HomeMy WebLinkAboutHO201300023 Legacy Document 2013-04-10OA 141 (7/01/2012)
' amyN.�D
oPERa NG TY
n
FIOR COMMONCIARRIERS OF'PASSENGERS'CATION
Virginia Department of Motor Vehicles
Post Office Box 27412
STATE
VA
Richmond. Virginia 23269-0001
BUSINESS MAILING ADDRESS (if different from above)
Purpose: Use this form to apply for or change existing authority to operate as a Common Carrier over Regular Routes or a Common Carrier over Irregular
Routes in Virginia. For information on how to obtain For -Hire Intrastate Operating Authority for other types of for -hire services, visit
www.dmvNow.com.
Instructions: To ensure accurate and timely processing of your application, read and follow all steps outlined in the Operating Authority Certificate Application
ror common carriers or vassengers msrrucuons (LiA 4 f -f/. uiviv aces not accept appucauons via iax.
1 1. APPLICATION AND AUTHORITY TYPES
APPLICATION TYPE (check one)
❑ ADD OR RANSFER/ SALE
SERVICE AREAE ROUTE / ❑ (FeeGINAL APPLICATION Requi ed with application) ❑ RESTRICTION ICTION VE LIMITATION / ❑ (Fee Required with application)
AUTHORITY TYPE REQUESTED
® COMMON CARRIER — IRREGULAR ROUTE ❑ COMMON CARRIER — REGULAR ROUTE
2. BUSINESS INFORMATION
BUSINESS NAME
Comfort Caring Transport LLC
FEDERAL TAX IDENTIFICATION NUMBER
46-2028723
TRADE NAME OR DOING BUSINESS AS (if different from Business Name)
BUSINESS STREET ADDRESS (do not give P.O. Box)
3445 SEMINOLE TRAIL SUITE 179
CITY
CHARLOTTESVILLE
STATE
VA
IZIPCODE
122911
BUSINESS MAILING ADDRESS (if different from above)
CITY
STATE
I ZIP CODE
COUNTY NAME (if Virginia Address)
ALBEMARLE
TELEPHONE NUMBER
(434) 242-7200
FAX NUMBER
(434) 202-7984
PRIMARY CONTACT PERSON NAME
CRAIG S BURTON
TELEPHONE NUMBER
FAX NUMBER
PRIMARY CONTACT PERSON TITLE
PRESIDENT
PRIMARY CONTACT PERSON EMAIL ADDRESS
COMFORTCARINGTRANSPORT@GMAIL.COM
4. LICENSE I CERTIFICATE INFORMATION
3. BUSINESS ENTITY INFORMATION
3A. BUSINESS ENTITY TYPE (check one)
® CORPORATION
Provide information requested below for all
corporate officers and/or board members.
❑OTHER
Provide information requested below for all general
partners, managers or members.
Virginia law requires DMV to determine if persons applying for operating authority are fit to provide the service. Information from driving records is one of the
tools used to determine fitness. If any of the individuals listed below holds a driver's license issued by another state, you must enclose a current CERTIFIED
copy of that person's driving record with this application.
3B. LIST BUSINESS OFFICIALS:
FULL LEGAL NAME
ISSUING STATE
TITLE DRIVER LICENSE NUMBER (certified copy required
if not issued by VA)
CRAIG STEVEN BURTON
PRESIDENT 761258256 VA
IRP ACCOUNT NUMBER
BASE STATE
Has your business or any official of the business had any type of local, state, or federal certificate or license denied, suspended, or revoked?
® NO ❑ YES - list certificate / license type(s) and number(s) below.
Certificate / License Type
Certificate / License
Certificate / License was:
Reason
Number
(check if applicable)
4. LICENSE I CERTIFICATE INFORMATION
Does your business have ❑ NO - Skip to the next section
IFTA LICENSE NUMBER
BASE STATE
an IFTA or an IRP account? ❑ YES - enter applicable information
IRP ACCOUNT NUMBER
BASE STATE
IRP ACCOUNT NUMBER
BASE STATE
Has your business or any official of the business had any type of local, state, or federal certificate or license denied, suspended, or revoked?
® NO ❑ YES - list certificate / license type(s) and number(s) below.
Certificate / License Type
Certificate / License
Certificate / License was:
Reason
Number
(check if applicable)
DENIED
SUSPENDED/REVOKED
DENIED
SUSPENDED/REVOKED
OA 141 (7/01/2012) - Page 2
5. ZONING COMPLIANCE VERIFICATION
CURRENT CERTIFICATE HOLDER NAME
BUSINESS NAME (must match Business Name you gave in Section 2)
BUSINESS MAILING ADDRESS
3445 SEMINOLE TRAIL SUITE 179
Comfort Caring Transport LLC
STATE
VA
BUSINESS STREET ADDRESS (must match Address you gave in Section 2)CITY
STATE I ZIP CODE
3445 SEMINOLE TRAIL SUITE 179 1 CHARLOTTESVILLE
VA 22911
THE FOLLOWING INFORMATION• • OFFICIAL
(434) 242-7200
Virginia Code requires that the primary business location-7—the above named applicant must be in compliance with local zoning regulations before this
application can be processed by DMV. Please provide all of the following information for the address listed above.
