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Home My WebLink About2011-112 License - Ambulance Operators 0 "- -. c: ~ () ~ CD 0 )> ::J l/l ..... 3 CD )> ~ CD t/l C" ::T :T s::: Dl rl/l - - l>> Q) 0'3 ;j .::::J P CD CD Q. (") ::J...... l/l Dl "T1 c: CD CJl("l CD= () -. CD ,. 0 CD ..., .., :t~ >< CD en ::J '0.0 l/l "'C -. c l>> CD CD r-< ..., -. CD <D ;j l/l .., ~O ~3 Q. l/l Q) C C CD CD - ::J ::J :;0 0.. 0 Z." CD...... en ...... .., .l/l Wo t/l ~ - 0 0_ C") en ~~ c: r en -. ~O (") NO C CD ::T en ::::J Dl '0 en '0 l>> ...... CD CD ~ ..., 0> 3 (') .j>. en ~ 0 ;j - ::0 C1l C') 0 a. C1l ~ ..., C1l Dl C/l c. ..., C1l ..., CITY OF ASHLAND APPLICATION FOR AMBULANCE OPERATOR LICENSE AMC Ch. 6. 6.40 2011 Applicant's Name: CITY OF ASHLAND Trade Name, if any: ASHLAND FIRE & RESCUE Address: 455 Siskiyou Boulevard Ashland OR 97520 Teleohone number: (541) 482-2770 Ambulance descriDtions Manufacturer Vin# License # 1. 1992 FORD LIFELINE 1 FDKE30M7PHA05945 EXEMPT 2. 1998 FORD LIFELINE 1 FDXE40F2XHA00469 EXEMPT 3. 1996 FORD LIFELINE 1FDKE30F8THA48282 EXEMPT 4. 2002 FORD LIFELINE 1FDXF47F63EA10341 EXEMPT 5. 2006 FORD LIFELINE 1 FDXF47P06ED06467 EXEMPT 6. 2008 FORD LIFELINE 1 FDXF47R48ED90832 EXEMPT o 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. o Enclose with the application, the initial license fee of $300 plus $100 per ambulance. o Enclose a performance bond in the amount of $500,000. o Enclose an insurance policy meeting the requirements of AMC 36.40.110.7. 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. I 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. /7'?? /~ Signature: ~~ Print name: Greg I. Case Title: Division Chief Date: 04-19-2011 H:\Ambulance IiclCity Licensing\2011lic.app\2011 lic renewal.doc April 1 O. 2009 CITY OF ASHLAND APPLICATION FOR AMBULANCE OPERATOR LICENSE 2011 First Level Last Name Name MI EmDI Stat 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 ..----, ACORD'" CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIODNYVY) ~ 7/28/2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BElWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDI110NAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, SUbject to the terms and conditions of the policy. certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsementt~l. PRODUCER ~~~Cl Sandy Orr Beecher Carlson Xnsurance Agency LLC I~~g~.._. (541)7721111 I r~~ N~: (541)772-3785 707 Murphy lid I~~~~ss.sandy.orr@beechercarlson.com ~ng,.o::!~~~ 10 ..00006545 Medford OR 97504 INSURER(S) AFFORDING COVERAGE NAIC. INSURED INSURER A New York Marine & Gen :Ins CO INSURER B : city Of Ashland INSURER C : 20 E Main st INSURER 0 : INSURER E : Ashland OR 97520 INSURERF: COVERAGES CERTIFICATE NUMBER.2010-11 REVISION NUMBER. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELO/J HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N01WlTHSTANDlNG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT.TO 'M-lICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AlllHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE I ;!;[lUCY EFF- ~~~~~\ LIMITS LrR POLICY Nl..JolBER MM/OONYYV ~NERAL LIABILITY ~RRENCE $ - ~MERCIAL. GENERAJ.. lIABILITY PREM Ea OCCLIrr& $ - CLAIMSMADE D OCCUR MED EXP (Anyone person) $ PERSONAl.. & ADV INJJRY $ GENERAL AGGREGATE $ ~.