HomeMy WebLinkAboutbocc.con.118.2007APPROVED BY EOCC
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LICENSE AGREEMENT NO. /r ~ -2007
PITHIN COUNTY AMBULANCE LICENSE FOR:
AMERICAN MEDICAL RESPONSE
MEDIC 145
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 Iicense 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
THIS LICENSE IS VALID FROM; June 27, 2007 through December 31, 2007.
APPROVED BY THE PITKIN COUNTY BOARD OF COUNTY
COMMISSIONERS
,~ ~.
MICHAEL M. OWSLEY, Chair
Pitkin County Board of County Commissioners
PITKIN COUNTY
~
APPLICATION
FOR
AMBULANCE SERVICE LICENSE
GENERAL INFORMATION
Ambulance Service Name: E V'<\S C
Doing Business As: A'('('o,'?f'\'-~ me~,(C",-\ ~rc::;)C'>~<..@
Office Address: ~~O \t,rb"''6.wo......\ \)e~~ <f'
STREETIPO BOX ).. CITY
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Office Communications:2e?r 3 5~ -1.(X)Q 3m 'Z. 9'3 -0"15
VOICE FAX
C.O
STATE
B,o'Z.\("
ZIP CODE
DAJ"'. <5?o..<.Y..""U")/Cl) Q,,,,,~ . ",e\
E-MAIL INTERNET
SERVICE INFORMATION
Service Area: Ib... \u e.J' Service Director~J.. C. \~ \E:. r
Service Type: PUBLlC_ PRlVATE_ BLS_ ALS...h( EMERGENT_ TRANSFER_ SPECIAL~
Number of Ambulances Licensed: .1.
'* "PHYSICIAN ADVISOR INFORMATION
.:1ysician Advisor Name:h ~) ni tu;A' M 1> fkf" A:olorado License Number: () 7 ~ 0 I
Office Address: ~1 0 I 8/l.0C1 /.c..,t?l/ t2, Rt/v//C ('cJ g;c:J2/L
STREETIPO BOX ' CITY I STATE ZIP CODE
. -ice Communications: SO 1-5- ') 0- Fl f'?{l#of;k) t~ - J03"l22/ -/? 5.5 ]lIAc1..lliLlf/IJf€/JlJoL.
VOICE FAX' E-MAIL INTERNET CON{
I hereby certify that the information provided in this application is true to the best of my knowledge and belief and
contains no willful misrepresentation or falsification. Determination that an Ambulance Service License bas been issued based
on false information con.litutes grounds for license revocation, su.pension of operations and posslbie criminal prosecutio~.
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(FOR EMS COUNCIL USE ONLY)
Date Received: J\lr( \ @, >-007 Ambulance Permits Attached: '..(,Y'\ I'<\trnf', "t S
. .
EMS Council Comments: VA",,"<== .,'\ f'MrII.<" (f"^"'""(j=""'1lY1c-.<>... ft.! ilIAI/M,\ RJ.C\vuatli Cc,.'-IIJnL}
.;r",......... D 7-<>01
EMS Council Recommendation: \>AS,~ - oK n'Cnt..,..l\lr \....o~.....,,<=. :T"",~1..., ~l\..~}\..DB: ~~1.ao7
F-MS Council Chairperson Signature:
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Date Referred to BoCC:
7: -'9- ~/A) AI~ J
NAME ~ -
G/IB/Of
DATE
BoCC Action:
Date:
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06/19/2007 TUE 10150 FAX 3032930295 AMR Denver Operations
1dJ002/0 03
PITKIN couNTY'
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APPLICA nON c:---- ---..,.
AMBULANCE ~~ICLE PERMIT~
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SERVIn: INFORMATION
AmbulanceserVkeName:jml"t"\(0!0 f<\e~\C.~ ~~~\~Se..