TAX �PNUMBER
LOT NUMBER___j�
SECTION L�
ZONING DESIGNATION
Poo
TITLE
CURRENT CERTIFICATE HOLDER OR AUTHORIZED REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
I verify that the business location listed above is in compliance with the zoning ordinances of this city/county.
ZONING OFF!AL NAME � t)
ZONIN FFI IAL SIGNATURE
I
DATE (m . /dd/ )
�f �iJ
4A
ZONING OFFICIAL EMAIL ADDRESS
1✓ ' 3W
TELEPHONE NUMBER
Q - a 9 a
6. TRANSFER / SALE INFORMATION
Complete for APPLICATION TYPE TRANSFER / SALE
CURRENT CERTIFICATE HOLDER NAME
CERTIFICATE NUMBER
BUSINESS MAILING ADDRESS
3445 SEMINOLE TRAIL SUITE 179
CITY
CHARLOTTESVILLE
STATE
VA
ZIP CODE
22911
BUSINESS TELEPHONE NUMBER
BUSINESS FAX NUMBER
PRIMARY CONTACT PERSON NAME
CRAIG S BURTON
TELEPHONE NUMBER
(434) 242-7200
(434) 242-7200
(434) 202-7984
The following information MUST be completed by the current certificate holder or their authorized representative.
Are you selling all of the business to the applicant named in Section 2, "Business Information" of this application? ❑ NO ❑ YES
I certify that I currently hold a valid Virginia operating authority certificate and that I have agreed to transfer / sell the certificate to the applicant named in Section
2, "Business Information" of this application. I further certify that all the information provided in the "Transfer / Sale" section of this application is true and correct.
CURRENT CERTIFICATE HOLDER OR AUTHORIZED REPRESENTATIVE FULL NAME (print)
TITLE
CURRENT CERTIFICATE HOLDER OR AUTHORIZED REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
7. VIRGINIA TRAVEL INFORMATION
• If application type is ADD OR DELETE ROUTE/ SERVICE AREA —list only new OR amended trip information. I CERTIFICATE NUMBER TO AMEND
If you wish to delete a route / service area, precede the route's / service area's description with "DELETE - " .. .
• If application type is ORIGINAL APPLICATION — list the name of the location and address in the Virginia city or county where your trips will begin and end and
each and every street, road, etc. that you travel during each trip.
Example: Trip 7 - Start from Four Mile Mall north parking lot at 410 Four Mile Rd. in Alexandria, travel northwest 3 blocks to 1-395 South, travel 6 miles to I-95
south, travel 93.4 miles to Boulevard exit in Richmond City, turn right onto Boulevard, travel 6 blocks to end of trip 1234 Boulevard in Richmond City.
�mr FOR -HIRE INTRASTATE OPERATING AUTHORITY OA 141S (7/01/2012)
www.dmvNOW.com CERTIFICATE OR LICENSE APPLICATION SUPPLEMENT
Virginia Department of Motor Vehicles INFORMATION RELEASE AUTHORIZATION
Post
Richmond.
Virginia
23
Richmond, Virginia 23269-0907
Purpose: Applicants for For -Hire Intrastate Operating Authority Certificates or Licenses use this form to authorize the release of pertinent information
concerning themselves and/or their company to any agent or representative of the Virginia Department of Motor Vehicles (DMV), or the Virginia
Department of State Police in possession of this release.
Instructions: Submit an authorization to release information for the applicant and all Business Officials identified in the "Business Information" section of your
application for For -Hire Intrastate Operating Authority Certificate or License. If additional releases are needed, this form may be photocopied.
Ci ehmittarl n rthnri7atinnc Ml ICT ha nntari7ari ac inrliratPd heinw fnr FACH Business Official submittina a release.
RELEASE AUTHORIZATION INFORMATION
BUSINESS NAME (MUST match the business name provided on your For -Hire Intrastate Operating Authority application)
Comfort Caring Transport LLC
TRADE NAME OR DOING BUSINESS AS (if different from Business Name)
I/we the undersigned, hereby authorize and request the release of any information you have concerning me or my company to any agent or
representative of the Virginia Department of Motor Vehicles (DMV), or the Virginia Department of State Police who presents this release. This
authorization is given for a background check as a result of an application to DMV's Motor Carrier Services to obtain an operating authority
certificate or license. I further give consent to the release of the results of my Virginia Criminal History check to the Virginia Department of
Motor Vehicles.
