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HomeMy WebLinkAbout2014-076 License - Ambulance Operators 0), Le , { CD I: Ia-- C=J a ~/la ~ 1'f j J I'. CD 't 1: cn CD !(J,® 3' 3 'co CD (D 10. W\ CD CD CD ~i ALA~~~ ~ CD c- 3 CL cn C: CD ®r CD CE) D 1, ~ Q o co CD 0 C) U) z D I\, i v o I 0 n 14D "K c~~Lr r'~ m ` U) U) CD ty-- (D C) CD ~ pp.. Imo'®~ ~ ~ o r~l 'v a II, ~riA i ~ ~\~r~'`\/J4}yL1f~'~~/~ ~}yL,l\'f ~vr ~}y~ 1.vf~`~ CITY OF ASHLAND APPLICATION FOR AMBULANCE OPERATOR LICENSE AMC Ch. 6. 6.40 2014 Applicant's Name: CITY OF ASHLAND Trade Name, if any: ASHLAND FIRE & RESCUE Address: 455 Siskiyou Boulevard Ashland OR 97520 Telephone number: 541 482-2770 Ambulance descriptions Manufacturer Vin # License # 1. 1999 FORD LIFELINE 1FDXE40F2XHAO0469 EXEMPT 2. 2003 FORD LIFELINE 1FDXF47F63EA10341 EXEMPT 3. 2006 FORD LIFELINE 1FDXF47P06ED06467 EXEMPT 4. 2008 FORD LIFELINE 1FDXF47R48ED90832 EXEMPT 5.2011 FORD LIFELINE 1FDUF4HTOBEC53861 EXEMPT ❑ Attach information showing that every proposed driver, attendant and driver- attendant is qualified as required in Ashland Municipal Code Chapter 6.40 and as required by the laws of the State of Oregon. ❑ Enclose with the application, the initial license fee of $300 plus $100 per ambulance. ❑ Enclose a performance bond in the amount of $500,000. ❑ Enclose an insurance policy meeting the requirements of AMC §6.40.110.7. Attach additional pages as necessary. Explain any box not checked. Submit your application and required enclosures to Barbara Christensen, City Recorder, City Hall, 20 East Main Street, Ashland, Oregon 97520. 1 certify that each ambulance listed above is adequate and safe for the purposes for which it is to be used and that it is equipped as required by Ashland Municipal Code Chapter 6.40 and the laws of the State of Oregon. Signature: Print name: Greg I. Case Title: Division Chief Date: 05-23-2013 https://zimbra.ashland.or.us/service/home/-/2014 Lic. renewal. doc?auth=co&loc=en&id=165580&part=2 April 10, 2009 OREGON DEPARTMENT OF HUMAN SERVICES PUBLIC HEALTH DIVISION ' n Drr2r~ EMERGENCY MEdICAL SERVICES TRAUMA SYSTEMS PROGRAM > µ fj Y AOTCYNUMSER ' ` x +t 3' 4w -k "w glv 'I 1501 - OPENATION DATES ~ NO DAY Yfi THO ND DAY YR e., T c.S ~"t qj, n 3$ 7/1/21)14 }5/3%201b AMBULANCE AGENCY LICE NSE ;POST IN AGENI:Y t } City of Ashland #1501 s 455 Siskiyou Blvd fir 5' Ashland, OR 97520 rY PflryEVrDnTT i ry~' \'i;.,: •x s t„..?b ~ .t x' a:.. ~ i S ~ khF < $'Y *a , 14 - 'y y'~4 ~ v._ 4m >y. .1~ i Yry: Y~ ~ >Y MUST BE POSTED IN A CONSPICUOUS PLACE -NOT TRANSFERRABLE ~ i UThlOF711Y tsr » YwDIT NO yL{ a' QR~G _ QNfLTH `4% r2 ✓ p ✓Y'' 3s s q a 4 A " tab > < X y _ F ,..y qk~,',EMEf2GENCY MEDiCAL~SERV4~CES gc,RAUIuSASSTEMS P ROGftAM }T O$ sES2s~z 4, ,rX zA♦ r r f ,l V , ~ ~ 1K a tieNSENUnneea, k~ ss• z` ..a:~~ spat t 80'0QW PA•rMEoii~ciGeD E244394 / Cs VIN raa EXPIRATION 4ya''?> e ~,{{11"a~>e;,`~A. ~#~aa / a•. tr✓-'^'.