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Home My WebLink Aboutbocc.con.068.2008CONTRACT #,~f $--0 S LICENSE AGREEMENT NO. 0~-2008 PITKIN COUNTY AMBULANCE LICENSE FOR: MEDIC 6 (MOUNTAIN AMBULANCE) GRANT OF LICENSE/PERMIT The undersigned, representing the Boazd of County Commissioners of Pitkin County, Colorado, does hereby grant a license to the above-named applicant to provide ambulance service within Pitkin County. This license shall have upon it any restrictions listed below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the Boazd pursuant to the provisions of Title Six (Health and Safety-Ambulance Licensing) of the Pitkin County Code and any other applicable County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, C.R.C. RESTRICTIONS/CONDITIONS: Basic Life Support License. WAIVERS GRANTED: Not applicable. THIS LICENSE IS VALID FROM: January 1, 2008 through December 31, 2008. APPROVED BY THE PITHIN COUNTY BOARD OF COUNTY COMMISSIONERS MICHAEL M. OWSLEY, Chair Pitkin County Boazd of County Commissioners P/TK/N COUNTY Application for Ambulance Permit Service Information Service Name ~,sr~ e1 ~lY~3LVa,yc~_ d7lim.er Street/r.0. 910) J City (`1-1°~ State zip Communication gyy _ Isg o sti~t- 157 8 Voice Fax E-Nail Vehicle Information Cgl.o-C5'.1~. Radio Call Sign M ~.c. io License Plate (te...l _ g ~.~ VIN ~ t;,T~e 3'-~ t= l r E Zc. l~. zee 4X4 Yes (~ No ( ) CHeyl ~ Year ~ ~ b Make l~l e ,r lv'x t uF,ra Type ~G~_81~1( Where will Vehicle be Stationed , ~l~~~ GlJorat~. o~~ cnc ~sf ~- ie R.r~ ~sq~l~ C 8t e l l Waiver Request (Include Reason for Request) Service Director's Name Signa[nre (Ambulance Inspector lase Only) Valid Insurance Card Yes (xl No ( ) Valid Registration Card Yes (~ No ( ) Inspection Fee $50.00 9Q Mechanical Condition Certificate Attached (~ Required BLS Equipment List Attached ~" Required ALS Equipment List Attached (~ Pass Inspection Fail ()Reason for Failure Date y 1 Z-~ ~~ Pi tkin County Required Basic Life Support Equipment List Inspector ~,c, DNS -.-.1 Vehicle Radio Call Sign Pn~~c, is Date 2. Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. l~ Bulb syringe. House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2-patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1-15 L.P.M. ~(/~ Portable oxygen system with a minimum storage capacity of 15 c.f. (D cylinder) and a minimum delivery capability for 1-patient at flows of a least 1-15 L.P.M. ~' Transparent, non-rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag-valve mask resuscitators with oxygen reservoirs and standard 15mm / 21mm fittings in the following sizes; ,(/) SOOcc bag with transparent masks for infant and neonate. /(i}' 750cc bag with transpazent masks for children. ~ I OOOcc bag with transparent masks for adult. r(lJ. Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. ,(/} Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment ~:(.~~ Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. k)' Stethoscope in adult and pediatric sizes. ~.) Penlight. ( ~, Pulse oximeter with adult and pediatric sensors. 2 Splinting Equipment ~() Lower extremity traction splint. ~-) Upper and lower extremity splints. r() Long board with equipment to immobilize the patient from head to heels. } Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize ~~. The patient from head to heels. ,(~')- Short board or equivalent, with the ability to immobilize the patient from head to pelvis. ,(') Pediatric immobilization device or adult immobilization device that can be Adapted for pediatric use. .~() Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials (') Bandages -various types and sizes per agency needs and Physician Advisor protocol. ,F-}~ Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (. r Sterile burn sheets. ~~ (/S Alcohol swabs or equivalent. ~( ~) Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (,. Y Sterile irrigation solution. Obstetrical Supplies ~ij Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. ~/) Neonate stocking cap or equivalent. Miscellaneous Equipment /(-)- Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. () Two working flashlights. y) Blankets and appropriate heat source for the ambulance patient compartment. () Ambulance Service Medical Treatment Protocols. ~(~-} Oral glucose. Activated charcoal. ,F") )~ Spill proof emesis container. Xf Universal and/or separate male /female urinals. ,(~f Stair Chair Communications Equipment () All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two-way communications that will enable the ambulance personnel to communicate with: (-'J ambulance service's dispatch k~~ medical control facility or a physician (~ )' receiving facilities '() mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; ,(-) Non-sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. ,() Protective eyewear. () Non-sterile surgical masks. ~ () Fluid proof gowns with full-length sleeves or equivalent. () Disinfectant spray or wipes for personnel and equipment. () Sharps containers for the appropriate disposal and storage of medical waste and biohazards. .,_( ) ~ Particulate respirator, N95 type or better. Safety Equipment .(~') A set of three (3) warning reflectors. ,(~) One (1) ten pound (10 IbJ or two (2) f ve pound (5 lb.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous yeaz per NFPA 10 section 4. .~) Child safety seat or equivalent ~(~-~ Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. .() Properly secured patient transport system (i.e. wheeled stretcher). ~.-)" Triage tags as approved by the Colorado Department of Public Health and Environment. () ~ Restraining devices for all items not in a securable cabinet. J(. } Two "NO SMOKING-OXYGEN IN USE" signs, one in cab, one in patient compartment. )' Reflective vests, coat or equivalent for each member of the crew normally assigned. i ~. i ~tre~ ._~ __._- i;,,,,ln\_'l --- ---1~- - --.-._... ~ .1 --- --~s_~Lk~~"ELF" ~5/l~/jf '~ I:;11;,1 'Ili Iit_ ~.~ " %L3I '• ( 1 I ., ,, (_: tiu _.__.._., .-_ _.._1 -..._. ~~ f ._ -__ --.____. -.._.-_____ ~" ' / l/ C~ oCv ~~ .tm:cla~l \ .h ;,, ` t:n!, t„ _ ier. c.f ahu ~, ilr \ . ~c..u.Itcd t~,~ , t,r~.rl a r. ail ~ •.IC,~', u, '_•. i rtl~~ ii u ~ ~~~; n ] ~o r r,_ ul~:,ion. / ~~ ~~~nf K L;7U n~ . _. , ~, t.:r__ .......... ..... .~__ _.__ _ I I r ,.. .... ~ .. ., . ~. .. r.'.i. \:ICi~,a.U `: :.. :I alUI~i.S'Cf .1i .,.^?).. li'I C:i _...: Ll. CJll it i', :, r~_<n pfli~ l'tlc i.... :i!'~. it J711liii(.