BUSINESS OFFICIAL INFORMATION
BUSINESS OFFICIAL'S FULL NAME (last, first, middle initial)
BUSINESS OFFICIAL'S TITLE
CRAIG STEVEN BURTON
PRESIDENT
DATE OF BIRTH (mm/dd/yyyy)
SOCIAL SECURITY NUMBER (Do not list company FEIN)
DRIVER LICENSE NUMBER
ISSUING STATE
T61258256
VA
SF,(
RACE
CITY OR COUNTY OF BIRTH
MALE
AFRICAN AMERICAN
QUEENS
STATE OR COUNTRY OF BIRTH
TELEPHONE NUMBER
NEW YORK
(434) 242-7200
PERSONAL RESIDENTIAL ADDRESS
CITY
STATE JZIP
CODE
1570 BROAD CROSSING RD
CHARLOTTESVILLE
VA
22911
BUSINESS OFFICIAL SIGNATURE
DATE SIGNED (mm/dd/yyyy)
NOTARIZATION (must be completed by notary public)
Commonwealth of Virginia, city or county of subscribed and
NOTARY PUBLIC SEAL (if required)
sworn before me on this day of
(MONTH) (YEAR)
by in the city or county and state aforesaid.
REGISTRATION NUMBER (6 digits)
MY COMMISSION EXPIRES (mm/dd/yyyy)
NOTARY PUBLIC NAME
NOTARY PUBLIC SIGNATURE
BUSINESS OFFICIAL INFORMATION
BUSINESS OFFICIAL'S FULL NAME (last, first, middle initial)
BUSINESS OFFICIAL'S TITLE
BURTON CRAIG S
PRESIDENT
DATE OF BIRTH (mm/dd/yyyy)
SOCIAL SECURITY NUMBER (Do not list company FEIN)
DRIVER LICENSE NUMBER
ISSUING STATE
08/11/1965
T61258256
VA
SEX
RACE
CITY OR COUNTY OF BIRTH
MALE
AFRICAN AMERICAN
QUEENS
STATE OR COUNTRY OF BIRTH
TELEPHONE NUMBER
NEW YORK
(434) 242-7200
PERSONAL RESIDENTIAL ADDRESS
CITY
STATE
ZIP CODE
1570 BROAD CROSSING RD
CHARLOTTESVILLE
VA
22911
BUSINESS OFFICIAL SIGNATURE
DATE SIGNED (mm/dd/yyyy)
NOTARIZATION (must be completed by notary public)
Commonwealth of Virginia, city or county of subscribed and
NOTARY PUBLIC SEAL (if required)
sworn before me on this day of
(MONTH) (YEAR)
by in the city or county and state aforesaid.
REGISTRATION NUMBER (6 digits)
MY COMMISSION EXPIRES (mm/dd/yyyy)
NOTARY PUBLIC NAME
NOTARY PUBLIC SIGNATURE
OA 141 (7/01/2012) - Page 3
8. TRAVEL JURISDICTIONS INFORMATION
AUTHORITY -Complete for Delete -Route
Check the box next to EACH city and county you plan to travel through. You must be able to drive a connecting route through the neighboring cities / counties
you selected or your application will be returned.
For example, if you plan to travel from Charlottesville to Petersburg you would check the following cities and counties if you were traveling on routes 1-64 and
1-95: Charlottesville City, Albemarle County, Fluvanna County, Louisa County, Goochland County, Henrico County, Richmond City, Chesterfield County, Colonial
Heights City, and Petersburg City.
NOTE: For APPLICATION TYPE "ADD OR DELETE ROUTE / SERVICE AREA", check only the cities and counties you want to add to or delete from your
current certificate. Enter "A" to indicate selection is to be added or "D" to indicate selection should be deleted.
® CHECK HERE IF YOU ARE APPLYING TO TRAVEL STATEWIDE. If you check here, you do not have to check the jurisdictions separately below.
I certify that I will comply with all of the applicable provisions of the Code of Virginia, Title 46.2, and with all applicable requirements prescribed by the Virginia
Department of Motor Vehicles. I affirm that all taxes, fees, penalties, interest, and judgements due the Commonwealth of Virginia have been paid or satisfied and
that I am in compliance with the Worker's Compensation Act of Title 65.2 and with the Business, Professional, and Occupational License Tax requirements. I
further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I make these certifications and affirmations under penalty of perjury and I understand
CITIES
license issued to me can be suspended and revoked if any of the information in the application is found to be untrue or inaccurate.
