HomeMy WebLinkAboutbocc.con.117.2007APPROVED BY BOCC
ON ~P - Z~ --D V7
LICENSE AGREEMENT NO. i/ 7 -2007
PITKIN COUNTY AMBULANCE LICENSE FOR:
ASPEN AMBULANCE DISTRICT
MEDIC 1
GRANT OF LICENSE/PERMIT
The undersigned, representing the Board 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 Board 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.S.
RESTRICTIONS/CONDITIONS: Not Applicable
WAIVERS GRANTED: Not Applicable
THTS LICENSE IS VALID FROM: June 27, 2007 through December 31, 2007.
APPROVED BY THE PITKIN COUNTY BOARD OF COUNTY
COMMISSIONERS
MICHAEL M. OWSLEY,
Pitkin County Board of County Commissioners
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1
PITKIN COUNTY
\
APPLICATION
FOR
AMBULANCE SI;RVfCE'1-ICENSE
GENERAL INFORMATION
Ambulance Service Name:---,-A.s!)~ ~M~vlA.N.Cg.,_ t:D\\~W1t"
Doing Business As.: (~ ,,\~,,,, .Ih"'"'-,t>..........( ?\nUMCe-."\l"'t>
Office Address:~.,; P\-;'IH~\..J ,Q,\\~ ~:s p'1"1\L n ,+.01 (R.~("'. CA~ Ill)
STREETIP9110X '-J CrIi' ' STATE
\'qo) , ('='11-)',
Office Communications: S4~- l -"'i'-.<:> $l{'i-\-s'1 e
VOICE FAX' E.MAIL
~~,,~ c... f>,1t_1 \ '
ZIP' CODE '
INTERNET
SERVICE INFORMATION
Service Area: A.~\,-.\ N\i\....,.l,,"""E-.. U. ~n.W'" ^"",,'ll"'A....~ervice Director: R\e~l\r.l..o, l.JALlL"t--' '
Service Type: PUBLlCL PRlVATE_ BLS_ ALSX EMERGENT-X.. TRANSFER-X- SPECIALEVENTS~
Number of Ambulances Licensed: \ (\'1\ E~"',. ,\ ')
PHYSICIAN ADVISOR INFORMATION
n\ysician Advisor Name: ,1~ CWA.,s ~'A.~"~"1 ",' ""
.. t-1om...' ~-\(~ '? ~ ''i' ?~"Q c. lrtl'''''S~
,,' " V~"\I~~ -tr{ 2..001 '
Office Address: q~ 1lI.'S~~'\~ l\.n~r ._\
STRE /PO BOX
,", .. ('\'1,p)
Ice CommUll1catIons: 'S4 '1 - \ ~ \,-\
VOICE
~ 01 \....~TI~r"\?
CrIi'
C. ,,\,0)
<54~ ' 5"'0 (::)
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" . ' Colorado License Nuinber; ~o c; 'l ~
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STATE J ZIP CODE
FAX
E.MAlL
INTERNET
I hereby certify tbat tbe information provided in tbls application Is true to tbe best of my knbwledge and belief aDd
contains no willful misrepresentation or falsification. Determination tbat an Ambulance Service License bas beeD Issued based
on false information constitutes grounds for license revocation, suspenso of operations and possible criminal pr secut D.
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SE~ICE DIRECTOR SIGNATURE
"ll fJ I '" ]
ATE'
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Date Received: J~. \ 8,2.<:)01 Ambulance Permits Attached:-.!..C..,("" ~...,,<:... 11
EMS Council Comments: l' p.~~ ~ Snrl\C- C ~F~ M",-"..~L \'IL\\ll"t\ p>cv.jov.>.1<P"l-I<..I.\
. . (}\> 101__ \:} 2...0 0 i..i .
EMS Council Recommendation:_1>po.~, _ ~\(....,.,. ~'l" 1'0"-"'<"",, 3"\1,.... 'l..." ~")\. ~~1.,> 1..001
(FOR EMS COUNCIr: USE ()NL Y)
J::MS Council Chairperson Signature:
) .
Date Referred to BoCC:
?
/
C( / LJA/-< "" )
NAME
G./Ie.ja1
. DATE
BoCC Action:
Date:
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PITKIN COUNTY
M.l:-\)IC I
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.
APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
SERVICE INFORMATION
Ambulance Service Name: ~ <;;~......\ A.'Y\(',>J l...",c~ ~')'P'l"'q-
Office Address: 0/", r-o..~""'\ J!'>.-\,~ +k>s:,.~L o'talt.A.SPo=- en - < to
. ..' STREET ~;...) --J ('11"') CrIi' . STATE
OfficeCommumcatlons: ~4-l<;"&O ~'-t 15tSl..
VOICE FAX E.MAlL
~f ~' ('~ p. 11~\1
ZIP'CODE
INTERNET
~HICLE INFORMATION ro. .
~,","",,-c:. I , , '-o~. \Il!M1". MoL..
