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Home My WebLink About2015-090 Agrmt - Ambulance Operators License 10) ~ 66~~ C:l a F CD - j {7 D ~~4 U) CD swum mum= f l 5 (D (D CD CD X D CD (n ch CD- c- 3 c (D CD - r (n CL rp> co `t~ a, c 0 ~ CD room CD MR= a 03 (D CD m'~'~~ ' C17 0) CD ~~,~7 ►r 1 emit. p CL 0! CD (D CITY OF ASHLAND APPLICATION FOR AMBULANCE OPERATOR LICENSE AMC Ch. 6. 6.40 2015 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 1 FDXE40F2XHAO0469 EXEMPT 2. 2003 FORD LIFELINE 1 FDXF47F63EA10341 EXEMPT 3. 2006 FORD LIFELINE 1 FDXF47P06ED06467 EXEMPT 4. 2008 FORD LIFELINE 1 FDXF47R48ED90832 EXEMPT 5. 2011 FORD LIFELINE 1 FDUF4HTOBEC53861 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: 04-03-2015 C:\Users\christeb\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\3G9MSP7Q\2015 Lic renewal.doc April 10, 2009 i I OREGON DEPARTMENT OF HUMANERUiCES_ PUBLIC HEALTH C~IVtSIOI~i au~a+r25 EMERGENCY MEDICAL SERVICES & TRAUMA SYSTEMS PRO AGP-NCY NUMBER: GRAM 1501 OPERATION DATES MO. DAY YR. THRU MO. DAY YR. 7/1/2014 6/30/2015 AMBULANCE AGENCY LICENSE -:POST 14 AGENCY City of Ashland #1501 455 Siskiyou Blvd Ashland OR 97520 PAYMENT DATA MO. DAY YR. 04/28/2014 MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERRABLE CERTIFICATE OF COVERAGE Agent This certificate is issued as a matter of information only and confers no rights upon the certificate holder other DIRECT than those provided in the coverage document. This certificate does not amend, extend or alter the coverage afforded by the coverage documents listed herein. 40 Citycounty insurance services Named Member or Participant Companies Affording Coverage City of Ashland COMPANY A - CIS 20 East Main Street COMPANY B - National Union Fire Insurance Company of Pitts, PA Ashland, OR 97520 COMPANY C - RSUI Indemnity LINES OF COVERAGE This is to certify that coverage documents listed herein have been issued to the Named Member herein for the Coverage period indicated. Not withstanding any requirement, term or condition of any contract or other document with respect to which the certificate may be issued or may pertain, the coverage afforded by the coverage documents listed herein is subject to all the terms, conditions and exclusions of such coverage documents. Type of Coverage Company Certificate Effective Termination Date Coverage Limit Letter Number Date General Liability A 14LASH 7/112014 7/1/2015 General Aggregate: $15,000,000 X Commercial General Liability Each Occurrence: $5,000,000 X Public Officials Liability X Employment Practices X Occurrence Auto Liability A 14LASH 7/1/2014 7/1/2015 General Aggregate: None X Scheduled Autos Each Occurrence: $5,000,000 X Hired Autos X Non-Owned Autos Auto Physical Damage A 14APDASH 7/1/2014 7/1/2015 X Scheduled Autos X Hired Autos X Non-Owned Autos X Property A/C 14PASH 7/1/2014 7/1/2015 Per Filed Values X Boiler and Machinery A 14BASH 7/1/2014 7/1/2015 Per Filed Values X Excess Crime B 14ECASH 7/1/2014 7/1/2015 Per Loss: $250,000 Excess Earthquake Excess Flood Excess Cyber Liability Workers' Compensation Description: Jackson County is named as additional insured per the agreement made between Jackson County and the City of Ashland giving Ashland Fire & Rescue the exclusive right to provide ambulance service in ASA #3. Certificate Holder: CANCELLATION: Should any of the coverage documents herein be cancelled before the expiration date Jackson County thereof, CIS will provide 30 days written notice to the certificate holder named herein, but failure to mail 1005 East Main Street such notice shall impose no obligation or liability of any kind upon CIS, its agents or representatives, or the Medford, OR 97504 issuer of this certificate. i Date: August 25, 2014 ti CITY OF ASHLAND APPLICATION FOR AMBULANCE