~ Iz DATE 2011 1 FDUF4fIT08 C$3861 i h ~ / u e a ' t$or ° T rR r q. r q~•Ir/lx ~m y~~^4~y J y z 4A S ..LANCE L1.. POST IN AGENCY h z . s ,dt ~5 ai~Wd 7~ 7 06/30(2015 '~'tt a 5 y tai' av >Ez»~. Xvsx.d "r vI"i"v~ /sy/> z ,y r1vt: x 3 f~> s / City of Ashland #1501 ~w3 9 F a P a f Ian d `r 455'ISkrybu`rBly`d 5 ' s 2 a S w „ ~ t ;Z, *t 'ADMINISTRATOR t r ASWand OR197520 ry w" a " coNHr r nau Nqa xvy Cyti+ ri > °U xs ° yt` 'tz' ,fiL K y y~ P y..; is fiY S* y is" .x 4> a3h-, i° "s - r# rr y °S?~r{ s Lx 3, ka '"^,T ~:3 n 5 r 3S OL x,> T a Z-" } K xf• f ~'a z G s'~ ' ?fy °t .3 r Y~ 'v x z& P `St ri > 1 4[ i s ttJ 4",, MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE svs~s~r 52932 ~ x Y rr' _ R t a 3T ~ . ©REGQN I-I~ALTI-I /~UTf-JDRITYzz~ ~ ~ r~rs ~ < ,n~ ~ ~~SDI~Ng~ , ECv1ET2~ENCY,MEDJC L SERVIES ~,TRAUMASYSTEMSPR GRA1V14 x u 52931 g yf h ar r r - 'Q Fy;.- &-7..a` $ k ~"K e' ' 3 ~v f. ,yYS ft Z r uLz` K may,.. E 0m ucE s KeE z s~ fr 4 ` n 'K » 80 00 PAYMENT REGEIVED E68 'c f &43 VIN, v„351r ,?j'` 4V `zue ~r' a'7iJ flh.,, o6f 'z~w~r`^ EXPIRATION VK ~ y s rl" r 12008 1 f=pXF47fR48ED90832 ~ 7ti~ ~ 'r ,t i l~. ~ ~ ~ r^ A «A1O DAr rR+ -x ? A A~ Sz ~ :y a~ rrr Y. a T Sry ~ Vi . [ s u x ,i. 4 s 1 s. Np I eI f!t° flr ! ✓ r r c ~ ~ ~ ~~'"~~~aL ~ ~ q, 1~ I s ~ k n r- 6130/2~15 s. X ~ANIBULANCE LICENSE POST IN 0 wx. ~r i:'S'~` zf y.H.: s~~l✓~ a ~~'x ^ s` ~ '@a , ^i ~ 1~T a u ~u. City of Ashland #1501 i G A ' ' a7 y 4 ~'IISkIYOC1igIVd ~ KADMINIS'T'RATQR s t; yYs` Ashland OR 97520 x ' ' Xa y ORcrop Ee rNAUr ORIiv 3 F a r zk ~ t' ~ a Sv T a r g :ti 5,~~ s ° C 33 z ti4 i da kr yz J' t s.' S~r:.a (1 st /u r.3 F y 4c x- 4 - f .K`' II:"Juz °I r& ~~4 i 'Z ~Y~ :x~ `KX ~e~,. MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE cts~w83z- 52931 80.00 E244368 2008 FORD 06/30/2015 City of Ashland #1501 4515 Siskiyou Blvd Ashland OR 97520 fi sp ~y OREfaQAfEALTki ~UTFfORITYa` ' s r z.~ 3 uDhNO L Cc`5. Jv F 5% iy tl tiS~ 1 it tEME26E,N1EDiCALtRVI~CESc,2ACIMHSYSTE(>YI3j,l2gGRAhA i { , fi 52927 a' 3. y. >u :x u< kq -F Y` vz x Z :u < 'w jz x~" Rl { x' L'ICEN5E NUMBER t ky Via' £ a~ iv,' G rS~ PAY"niaris'FRC,~'iGEO E222273 , C1 F ERPIRAMN VIN Y y, t: ✓ t y ~V ~~~t y. y xYi' yam ^~zf 5 * f t Zs V~ Sr. 'DATE 0% h S s +C'p; .t n g; "e {i.<om3 t. `f a NO oAY vR n S.2 } 2002','lF.DkF4d `7 .63EA'}034T 4#7, 1~ "i st l! 5 r,x e:AMBUTANGE LICENSE -'POST IIdAC;Ey~NCY h`~~° ksL~/ K 6' 't"fx°" xj .tuvfi .d rN~,y, *'a'^>" t~ x r4'`v~'r l rf , td vF z"yo-" xw"" ks ii City of Ashland #1501 t ,zx+' f3" 1 fr'Id ;pr x" /~W, ,7 g: Lgi-f s ' ~ y s+s~'455'SlsklyoU Blvd ~`~;a F s~`r" ~ ~ s= e ~ ADMINISTRATOR -Ashland OR 97520: ^y,'.{~ ~sf~'' ' Q a~racu+HE!}crN.~~ri?wrv eo re, q V. firc 4 Al p" a tss'~'"''' x r.3- 4 ,vim°5+~" .~£~r 3 ' s~C^ ,t wrf yY'`T, .ri±,. '{fd { y1 •^"x9`.~- ' y' . ''x(, `G'~fCi »u+c't~.>~'K' ;>vAatir "s;`yzsis s" ,ssf~- •`xs...[h :kt3.:r` '1< x,{~s,1'Y`R MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE yc z/88,0 52927 80.00 E222273 1nn1 L~..A . 3 Gy €gss' f x ti.a s.. A `^i° ',Yi kv - J'n' •3. Y •AUDR NO trr. r r A Ei1EftGEf+7CYk,MED~C1tLSERVtES$eTRAUM~I~SYSTENISRF2GGRAM 52926 a' > d s j *r r z 4r T Y^ 'A ftt oti .