~ AGG~EnEILMIT APnS, PER: . PRODUCTS - COMPIOP AGG $ POLICY P.B9.; LOC $ ~UTOMOBILE LIABILITY COMB~ED S~GLE LIMIT $ (Eaaccidert) - f>NYNJTO BODILY NJURY (Per person) $ - ALL OWNED AUTOS BODILY INJURY (Per accident) $ - SCHEDULED NJTOS PROPERTY DAMAGE HIREDALlTOS (Per accident) $ - - NON-O'N>lED AUTOS $ $ - UMBRELLA LIAS H OCCUR EACH OCaJRRENCE $ EXCESS LIAB ClAIM5-M.ADE AGGREGATE $ - DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION I!:x:cess Workers X IT~~Tf;W-<:: I IOJ.!t AND EMPLOYERS' LIABILITY Y I N Compensation 000 ANi PROPRIETORIPAATNERIEXEOJTIVE 0 EL EACH ACCIDENT $ 1 000 OI=I=ICERlMEMBER EXCLLDED? N/A /1/2010 /1/2011 (Mandatory In NH) MWlOO281 EL DISEASE - EA EMPLOYE $ 1 000 000 If yes. describe under 1 000 000 DESCRIPTION OF OPERATIONS b9low E.L. DISEASE - POLICY lMIT $ Dedudible-COde7539 $650,000 Deductible-All other $450,000 DESCRIPTION OF OPERA TlONS I LOCATlONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Contract for re-assignment of ASA *3 to Ashland Fire and Rescue. CERTIFICATE HOLDER CANCELLATION bergmapl@jacksoncounty.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOnCE WILL BE DELIVERED IN Jackson county ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Penny Bergman 1005 E Main street AUTHORIZED REPRESENTATIVE Medford, OR 97504 Sandy Orr/SANDOR 0a-rJdJuLO<. D.v.- ACORD 25 (2009/09) INSD25 (200909) @1988-2009ACORDCORPORATION. All ,ights rsssrved. The ACORD name and logo are registered marks of ACORD OREGON DEPARTMENT OF HUMAN SERVICES ... . . . PUBLIC HEALTH DIVISION. ... .. ......... .. EMERGENCY MEDICAL SERVICES & TRAUMA SYSTEMS PROGi}AM .... AGENCY NUM8ER: 1501 ;""' . ,'- .\ , '. . . . .". '. "', . AMBOLANCEAGENCY LICENSE -I'OSTIN AGENCY.. ";:- \','. -.-':. .--,- ..... .. <0412912010 .", ,:,:~'~'~:'.i.:' ," . ". . City of Ashland #1501 455 Siskiyou Blvd Ashland. OR 97520 MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERRABLE AUDIT NO. .~,::-i'f;'!:(.7f,!nt~ . 25596.' OPERATION DATES MO. DAY YR. THRU MO. DAY YR. 06/30/2011 PAYMeNT OA~ MO. DAY YR..~ " . 04/29/2010 OREGON DEPARTMENT OF HUMAN SERVICES EMERGENCY MEDICAL SERVICES & TRAUMA SYSTEM CERTlFlCAnQN NUMBER; E233465 AMBULANCE TYPE: 2006 .' .... . . . . . .. . . . . . '. .' . '.' . .' .', . . . . . . .. . .' ,.. . . .., . '. ... AMBULANCE LICENSE"'; POSTlN VEHICLE, ,.-.-.-.----.--.-.-.-.-.-.-.-.-.-.-.-.--.--.--.-.-.--._._._._.__._-_._'-~._._j Ii.... : City of Ashland #1501 j: i 455 Siskiyou Blvd i : Ashland OR 97520 I. I .i r .1 ;..~._._._._._._._._._._._._._._.__._._._._.__._.__._._._._._._._._.________._._._._._..1 . -.;.:' MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERRABLE OREGON DEPARTMENT OF HUMAN SERVICES" EMERGENCY MEDICAL SERVICES & TRAUMA SYSTEM ...... CERTIFicATION NUMBER; E244368 AMBULANCE TYPE: 2008 FORD "-' '-. . "" I, ":.:. . .': . . ,. ,. AMBULANCE L.iCENSE"'; POST IN VI:HICLE .... . . ~--_._._._._._.