APPLICANT OR AUTHORIZED REPRESENTATIVE NAME
APPLICANT OR AUTHORIZED REPRESENTATIVE TITLE
APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
® Alexandria
A
® Colonial Heights
A
® Fredericksburg
A ® Manassas
A
® Poquoson
A
® Staunton
A
® Bedford
A
® Covington
A
® Galax
A ® Manassas Park
A
® Portsmouth
A
® Suffolk
A
® Bristol
A
® Danville
A
® Hampton
A ® Martinsville
A
® Radford
A
® Virginia Beach
A
® Buena Vista
A
® Emporia
A
® Harrisonburg
A ® Newport News
A
®Richmond
A
®Waynesboro
A
® Charlottesville
A
® Fairfax
A
® Hopewell
A ® Norfolk
A
® Roanoke
A
® Williamsburg
A
® Chesapeake
A
® Fails Church
A
®Lexington
A ®Norton
A
®Salem
A
®Winchester
A
® Clifton Forge
A
® Franklin
A
® Lynchburg
A ® Petersburg
A
® South Boston
A
COUNTIES
® Accomack
A
® Caroline
A
® Franklin
A ® King George
A
® Nottoway
A
® Scott
A
® Albemarle
A
® Carroll
A
®Frederick
A ® King William
A
® Orange
A
® Shenandoah
A
® Alleghany
A
® Charles City
A
® Giles
A ® Lancaster
A
® Page
A
® Smyth
A
® Amelia
A
® Charlotte
A
® Gloucester
A ® Lee
A
® Patrick
A
® Southampton
A
® Amherst
A
® Chesterfield
A
® Goochland
A ® Loudoun
A
®Pittsylyania
A
® Spotsylvania
A
® Appomattox
A
® Clarke
A
® Grayson
A ® Louisa
A
® Powhatan
A
® Stafford
A
® Arlington
A
® Craig
A
® Greene
A ® Lunenburg
A
® Prince Edward
A
® Surry
A
® Augusta
A
® Culpeper
A
® Greensville
A ® Madison
A
® Prince George.
A
® Sussex
A
® Bath
A
® Cumberland
A
® Halifax
A ® Mathews
A
® Prince William
A
® Tazewell
A
® Bedford
A
® Dickenson
A
® Hanover
A ® Mecklenburg
A
® Pulaski
A
® Warren
A
® Bland
A
® Dinwiddie
A
® Henrico
A . ® Middlesex
A
® Rappahannock
A
® Washington
A
®Botetourt
A
® Essex
A
® Henry
A ®Montgomery
A
®Richmond
A
®Westmoreland
A
® Brunswick
A
® Fairfax
A
® Highland
A ® Nelson
A
® Roanoke
A
® Wise
A
® Buchanan
A
® Fauquier
A
® Isle of Wight
A ® New Kent
A
® Rockbridge
A
® Wythe
A
® Buckingham
A
® Floyd
A
® James City
A ® Northampton
A
® Rockingham
A
® York
A
Cam bell '
A
Fluvanna
A
Kina and Queen
A Northumberland
A
Russell
A
9. REMOVE LIMITATION / RESTRICTION INFORMATION
For application type "REMOVE LIMITATION / RESTRICTION", enter limitation or restriction information to remove.
10. CERTIFICATION
I certify that I will comply with all of the applicable provisions of the Code of Virginia, Title 46.2, and with all applicable requirements prescribed by the Virginia
Department of Motor Vehicles. I affirm that all taxes, fees, penalties, interest, and judgements due the Commonwealth of Virginia have been paid or satisfied and
that I am in compliance with the Worker's Compensation Act of Title 65.2 and with the Business, Professional, and Occupational License Tax requirements. I
further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I make these certifications and affirmations under penalty of perjury and I understand
that knowingly making a false statement or representation on this form is a criminal violation. I understand that any Virginia Operating Authority certificate or
license issued to me can be suspended and revoked if any of the information in the application is found to be untrue or inaccurate.
APPLICANT OR AUTHORIZED REPRESENTATIVE NAME
APPLICANT OR AUTHORIZED REPRESENTATIVE TITLE
APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
aAVOID DELAYS in processing your application, review Instructions OA 141-1 to ensure you have completed this application correctly.
11. PAYMENT METHODS
Applicants that have APPLICATION TYPES "Original Application" or "Transfer / Sale" must include a NON-REFUNDABLE $50.00 fee with this application. If
this application must be returned to you for any reason, you may be required to pay another $50.00 filing fee.
PAYMENT METHOD:
❑ CHECK --,Made payable to DMV ❑ MONEY ORDER — Made payable to DMV ❑ CREDIT CARD -- complete the credit card information below.
NAME APPEARING ON CREDIT CARD
DAYTIME TELEPHONE NUMBER
CREDIT CARD
DATE CARD
AMOUNT TO BE CHARGED
NUMBER
EXPIRES (mm/yy)
$50.00
1 authorize DMV to charge the
CARD HOLDER SIGNATURE
credit card account listed above.