using the address in the Contact Details section. Collection of Personal Information Personal information collected by WorkSafe in connection with this application will be used for the purpose of assessing the application and administering the licence. The information may also be used for the administration and enforcement of legislation administered by WorkSafe, administration and evaluation of WorkSafe s programs generally and legal proceedings. WorkSafe may disclose personal information to its contractors and agents; to a court or tribunal; to other regulatory agencies (including police, for the purposes of investigating or conducting an interview in connection with the application) and to any person authorised by the individual to whom it relates, or by law, to obtain it. WorkSafe maintains a publicly available database of licence holders. WorkSafe may publish this information on WorkSafe website. You may ask us not to publish information about your licence status on the website by sending your request, in writing, to the Manager, Licensing Branch. WorkSafe may disclose a person s licence status to employers or prospective employers and members of the public who wish to check this status. Collection of this information may be required by Victorian occupational health and safety legislation. If you do not provide any or all of the information, your application may not be accepted or processed. You have rights to have access to any personal information WorkSafe holds about you. Requests to access your personal information are forwarded to WorkSafe s Freedom of Information Unit at foi@worksafe.vic.gov.au. You can access WorkSafe Privacy Policy at www. worksafe.vic.gov.au. Contact Details Submit your completed application form and all supporting documentation to: WorkSafe Victoria Telephone: 1300 852 562 Licensing Branch Facsimile: 1800 060 727 GPO Box 4293 Email: licensing@worksafe.vic.gov.au Melbourne VIC 3001 Further information relevant to this licence is available on our website www.worksafe.vic.gov.au WorkSafe Victoria is a division of the Victorian WorkCover Authority FOR602/08/06.17