__._._-_.__._.__._.__.__._-_._._----_.-------..." i i i i." r City of Ashland #1501i i i i 455 Siskiyou Blvd ; i i : Ashland OR 97520 j . i i L_.__._._._.___._.__._._._._._._.__.__._._.__.__._._.__._._._._.__._._._.__._._J . ':. .. MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERRABLE OREGON DEPARTMENT OF HUMAN SERVICES EMERGENCY MEDICAL SERVICES & TRAUMA SYSTEM CERnF~AllONNUMB~ E222273 AMBUlANCE TYPE: 2002 Ford . . .. ".. . .... . ". . ". ,. '. '. . . . ,- ",. .".. '. ", ',' . "-"."". -', . ". . . . '"." ,. ,"" . . .. AMBULANCE L.ICENSE ~ POST IN VEHiCL.E ...... ... ... r---.----.-~~t:-:f-::~I:~~-:~:~~-----._----------'---l.' : 455 Siskiyou Blvd : ! Ashland OR 975201 l._._._._._.__._.__._._._._.___ .-.-.-.-.--.-.--.-.-.-...,.-.-.-.-.-.-.-.---.--.-.-.-.-,-'~l' '. . '." , ~ MII~T RF POl=:TFn IN A r:ONl=:PIr:l JOII!=; PI Ar.F - NOT TRAN~FFRRARLE S'83 ( AUDIT NO. .. 25604 . ! 80.00 .. . ., .- .:', PAYMENTAECEIVEO EXPIRATION D.... MO. DAY YR. .. 06/30/2011 ADMINISTRATOR STATE HEAlTH QIVlSION ':.' ft:? 3?- AUDIT NO. . . ~ 25608 .. 80.00 .. .' '.' . .... PAYMENTREcENEiJ.... . EXPIRATION ;. . DA'" MO. DAY YR. 06/30/2011 ADMINISTRATOR ',':,STATEHEALTHDIVISION.:'. . 9'833 AUDIT NO. . .., '1i;j 25603... .. 80.00 ~AvMeNTRECE~"" :. EXPIAA TION .' . . D.... MO. DAY YR. . 06/30/2011 ADMINiSTRATOR STATE HEALTH DMSION",' . ..... , OREGON DEPARTMENT OF HUMAN SERVICES. EMERGENCY MEDICAL SERVICES & TRAUMA SYSTEM CERTIFICATION NUMBER: E198560 AMBUlANCE TYPE: 1996 Ford . . . . . '" '.... . -..- '-. " . . .. AMBULANCE LICENSE - POST IN VEHICLE. .. . . r-.--.-.----.--.-.--.-.-.---.--.--.-.--.-.-.-.-.-.----'--'.'-':'-'-'-i i i . i City of Ashland #1501 ;. I f , 455 Siskiyou Blvd i j i i Ashland OR 97520 i i i i I L__.__....._._........._.___...____.____.__.__..........._..._._...__.__J : -'," . . . "'. .... -' MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERRABLE OREGON DEPARTMENT OF. HUMAN SERVICES. EMERGENCY MEDICAL SERVICES & TRAU~ SVEjTEM ... .. . CEATlFICATlON NUMBER: E211465 AMBULANCE TYPE: 1998 Ford "." . -"" , . . , '. .' . " " . . , . . AMBULAl-JCE LICENSE ~ POST IN VEHicLE i ~._._._._._._._._._._._._-_.__._._._._._._._._._._._.-._.__._.__.__.__._-_._~_._._...:;, , , ! L . : City of Ashland #1501 I i 455 Siskiyou Blvd i I Ashland OR 97520 I:. . i i j f. L_......._....._._._._..._..._._._.__._._._..._..._.__..._._._._.____...__._...___....j. ", - '" .-- -- ~""'''''''''r:.... '... ^ r-rU..l5::PIr.IIOUS PLACE - NOT TRANSFERRABLE OREGON DEPARTMENT OF+'/UMAWSERVICES EMERGENCY MEDICAL SERVICES & TRAUMA SYSTEM CERTIFICATION NUMBER: E186951 AMBulANCE TYPE: 1992 Ford . .. . ..... ..: . -.-.. . .., . ....... .: ..., .':. ..:: . .......... .; .... .': .:'. ... ':,. .. . .. . ... ..:.. ..:. .. ... .. r--_~P!'_E!.I!~NC.!=_~ICE~~~~ POST IN VEHicLE.. . . J --.-.--.--.-----.---..;.:,-~ i j j City of Ashland #1501 I ... j 455 Siskiyou Blvd i I i i Ashland OR 97520 i j j.: j i . --- -.-- - - -.