}p q`a ts:. "<x~ rr i~r 5'+ w .y 1 ' w & '!fr- s c f2 1 e " Y LLLENSE'I ER V`¢ "5.n w u ;`xt s o R x 1 'V Yx 5~. of z 00~ ' 4' ~{ice 'r[4,t+,m y~~ ~'~t~ 4 v~F~ , "Y }Ntrs PAYMENTAEEEIVED E211465 F IXPIRATIDN VINO -:grSt Ca,: ~"Yr=w ~~.cx3rc£?; Z+ DATE . ~,i.". > F s` + yrc .r s i " a e < C~2y. MO DA7 YR r, 1998 1F©XE40F2XHA00469 g r c J lw s-, r .`e,£. `x ,r ilK, a 4 " ~r v. 'K ?L tM r ~kOj05/30/^~015c ' CE fiZ S +'r Yx, j 4 C ~F RMBULANCEZ ICENSE VOS7'IN RGENCY nt a 9~ u ;-n rr ;r r x rl~ S` V 1'`~'Cz-i i za~i ✓a° City, of Ashland #1501 / 4 T ne 1 r Y 3 o t r s~ r f - ~,`~~455'$iskiyou Blvd ~x . a k z~ Ld r~ i~ ~ ` £ Fs`~ s~-t g ptT $OMINfSTRATQR ~n' A, tsAshland OR79752Us ' ' r 4 v ORECONHEAtmAvr M n {xz.i'L'r ysys Y,~:' L~fi .a,., n`'<c T x4'~ n ?r h Y rF.,'S' -t'~'^f. },x3` J,~ Y: MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE 52926 80.00 E211465 1998 Ford 06/30/2015 CITY OF ASHLAND APPLICATION FOR AMBULANCE OPERATOR LICENSE 2014 First Employee Last Name Name MI Level Status Anders, Brian W. EMT-Paramedic PFT Beck Todd E. EMT-Paramedic PFT Boyersmith Steven P. EMT-Paramedic PFT Burns Kelly W. EMT-Paramedic PFT Case Greg I. EMT-Paramedic PFT Formolo Curt J. EMT-Paramedic PFT Foss Justin EMT-Paramedic PFT Freiheit Matthew E. EMT-Paramedic PFT Hadden Jennifer A. EMT-Paramedic PFT Hanstein David C. EMT-Paramedic PFT Hegdahl Tim R. EMT-Paramedic PFT Hickman Margueritte LR EMT-Basic PFT Hollingsworth Scott M. EMT-Paramedic PFT Knutson Brent A. EMT-Paramedic PFT Garfas-Knowles Ronald W EMT Paramedic PFT LaCoste Rod T. EMT-Paramedic PFT Manning Ashley EMT Paramedic PFT Menold Lance W. EMT-Paramedic PFT Rasor Marshall G. EMT-Paramedic PFT Roselip David EMT-Paramedic PFT Rosenlund Derek A. EMT-Paramedic PFT Sallee Dana S. EMT-Paramedic PFT Shepherd David G. EMT-Paramedic, PFT Stephens Robert W. EMT-Paramedic PFT Stoy John Trent EMT-Paramedic PFT Stubbs Todd C. EMT-Paramedic PFT Trask Robert EMT-Paramedic PFT Turner Shannon W. EMT-Paramedic PFT ASHLAND FIRE & RESCUE AMBULANCE SERVICE AREA III 2014 Vehicles/ Equipment Level 'as of 01-00-14 VEHICLES MILEAGE TYPE LEVEL Unit # Year Model License VIN # ALS/BLS Shop # Ford 8831 2011 Lifeline E244394 IFDUF4HTOBEC53861 1 ALS 845 F-450 4X4 Ford 8833 2006 Lifeline E233465 1FDXF47F06ED06467 1 ALS 552 F-450 4X4 Ford 8832 2008 Lifeline E244368 IFDXF47R48ED90832 1 ALS 615 F-450 4X4 Ford 8834 2003 Lifeline E222273 1FDXF47F63EA10341 1 ALS 462 F - 450 4X4 Ford 8835 1999 Lifeline E211465 1FDXE40F2XHA00469 3 ALS 364 E-450 4X4 AT 3 xa . ©RECtiOHk H~EALTW1THORITY, tsr, g'; k fix yy fi" oRM° ,4 2 f EME€+'GF1CY MF~iCAL3SRVJCES & TRAUMA+SYSTE' SFP<OGFL4M S+ x 53076 6ENSEfIUMBER -h ? Kt' £ f `S 4'"y'.* t f I*E` " r3~ nri SQ QQ i~ f. ,.'4 vnVME1J'fkEVEO44 wN E233465 r ~rl~r u w. , r ,'Or ^r' Exr(RnnoN 5~Ma oAVjrR r .tr fz f rr w, w s < s .a~I1^ x,?r~ 4~ '3 . r M ° ~'ANTBI~CANCEL~ICE'~ISE POS'TINAGEFIC~'~ ~ ~1\~ I' ~~~'I_r ~ ~ Q6 2015 Kr CIty of Ashland #'501 ` ~ z i ' ////J ~ f b' qF .N "73+ f' r ,y q$° 5 ~yYv q a ] F' ~ T ADMINISTIATOR kn ~10Rli~ciI~AUht~e~ti~ ` a5 s ` K s § x` 'y} aY i f4 ✓y k si .rte ^t 1`' o S, a4 3 3a ! .7~.' _ •'s SGGG::: .x L4-t ^s z i .qG ~c K.,. °t Lt y,}aTi w ~k n1 y y P , 1~ n `s . x > ~ R JR: 1y. `'w».! -{~~3 ~~a+. ".3~~'.d'•Z"M`` ^r`J" '35.344y'{4~ i i~.!"SI ~)'~n 5~~r ~Yp~r'~ ~F~'~({~!V%` r '4F:>a• MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE 53076 80.00 E233465 2006 ~`ff o33 06/30/2015 City of Ashland #1501 455 Siskiyou Blvd Ashland OR 97520 CENTERS FOR MEDICARE & MEDICAID SERVICES CLINICAL LABORATORY IMPROVEMENT AMENDMENTS CERTIFICATE OF WAIVER 1 LABORATORY NAME AND ADDRESS CLIA ID NUMBER 1 ASHLAND FIRE & RESCUE 38DO866813 LABOTATORY 455 SISKIYOU BLVD EFFECTIVE DATE • ASHLAND, OR 97520 01/01/2014 1 0 LABORATORY DIRECTOR EXPIRATION DATE 0 GREG I CASE 12/31/2015 Pursuant to Section 353 of the Public Health Services Act (42 U.S.C 263a) as revised by the Clinical Laboratory Improvxosent Amendments (CIJA), the above named laboratory located at the address shown hereon (and ad= approved' - - ti ) may accept human speamrns for the purposes of performing laboratory examirrations or procedures. ' pu~ revocation, suspension, limitation, or other sanctions abonx% fat 1 • This certificarc shall be valid mid hh~o the to Act or the buregulations t is subject 1 CMS Judith A. Yost, Director Division of Laboratory Services ~ms.sevessraaok xsvr Survey and Certification Group Center for Medicaid and State Operations 2160 Germ 120313 If this is a Certificate of of RWNtrssL tionsL Lon, it represents only the enrollment of the laboratory in the CLIA program and dose not indicate a Federal certification of compliance with other CLIA requirements. The laboratory is permitted to begin testing upon receipt of this certificate, but is not determined to be in compliance until a survey is successfully completed. • If this is a Certificate for ProviderPeoed~~oscoPtaced~for ProviderPeoed~~oscoPtoced, it certifies the laboratory to perform only those laboratory procedures that have been specified as provider-performed microscopy procedures and, if applicable, examinations or procedures that have been approved as waived tests by the Department of Health and Human Services. • If this is a Certificate of Wailverof WaiEver, it certifies the laboratory to perform only examinations or procedures that have been approved as waived tests by the Department of Health and Human Services. FOR MORE INFORMATION ABOUT CLIA, VISIT OUR WEBSITE AT W W W.CMS.HHS.GOV/CLIA OR CONTACT YOUR LOCAL STATE AGENCY. PLEASE SEE THE REVERSE FOR YOUR STATE AGENCY'S ADDRESS AND PHONE NUMBER. PLEASE CONTACT YOUR STATE AGENCY FOR ANY CHANGES TO YOUR CURRENT CERTIFICATE. i _ CERT ICATE OF COVERAGE ° Agent This certificate is issued as a matter of information " DIRECT only and oonfers no nghts lpon the cerufcata holder ' other than those Provided in the coverage document. This cerdncate does not amend, extend a site, the 6 overage afforded by the =erage documents listed , - r . . harem, citycaunty irlsuronce services • Named Member or Participant -i' Companies Affording Coverage - City of Ashland - ' COMPANY K- CIS - 20 East Main Street COMPANY B - National Union Fire -Insurance Company of Pitts, PA Ashland;OR 97520 COMPANY C'- RSU1 indemnity LINES OF COVERAGE, " Thus Is to certify that coverage document, listed herein have Veen issued to the Named Member herein for the Coverage