Office Address:. 'ctqO\ h!'Y\ClA'W0^-.,,\ . \)"'t-\-..J.u' (,\ 80L\0
. S1llEETfPOBOX I CITY STATE ZIP COilE
'Office Cominunications: (So)\' J.C\'~ - (::i)'<\ 5 \)t\ V E _S;:>AL"''''',(),~(O)G.''''''N'",I,
VOICE - FAlC E,MAlL INTERNET ,<J:.""
~HIr.I.E INFORMATION
Des'ignation: \ ~5 LieensePJ~te: \\5-C;~1:. VIN:..1 ~US~34~5.~83
ChassisYear:~ Make: '~c>r(\ . Type: 1_ nX Ill_ 4x4:y~ ~. no
.. ' . A .. r Il,"";t., ,,,,0 II IS 3
Ins~ce Coml?Bny: <"t:.-nlS ({"'''f\~'~ Policy Number:ISA "odZ., ;70 Expiration: . ,
Vehicle Location:: ~CIr-,\ :2C',..,r.~" \("i b,)~ Gn 'P'{SZ-\(fJ
. S~ BOX Cl1Y STAn' mc;oDE
.:... ~EOlJEST FOR W A JVF:R (include reason for request)
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SERVICE DIIIECTOa'S SICiNATlJRE
Clear CCIC:~
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tFOR AMBULANCE Il'ISPECTOR'S USE ONLY)
Clear NCIC:~ Insurance Card Present: /
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Registra~oD Card Present: ./
X pennit Fee Attached
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X Advance Life Support Provider Requi:.ed Equipment Certification Attached
CornmemslRecomrnendation: p A,') ~IEO \N..,1l::l;; n~
Basic Life Support Required Equipment List Attached
Mechanical Condition Certificarion Attached
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INSPECTOR'S SIGNATURE
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FAX 3032930295 AMR
Denver Operations
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COLORADO
INsuRANCE IDENTIFICATION CARD
COMf>ANV NUMBER
2~~1
POLICY NUMBER
!SA Hoal1~:~-fu
Y~R
COMPANY
ACI:: A.lI'lenun 1"'1J1'MI;~ Compuy
EFFECT1VE OA TE:
)(.1"2001
EXPlRA nON OA rE
}fJ1I200a
MAKE/MODe.
VEHICLE 100NTIFlc~nON~UM:Q.ER
PL$Ilf. OO~K~fAl.fl.'-'1NSVU'O
ACiI:W(;vT.e;tr::Vlf(n!{~ M,iMetJl.
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AGENCYfCQMPANY ISSUING CARD
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INSURED
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Gr_oodVJIl../;~ CO 10\11 US...
SEE-IMPORTANT NOTJCE ON REVf.RSE SlOE
1li003/003
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PITKIN COUNTY
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ADVANCED LIFE SUPPORT PROVIDER
REQUIRED EQUIPMENT CERTIFICA nON
Ambulance Service Name: IlIr1&Rlel1trl mf':1Jfel1J. tf(gsiJr7111SE Ambulance Designation: tR)S
REQUIRED AI.S EOUIPMENT
1. 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.
~ .<\dult, pediatric and neo-natal vascular access supplies and 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 service.
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 administration equipment and supplies as authorized in medical protocols
') approved for this ambulance service.
~
7. Any additional equipment and supplies needed to perform other procedures as authorized in medical
protocols approved for this ambulance service.
y-~_.
As Physician Advisor for W ~ aft tI--t'/2 iJ /~ /2 a. h dM. J , I certify that this ambulance
carries the equipment pplies 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."
cJ-760/
OfJ-#?/o?
COLORADO MEDICAL LICENSE NUMBER
DATE
J
PITKIN COUNTY
"
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VEHICLE SAFETY AND OPERABILITY
CERTIFICATION
Ambulance Service Name:&IY'I~ r; ("" rwir u I R'"'ro~ense Plate: I (')h~! Ambulance Number: /4 <=)
SYSTEMS . ACCEPTABLE NOT ACCEPTABLE COMMENTS
Wheels & Tires )(
eering V
Aligmnent ><
Suspension '<'
Service Brakes v
Parking Brake V'
Driving Lights )(
Visual Warning Systems X
Audible Warning Systems x
'!::lectrical System \I
Exhaust System )/
Fuel System .,/
Glass, Mirrors )(
Body & Sheet Metal I(
I, ~ S \ J .ij-n V"-, ' 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 indicated 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.