--- --. I. - - - - - - - -- ..---.--- -- --.- --.- -_._-----~ . ... ...: .'..., .., ... -. .,- . . ..: ... '...' _:_' __,' ._c, _ " MUST BE POSTED IN A CONSPICUOUS PLACE _ NOT TRAN~FER~BlE 'ffSJ'-( AUOIT NO, . 25586.. 80.00 F'A'fMENTRECEIVEo .: : EXPIRATION' : .. DATE MO. DAY YR. .. 06/30/2011 ADMINISTRATOR STATE HEALTK DIVISION,.: . .... >. 'i?fJ~ AUDIT NO. 25602. .... . . 80.00 ... - ' . . PAYMENT RECEIVED -; EXPIRATION . DATE , .MO. ,DAY YR. 06/30/2011 ADMINISTRATOR STATE HEALTH DIVISION . ,. l?1l3~ AUDIT NO. 25584. .80.00 . . PAYMENTRECsVeo .. : ;. EXPlRA1lOH ..,. ,. DATE . 1l0~ bAY YR. .. 06/30/2011 . . . ..- . .... .... .... ADMINISTRATOR .: STATE HEALTH DMS100 . ASHLAND FIRE DEPARTMENT, PAUL S MD ROSTYKUS, PAUL S MD 455 SISKIYOU BLVD ASHLAND, OR 97520-0000-000 1'.'"'."""1",'..11"",1.""""1",,1,,,,1,,,,,."II",' DEA REGISTRATION TlilS REGISTRATION FEE I CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE NUMBER EXPIRES PAID I UNITED STATES DEPARTMENT OF JUSTICE I BA3050692 06:30:2012 FEE EXEMPT I I DRUG ENFORCEMENT ADMINISTRATION I WASHINGTON D.C. 20537 SCHEDULES BUSINESS ACTIVITY .. ISSUE DATE I This registration is only for use at Federal or Slale institutions. I 12,2N, PRACTITIONER 05-11-20091 I " I 3,3N,4,5, I ASHLAND FIRE DEPARTMENT, PAUL S MD I Sections 304 and 1008 (21 use 824 and gS8) of the ConlJolled ROSTYKUS., PAUL S MD ;: I Substances Act of 1970, as amended, provide thai the Attorney I General may revoke or suspend a registration 10 manufacture, 455 SISKIYOU BLVD . distribute, dispense, Import or export a controlled substance. -' I ASHLAND, OR. 97.520-0000 ,$- ". 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. -----------------------------------------------------------------------. -.- 00 -- _.~_. .. 00.. CONTROllEO SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE " , , ., - DRUG ENFORCEMENT ADMINISTRATION ',. WASHINGTON O.C. 20537 .'. >', " DEA REGISTRATION THIS REGISTRATION FEE ' "or. , NUMBER EXPIRES PAlO I BA3050692 06-30-2012 FEE EXEMPT I Thi5'registration is only .. for use at Federal or " -. Stale institutions, SCHEOULES BUSINESS ACTNITY ISSUE DATE 12'2N, PRACTITIONER 05-11-2009/ " 3,3N,4,5, F:' ASHLAND FIRE DEPARTMENT, PAUL S MD Sections 304 and 1008 (21 USC 824 and 958) of Ihe '" :!. ROSTYKUS, PAUL S MD Controlled S~bstances A~ of 1970, as ~mended, '" iii 455 SISKIYOU BLVD provide that thE! Atlorney -General may revoke or ASHLAND, OR 97520-0000 suspend a registration. to manufacture. distribute, ili dispense, import or export a controlled substance. 0 E THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROl,lOCATION, OR BUSINESS ACTIVITY, I 0 "- AND IT IS NOT VALID AFTER THE EXPIRATION DATE. CITY OF ASHLAND Memo DATE: 4-19-2011 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 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 has sent the Memo to Martha 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 Fire & Rescue 455 S~kiyou B~d. Ashland, Oregon 97520 VN/rN.ashland.or.us Tel: 541-462-2770 Fax: 541-466-5316 TTY: 600-735-2900 r.l'