pined indiceted. Not withstanding any requirement;'ukrtn or andrtonolarty conic= or other ddWlrienI win respect to which due lxaucicale may be issued or may :Pertain, me coverage afterded by the coverage . doaimems listed herein is suiilect to all the tenor, conditions and a usl0ns Of such coverage documents. - Company Certificate Effective Termination Type of Coverage - - _ Coverage Limit 1 'Letter' Number Data .Data.: - General Liability A - 13LASH 7/112013 7/1/2014 General Aggregate' $15,000,000 ' X. Commercial General Liability • - - - Each Occurrence: ` $5,000,000 + 3 X Pubric Officials Liability 11 X Employment Practices X Occurrence Auto Liability - A 13LASH 7/1@013 ` 7112014 General Aggregate: None X Scheduled Autos Each Occccurrence:. $5,400,000 d X Hired Autos - j X Non-Owned Autos - Auto Physical: Damage` - - - A - ° 13APDASH 7112013 ' 711/2014 • . - X Scheduled Autos : , - - - _ - I X Hired Autos . ° - X Non-Owned Autos . ' , X. Property. A 13PASH 7112013 : 711/2014 Per Filed Values X Boller and Machinery - A 138ASH 7112013 7/112014 - - Per Filed Values X Exceeds Crime . - B '13ECASH 7/112013 : • 71112014 Por Loss.' $250,000 - 1 Excess Earthquake - i - i_. Excess Flood... Excess Cyber Liability. ° a - L Workers' Compensation ! Description;. - - - Jackson County is nam6d as additional insured par the agreement made between Jackson County and the City of Ashland giving Ashland Fire 8 Rescue the exclusive right to provide ambulance service in ASA #3. I I Certificate Holder. CANCELLATION: Should any of the my ge documents herein he cancelled before the expiration date . thereof, CIS will provide 30 days wriden notice to the certificate holder named herein, but failure to mail " Jackson County such motto Shan impose no obligation or liability of any laid upon. CIS, its agents or repssse brffw a, a 1005 East Main Street the Issuer of this oerMwte. - - I Medford. OR 97504 - - Date: July 1, 2013 i CITY OF ASHLAND Memo DATE: 5-19-2014 TO: Cindy Hanks CC: Barbara Christensen, City Recorder FROM: Greg I. Case, Fire Dept - Division. Chief RE: Renewal of City of Ashland Ambulance Operator License Fee Cindy, It is time once again for our ambulance renewal and a check must accompany our Ambulance license renewal. Could you do an inter-departmental transfer or Check for the Ambulance Licensing Fees for $800.00 from the EMS account # 110.07.13.00.604160 to the City of Ashland accounts receivable. It needs to be included in the renewal Application for Ambulance Operators License that includes the required certifications and documentation required by the AMC 6.40. the Chief will send the Memo to Dave and a Council Communication requesting ambulance license renewal and is not yet scheduled for a council meeting. As in the past the fees and bond have just been charged to our budget - let me know if this is still correct. Should, you need any other information please let me know and I will get it to you as soon as possible. Thank you! Ashland Flue Rescue Tel: 54148 ~A 455 Sisk'ryou Blvd. Fax: 547-0888--531 5378 Ashland, Oregon 97520 TTY: 800-735-2900 w .ashland.ocus