Designation: Mc:.c:..1M I ".~License Plate: ;t~rl,'Gl.(t.9'VlN: i t:::bt...l F :1" ? 'lJl E: \7, I 'C\ 5"
. I '\ 'S''\ 5' <0 -, C ----'-+'
Chassis Year: iool Make: f':orL-O F J'S'o Type:IjL II_ III_ 4x4:yesx... no_
, ' ~',l"\l\..rl"","",~\",,,,,- . . J I
Insurance Company: ~s.. (''1 Policy Number: c:..l'oc" '?, <> l z.. ~ 1 Expiration: 0 \ "'1 .os.
Vehicle Location: : ~""il."IA"'U5. -r\l","'.-:k t \).... a..,
STREET/PO BOX
tA- S. \,,"1. aC.
CrIi'
CJn.. "ff'-r-t..L
~ - 1+-.>0 p,-' G:. ~11o II
.
STATE r ZIP CODE
'" :EOUEST FOR WAIVER (include reason for request)
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~-... -, C)./
SERVICE Dl OR'S SIGNATURE
fA J....".~
JUN. /8 2~'97
DAtE
(FOR AMBULANCE INSPECfOR'S USE ONLY)
Clear CCIC: ~ Ill; Clear NCIC: 101)...- Insurance Card Present: ~. Registration Card Present: 'fe..--..f '
i Permit'Fee Attached
~ Basic Life Support Required Equipment List Attached
--t- Mechanical Condition Certification Attached
L Advance Life Support Provider Required Equipment Certification Attached
CommentslRecornmendation: )<I L ~ CoMf1~
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Mfi,LClXYd l~ atw-- 6w F PO
POSITION
G~ 1'C'-D7
DATE
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INSPECTOR 'S SIGNATURE
PITKIN COUNTY
,
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ADVANCED LIFE SUPPO!tT PROVIDER
REQUIRED EQUIPMENT CERTIFICATION
, ,
Ambulance Service Name: A. ~ 'f' .......1 ~N\>'>v IA-.I...... .f\' ,~n<u. ccr Arnbulan.:e Designation: N'\~\ c... \
REOlJIRF:D ALS EOUIPMENT
I. All equipment and supplies 'listed on the Basic Life Support Required Equipment List.
2. Pediatric diagnostic equipment, age/weight/vital signS chart and drug dosage/equipment size list.
~ A.dult, pediatric and neo-natal vascular access supplies arid equipment as authorized in medical protocols
approved for this ambulance service.
4. Adult, pediatric and neo-natal endotraCheal intubation equipment 'as authorized in medical protocols
approved for this ambulance seivice. '
5. Cardiac monitor/defibrillator with printer and adult and .pediatric monitoring and defibrillating capabilities
as authorized in medical protocols approved for this ambulance'service.
, '
~. Pharmacological agents and admini~tration equipmeriian4 supplies as authorized in m~dical protocols
) approved for this ambulance service. , : ", " ' , ' '
" , /"'" '. " l' ,. ' ,
7. Any additional equipment and supplies needed to 'perf~-othei pro~edures as authorized in medical ,
protocols approved fOT this ambulance service.
As Physician Advisor for A.., f ~ I\""~" ,^oJ c ~. D . s.... , < \" ' I certify that this ambulance
carries the equipment and supplies, listed above and meets the'minimum requirements, established by the State
of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the
Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6,
Section 4 "Medical Acts Allowed EMTs and Paramedics."
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COLORADO MEDICAL UCENSE NUMBER
L.'l~
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PITKIN COUNTY
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
S~ EQUIPMENT .'
One 2-1/2 lb. or larger ABC fire extln2Ulsher, accessible from the patient compartment and havmg been
. /serviced within the last year per NFPA 10 Section 4: .' .
V One 5 Ii,: or larger ABC fire extinguisher, accessible from outside the vehicle and having b~n serviced
/ within the last year per NFP A 10 Section 4.. :
V. Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment.
~/flash1ight, 2-D cell equivalent or better with spare bulb and batteries or charger.
\ ,set on reflective warning devices. ,
. V j)ne reflective vest, coat or equivalent for each member of the crew normally,assigned.
, V At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment.
. VRestraining devices for all items not in a securable cabinet ' "
0)
E~RGENcY W A RNTNG F.OlJIPMRNT
, ::::.- f.udible warnIng deVIce (sIren) WIth at least 2 different tones. .
VVisual warning' devices (lights) with alternating red andlor blue flashing or rotatiDg visible from all sides
simultaneously and clear flashing or oscillating visible from front.
~UNICA nONS EOUIPMENT . . , ,
. Mobile VHF radio with appropriate State, Pitkin County andiildividual agency frequencies.