QJJ~~
MECHANIC'S NAME
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AmR.
AGENCY/COMPANY
3 0 ~ ~:=57 Arilt) j z. 2Z 'i
PHONE NUMBER DATE
Z/2-S/tJ7
PJTKJN coUNTY
Required Advanced Life Support Equipment List
Ambulance Service it M J2-. Radio Call Sign
,
Minimum Equipment Requirement for Advanced Life Support Ambulances
f(J All Equipment Listed In BLS Equipment list
Ventilation Equipment
~ Adult and pediatric endotracheal intubation equipment to include stylets and an
endotracheal tube stabilization device and endotracheal tubes uncuffed size range
from 2.5 - 5,5, and cuffed size range from 6.0-8.0 per Medical Director protocol.
f:{J Laryngoscope and blades, straight, and/or curved of sizes 0-4.
f:il Adult and pediatric magill forceps.
OQ End tidal C02 detector or alternative device, approved by the FDA, for
determining correct tube placement.
Patient Assessment Equipment
t)(l. Portable, battery operated cardiac monitor- defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
0Cl Pulse oximeter with adult and pediatric probes.
({f Electronic blood glucose measuring device.
Intravenous Equipment
r(J Adult and pediatric intravenous solutions and administration equipment per
Medical Director protocol.
l(<5 Adult and pediatric intravenous arm boards.
Pharmacological Agents
~ Pharmacological agents and delivery devices per Medical Director protocol.
~ Ped!atric "length based" device for sizing drug dosage calculations and sizing
. eqUipment.
As Physician Advisor and Director for
I certify that this ambulance carries the equipment listed above. This ambulance 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.
;J 8
Signature
~
Physician Xdvisor Name
Lic, # Date
Director's Name
Signature
Date
PlTKlN COUNTY
Required Basic Life Support Equipment List
Inspector YtG/G 51-<d~A}ate S /;b- /0 7-
~7- ( ,
Minimum Equipment
fl.) Bag-valve mask resuscitators with oxygen reservoirs and standard 15mm /21 mm
(' fittings in the Ventilation and Airway Equipment
9<) 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 IT, through 14 IT,
M- Bulb syringe
~ House oxygen and portable oxygen bottle, each with a variable flow regulator,
with minimum storage capacity of 125 c,f, (M cylinder) and a minimum delivery
capability of2-patients simultaneously at flows ofa least 1-15 L.P,M,
yG Portable oxygen system with a minimum storage capacity of 15 C.F, (D cylinder)
and a minimum delivery capability for I-patient at flows of a least] -15 L.P,M,
l\t\) Transparent, non-rebreather oxygen masks and nasal cannula in adult sizes, and
f'" transparent, non-rebreather oxygen masks in pediatric sizes.
Hand operated, self inflating following sizes:
(y) 500cc bag for infant and neonate
(f) 750cc bag for children
(~ 1000cc bag for adult
Transparent masks for infants, neonate patients, children and adults,
Nasopharyngeal airways in adult sizes 24 IT, through 32 fr,
Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult, adult and large adult.
Patient Assessment Equipment E#
<\:'J Blnrul nressure cuffs to include large adult, regular adult, child, mfant nd
~on;rt9izes,
~ a' e in adult and pediatric sizes,
( enlight. a\:-.