OPERATOR LICENSE 2015 Employee EMPLOYEE LEVEL NUMBER Status # Todd E. Beck Paramedic 124333 PFT 1 Steve P. Bo ersmith Paramedic 120378 PFT 2 Kell W. Burns Paramedic 120248 PFT 3 Justin D. Foss Paramedic 131705 PFT 4 Matthew E. Freiheit Paramedic 121237 PFT 5 Jennifer A. Hadden Paramedic 124336 PFT 6 David C. Hanstein Paramedic 111814 PFT 7 Timothy R. He dahl Paramedic 135298 PFT 8 Mar ueritte L. Hickman Basic 128889 PFT 9 Scott M. Hollin worth Paramedic 113607 PFT 10 Ronald W. Garfas-Knowles Paramedic 132871 PFT 11 Brent A. Knutson Paramedic 130961 PFT 12 Rod T. LaCoste Paramedic 127119 PFT 13 Ashley L. Manning Paramedic 132690 PFT 14 Michael L. Mekkers Paramedic 135069 PFT 15 Lance W. Menold Paramedic 125954 PFT 16 Nick T. Palmesano Paramedic 134776 PFT 17 Marshall G. Rasor Paramedic 126969 PFT 18 David K. Roseli Paramedic 130561 PFT 19 Derek A. Rosenlund Paramedic 121067 PFT 20 Dana S. Sallee Paramedic 116336 PFT 21 David G. Shepherd Paramedic 123197 PFT 22 Robert W. Stephens Paramedic 123787 PFT 23 John T. Sto Paramedic 118911 PFT 24 Todd C. Stubbs Paramedic 130277 PFT 25 Robert A. Trask Paramedic 130008 PFT 26 Shannon W. Turner Paramedic 126208 PFT 27 Brandon L. Winwood Paramedic 136263 PFT 28 29 30 31 ROSTYKUS, PAUL S MD ASHLAND FIRE DEPARTMENT MED DIRECTOR: DR PAUL ROSTYKUS 0 N 455 SISKIYOU BLVD ASHLAND, OR 97520-0000-000 R 0 {{r{rr{rrr{r{r{rrr{r{{{rrr{{rrr{{rrr{{rrr{{rrr{{rrr{{rrr{{rrr w CP v DEA REGISTRATION THIS REGISTRATION FEE I CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE NUMBER EXPIRES PAID ( UNITED STATES DEPARTMENT OF JUSTICE BA3050692 04-30-2018 FEE EXEMPT 1 DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D.C. 20537 SCHEDULES BUSINESS ACTIVITY ISSUE DATE I Restricted to Government personnel for official duties only. 2,2N, PRACTITIONER 03-19-2015 1 3,3N,4,5, I l Sections 304 and 1008 (21 USC 824 and 958) of the Controlled ROSTYKUS, PAUL S MD I Substances Act of 1970, as amended, provide that the Attorney LIMITED TO OFFICIAL GOVERNMENT DUTIES ONLY I General may revoke or suspend a registration to manufacture, ASHLAND FIRE DEPARTMENT I distribute, dispense, import or export a controlled substance. 455 SISKIYOU BLVD I ASHLAND, OR 97520-0000 I THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF I OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, I AND IT IS NOT VALID AFTER THE EXPIRATION DATE. CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D.C. 20537 DEA REGISTRATION THIS REGISTRATION FEE NUMBER EXPIRES PAID BA3050692 04-30-2018 FEE EXEMPT Restricted to Government personnel for official duties only. SCHEDULES BUSINESS ACTIVITY ISSUE DATE 2,2N, PRACTITIONER 03-19-2015 3,3N,4,5, ROSTYKUS, PAUL S MD Sections 304 and 1008 (21 USC 824 and 958) of the V- LIMITED TO OFFICIAL GOVERNMENT DUTIES ONLY Controlled Substances Act of 1970, as amended, N ASHLAND FIRE DEPARTMENT provide that the Attorney General may revoke or 455 SISKIYOU BLVD suspend a registration to manufacture, distribute, ASHLAND, OR 97520-0000 dispense, import or export a controlled substance. 0 THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, L AND IT IS NOT VALID AFTER THE EXPIRATION DATE. DEA REGISTRATION THIS REGISTRATION FEE CONTROLLED SUBSTANCE/REGULATED CHEMICAL NUMBER EXPIRES PAID REGISTRATION CERTIFICATE BA3050692 04-30-2018 FEE EXEMPT UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D.C. 20537 SCHEDULES BUSINESS ACTIVITY ISSUE DATE 2,2N, PRACTITIONER 03-19-2015 Restricted to Government personnel for official duties only. 3.3N.4.5, Sections 304 and 1008 (21 USC 824 and 958) of the ROSTYKUS, PAUL S MD Controlled Substances Act of 1970, as amended, provide LIMITED TO OFFICIAL GOVERNMENT DUTIES ONLY that the Attorney General may revoke or suspend a ASHLAND FIRE DEPARTMENT registration to