Mobile UHF radio with appropriate State, Pitkin County, 'hospital and individual agency frequen~ies. 0
". 'c/ Portable radio with charger and/or cellular phone for baci~hp communications with dispatch lind
hospitals.
tlEDlCAL EOUIPMENT AND SlTPPLlF.S
Ai~:
V Fixed suction system with wide bore tubing, rigid pharyngeal cUIVed suction tip and soft catheter Suction
/tip with sizes from 5 Fr. to 14 Fr. 0
V Portable suction system with wide bore tubing, rigid pharyngeal cUIVed suction tip and soft catheter
~uction tip with sizes from 5 Fr. to 14 Fr.
/ Bulb Syringe.
~.NasoPharyngeal airways in pediatric and adult sizes.
Oropharyngeal airways in pediatric and adult sizes.
~ Bite stick or equivalent (oropharyngeal airway).
Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum
Jelivery capability for three patients simultaneously at flows of at least 1-15 LPM.
~Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum
/ delivery capability for one patient at flows ofal least 1-15 LPM.
Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks.
\/' Adult Bag; Valve-Mask with 1000cc bag, reservoir and adult mask.
~ . .. All mask attaclunents must be 15mm..
Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15
LPM. '.
1
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PITKIN COUNTY
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BASIC.LlFE SUPPORT
, REQUIRED EQuiPMENT LIST
MEDICAL EOUIPMENT AND SUPPLIES
Diagng,stic: . ',' ,
~lood pressure cuffs in large adult, regular adult, child;, infant arid neonatal sizes.
--;:::/" ztethoscopes in adult and pediatric sizes. ' ,
-V Pulse oximeter with adult and pediatric sensors. "
Immjl.b'iIization & ,Splinting:' "
~ne lowef extremity traction splint. "
~ Ypper and lo;"'er extremity splints of any type (vacuum, air, SAM, wire, board, etc.). ,
~Long spine board, vacuum mattress or equivalent with'appropriate accessories to immobilize patients
from head to heels.' . , ,
V' One orthopedic stretcher (scoop). ',' ' , ,
?hO~ s?ine~oard, KED or equi~alent with appropriate ~~ps .to immobilize patients from h~ to pelvis.
~edlatnc spmeboard or adult spmeboard adaptable to, pedlatnc use. , .
V Adult and pediatric sized head immobilization equipment fOf'each long spineboard and/or scoop stretcher'
V"~~~~Cal immobilization collars in ~l adult ihrough inf~t sizes.
Wound~arc: , " , ' '
~Bandages, including b~t not limited to, roll~r gaUlfe, ,triangular' and elastic per agency needs; ,
'~fe~SingS, including but not limited to, trauma, ABJ?,'g~uze; occlusive and bandaids per agency needs.
.' ~ .$tenle bum sheets. ' " '" " , , ,
~P.9vidone and alcohol swabs or equivalent:': ' , ..::, :..: ",:1"
~.Jlhesive tape, including but not limited to, 1'" arid ~;, Per agency needs.
-.0terile irrigation solution. , : ' ,
,~al Supplies: : "
Sterile OB kit to include: towels, 4x4s, umbilical tape Or confclamps, scissors, bulb syringe, sterile
~anket and sterile gloves.
Silver Swaddler and stocking cap or equival'ents.
Infectism Control:' " '
v,Exam gloves in small. medium and large sizes.' ,
~ ~ce and eye shields. .
VYluid-proof gowns with full length sleeves or eqUivalent.
V Disinfectant spray or wipes for personnel and equipment.
,Mi~lIaneous:
Oral glucose.
~ ~tivated charcoal. . ,
V,Aleavy duty bandage scissors or shears capable of cuning clothing, belts, boots, etc.
~UilI'Pfoof emesis container with at least I liter capacity.
\::?" u~iversal or separate male and female urinals.
~).1ulti-level.wheeled gurney
) V Stair chair or equivalent. .
~lankets.
7 Patient compartment heater.
j...:..
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PITKIN COUNTY
"-
.oJ
VEHICLE SAFETY AND OPERABILITY
CERTIFICATION
Ambulance Service Name:~sc~ I\~\....r...
cD' ':>~K.\
_ ~,~i''7
CiD I ~I
q.s; '1S.. '7 0
License Plate; , Ambulance Number: {'(\~, c... \
SYSTEMS I ACCEPTABLE NOT ACCEPTABLE COMMENTS
Wheels & Tires J ,
eering , ,
,
Alignment ,
Suspension
Service Brakes T
Parking Brake \ I
Driving Lights
Visual Warriing Systems
Audible Warning Systems
131ectrical System
. ~xhaust System X
'Fuel System V ,'I, ' .
,
Glass, Mirrors
, Body & Sheet Metal "
/
I, rZJl P {' ,}-, n Ct..- 'lit ~( , professing to be a motor vehicle mechanic with training in all of the ,
systems'listed above, have evaluated the condition of these systems on the ambulance iitdicated above and have
determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future
safety and/or operability of this ambulance due to conditions beyond my control.
d'J 7A '
MECHANIC'S NAME
ql()-
PHONE NUMBER
6-
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