~ Ise oximeter with adult and pediatric sensors,
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N-
<xi
3
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:
0/J- ambulance service's dispatch
f1 medical control facility or a physician
~ receiving facilities
~) mutual aid agencies,
Body Substance Isolation
~
,
~
~
9<l
l\6 Particulate respirator, N95 type or better,
Safety Equipment
() A set of three (3) warning reflect
Tj One (1) ten pound (10 lb,) 0 two (2) fiv ,) ABC fire extinguishers,
with a minimum of one extingUl m the patient compartment and
vehicle exterior and having been serviced within previous year per NFP A 10
section 4,
~
v<l
( )
~
(W
Body Substance Isolation (BS1) Equipment Properly Sized to Fit All Personnel
Non-sterile disposable gloves in small, medium, and large sizes, to include a
minimum I 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,
Child safety seat or appropriate protective restraints for patients, crew,
accompanying family members, and other vehicle occupants,
Properly secured patient transport system (Le, 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,
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,
2
Splinting Equipment
Lower extremity traction splint.
Upper and lower extremity splints,
Long board, 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,
~ediatric spine boar~r adult spine board that can be adapted for pediatric use,
Adult an ediatric head immobilization e ui ment
~
C>()
~
qq
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~
Adult and pediatric cervical spine immobilization equipment per Medical Director
protocol.
Dressing Materials
'rI...) Bandages - various types and sizes per agency needs and Medical Director
Y "- protoco I.
~ Multiple dressings (including occlusive dressings), various sizes per ambulance
service requirements, needs and Medical Director protocol.
Sterile bum sheets,
~
~ Povidone and alcohol swabs or equivalent.
<Xl Adhesive tape, per ambulance service requirements, needs, and Medical Director
protocol.
'f/J Sterile irrigation solution,
Obstetrical Supplies
rJ Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps,
scissors, bulb syringe, sterile gloves, and thermal absorbent blanket.
t)<J Neonate stocking cap or equivalent.
Miscellaneous Equipment
~ Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts,
boots, etc,
Two working flashlights,
lanket r r the ambulance patient compartment.
Ambulance Service Medical Treatment Protocols
l)Q
~
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APPROVED JULY 25, 2007
ATTACHMENT" A"
A PORTION OF THE PITKIN COUNTY BOARD OF
COUNTY COMMISSIONERS' MINUTES OF JUNE 27; 2007
AUTHORIZING A GRANT OF LICENSE/PERMIT FOR
AMERICAN MEDICAL RESPONSE (AMR) MEDIC 145
WITH A RESTRICTION AS CONTAINED IN THE MOTION
REFERENCED BELOW
MINUTES
PITKIN COUNTY BOARD OF COUNTY COMMISSIONERS
REGULAR MEETING
JUNE 27. 2007
NOTE: For all staff memorandums and associated documents, including
additional exhibits submitted to the record, refer to the BOCC PACKET FOR
JUNE 27, 2007.
CALL TO ORDER: Chairman Michael M. Owsley opened the regular meeting of
the Board of County Commissioners at 12:00 PM.
COUNTY COMMISSION MEMBERS PRESENT: Commissioners Michael
Owsley, Dorothea Farris, Jack Hatfield and Rachel Richards.
COMMISSION MEMBERS ABSENT: Commissioner Patti Kay-Clapper was
attending a meeting out of town.
GRANT OF LICENSE/PERMIT FOR ASPEN AMBULANCE DISTRICT MEDIC
1 AND AMERICAN MEDICAL RESPONSE MEDIC 145 - MOnON TO
APPROVE. AS REPRESENTED THAT IT IS FOR ONE SPECIAL EVENT THIS
YEAR AT THE WOODY CREEK RACEWAY. LOTUS CAR CLUB RALL Yl
STAFF: RICH WALKER
BOARD OF COUNTY COMMISSIONERS 1
REGULAR MEETING JUNE 27, 2007
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Hilary Fletcher requested that the board make a motion to accept these licenses,
specifically the AMR license, conditioned on the applicant's representation which
is that he is here to service one special event this year.
Commissioner Hatfield moved to approve the grant of license/permit for the
ambulance licenses, as conditioned on the AMR license that the applicant's,
representation is that he is here to service one special event this year
(Lotus car club rally at the Woody Creek Raceway). Commissioner
Richards seconded the motion. Motion passed 4 to 0 with Commissioner
Kay-Clapper not present.
BOARD OF COUNTY COMMISSIONERS
2
REGULAR MEETING JUNE 27, 2007