manufacture, distribute, dispense, import or 55 SISKIYOU BLVD export a controlled substance. SHLAND, OR 97520-0000 THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, AND IT IS NOT VALID -AFTER THE EXPIRATION DATE. I REQUESTING MODIFICATIONS TO YOUR I REGISTRATION CERTIFICATE I To request a change to your registered name, address, the drug REPORT I schedule or the drug codes you handle, please I o I CHANGES I 1. visit our web site at deadiversion.usdoj.gov - or I 2. call our customer Servioe Center at 1-(800) 882-9539 - or 3. submit your change(s) in writing to: N I Drug Enforcement Administration PROMPTLY I P.O. Box 28083 I Washington, DC 20083 0 I E I See Title 21 Code of Federal Regulations, Section 1301.51 1 for complete instructions. U- I You have been registered to handle the following chemical/drug codes: Barbara Christensen From: Greg Case [caseg@ashland.or.us] Sent: Tuesday, April 14, 2015 10:49 AM To: Cindy Hanks Cc: 'John Karns'; 'Barbara Christensen' Subject: Ambulance License funds transfer Memo DATE: 4-03-2015 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! Greg Case, EMS Division Chief City of Ashland / Ashland Fire & Rescue 455 Siskiyou Boulevard Ashland, OR 97520 caseg @ashland.or.us Phone: 541-482-2770 TTY: 1-800-735-2900 Fax: 541-488-5318 CONFIDENTIALITY NOTICE: This email transmission is intended only for use by the recipient indicated above. This email may contain information which is confidential or subject to the attorney-client privilege. Unauthorized distribution or use of this document for any purpose, in full or in part, is strictly prohibited by State and Federal privacy laws. If you have received this message in error, please notify me immediately and delete this message from your system. 1 CITY OF ASHLAND Council Communication 06/02/2015, Business Meeting Ambulance Operator's License Renewal FROM: John Karns, Fire Chief, Ashland Fire & Rescue kariisj!, a 'askilatld.01-AIS SUMMARY The Ashland Municipal Code requires that all ambulance service providers in the City obtain an ambulance operator's license. This is the Fire Department's request for the renewal by Council of the Fire Department's Ambulance Operator's License per AMC 6.40.110. BACKGROUND AND POLICY IMPLICATIONS: Ashland Municipal Code (AMC) Chapter 6.40.110 requires ambulance service providers operating within the City of Ashland to apply annually for an ambulance operator's license. The Fire Department has provided emergency services in Ashland since 1885. From 1926 to 1936, the fire department operated the ambulance service in Ashland, and in 1936 the ambulance service was sold to Litwiller Funeral Home. The fire department obtained its first medical response vehicle (Rescue 9) through community donations in 1973, and began providing first response emergency medical services to the community. In January 1996, the City of Ashland purchased the Ashland Life Support Ambulance Company and Ashland Fire & Rescue began providing ambulance services within a 650 sq mile ambulance service area in south Jackson County, known as ASA III. Ambulance services in Oregon are regulated by county governments, and within the City of Ashland they are required to obtain an ambulance operator's license. This license is renewed on an annual basis. FISCAL IMPLICATIONS: The license fee is $300 plus $100 per ambulance, for a total of $800. This is provided for by a line item in the department's emergency medical services budget (604160). STAFF RECOMMENDATION AND REQUESTED ACTION: Staff recommends renewal of the Ambulance Operator's License for Ashland Fire & Rescue. SUGGESTED MOTION: I move approval of the application for an Ambulance Operator's License for Ashland Fire & Rescue. ATTACHMENTS: Ambulance license renewal application. Page I of 1