Item C03 � C.3
� � �, BOARD OF COUNTY COMMISSIONERS
County of Monroe � ��r�i
�r � s�� Mayor Heather Carruthers,District 3
The Florida.Keys � � � ������]�j Mayor Pro Tem Michelle Coldiron,District 2
Craig Cates,District 1
^_,
David Rice,District 4
Sylvia J.Murphy,District 5
County Commission Meeting
August 19, 2020
Agenda Item Number: C.3
Agenda Item Summary #7116
BULK ITEM: Yes DEPARTMENT: Emergency Services
TIME APPROXIMATE: STAFF CONTACT: James Callahan (305) 289-6088
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AGENDA ITEM WORDING: Approval to issue (renewal) a Class B Certificate of Public
Convenience and Necessity (COPCN) to Florida Keys Ambulance Service, Inc. (FKAS) for the
operation of a non-emergency medical transportation service for the period September 17, 2020 to
September 16, 2022.
ITEM BACKGROUND: In September of 2016 a Public Hearing was held and a Class B COPCN
was issued to FL Keys Ambulance Service (FKAS)to operate a non-emergency medical
transportation service for the period September 17, 2018 to September 16, 2020. In view of the fact
that this COPCN will be expiring on September 16, 2020, FKAS is applying for renewal.
PREVIOUS RELEVANT BOCC ACTION:
On September 21, 2016, Item C.27, the MCBOCC approved the issuance of a Class B COPCN
to FKAS for the operation of a non-emergency medical transportation service for the period
September 17, 2016 to September 16, 2018.
On August 15, 2018, Item C.17, the MCBOCC approved the issuance of a Class B COPCN
to FKAS for the operation of a non-emergency medical transportation service for the period
September 17, 2018 to September 16, 2020.
CONTRACT/AGREEMENT CHANGES:
None
STAFF RECOMMENDATION: Approval
DOCUMENTATION:
Florida Keys Ambulance Class B Application
FL Keys Ambulance Service, Inc. - Renewal of COPCN Class B Certificate
FL Keys Ambulance - Class B COPCN Final
FINANCIAL IMPACT:
Packet Pg. 147
C.3
Effective Date: 09/17/2020
Expiration Date: 09/16/2022
Total Dollar Value of Contract: N/A
Total Cost to County: N/A
Current Year Portion: N/A
Budgeted: N/A
Source of Funds: N/A
CPI: N/A
Indirect Costs: N/A
Estimated Ongoing Costs Not Included in above dollar amounts: N/A
Revenue Producing: N/A If yes, amount: N/A
Grant: N/A
County Match: N/A
Insurance Required: Yes
Additional Details: N/A
REVIEWED BY:
James Callahan Completed 08/03/2020 10:18 AM
Pedro Mercado Completed 08/03/2020 10:49 AM
Purchasing Completed 08/03/2020 11:41 AM
Budget and Finance Completed 08/03/2020 12:25 PM
Maria Slavik Completed 08/03/2020 1:54 PM
Kathy Peters Completed 08/03/2020 3:03 PM
Board of County Commissioners Pending 08/19/2020 9:00 AM
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BOARD OF COUNTY COMMISSIONERS
County of MonroeMayor Sylvia J. Murphy,District 5
CFloriday3 Mayor Pro Tern Danny L.Kolhage,District I
Michelle Coldiron, District 2
Heather Carruthers,District 3
David Rice.District 4
Division of Emergency Services
Fire Rescue Department
490 63`d Street,Ocean
Marathon,FL 33050
Phone: 305-289-6004
Fax: 305-289-6336
COPCN CJ
ClasscList
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Please Attach all of the following documents when submitting your application: ca
The name, business mailing address, and telephone number of the service.
The name,age, address and telephone number of each owner of the nonemergency medical
transportation service,or, if the service is a corporation,the directors of the corporation and of each
stockholder of the corporation,or, if the service is a volunteer organization,the names of its officers.
The date of incorporation or formation of the business association.
The year, model,type,department of health vehicle permit number, mileage, passenger capacity,and L'
state vehicle license number of every vehicle that will be used for patient transport.
G The location of the place from which the applicant will operate, and the geographic areas to be served
y the applicant. y
L5 A description of the applicant's communication system, if any, including its assigned frequencies,
mobiles and portables,and a copy of each FCC license issued for those frequencies.
V The names and addresses of three U.S. citizens who will act as references for the applicant.
t� A schedule of rates which the applicant will charge during the certificate period.
Verification of adequate insurance coverage during the certificate period. E
I An affidavit,signed by the applicant or an authorized representative thereof, stating that all information
provided in the application,to the best of the applicant's knowledge, is true and correct.
A statement indicating the method of screening that will be used to assure that all calls responded to
require only transportation as may be provided by a nonemergency medical transportation service and
vehicle. o
❑ Such other pertinent information as the administrator may request.
C n initial nonrefundable application fee of 50.00/$25.00 for Renewal
An audit to be provided to the county administrator by an independent certified public accountant of
the accounts and records of the service involved,said audit to be done annually to coincide with the end
of the business year of the service.
Packet Pg. 149
MONROE COUNTY, FLORIDA
APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN)
CLASS B NON-EMERGENCY MEDICAL TRANSPORTATION SERVICE
(PRINT OR TYPE)
❑ INITIAL APPLICATION-S50.00 ® RENEWAL APPLICATION-S25.00
IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE: # 18-03B
1. NAME OF SERVICE FLORIDA KEYS AMBULANCE SERVICE, INC.
BUSINESS MAILING ADDRESS P.O. BOX 1259 TAVERNIER, FLORIDA. 33070
BUSINESS PHONE NUMBER 305-414-8136 EMERGENCY PHONE NUMBER 305-975-4387
2. TYPE OF OWNERSHIP(i.e.,Sole Proprietor,Partnership,Corporation,etc.) S CORPORATION z
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DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION August 6, 2012
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3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS (Use separate sheet if necessary):
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NAME AGE ADDRESS TELEPHONE# POSITION/TITLE
EDWARD F BONILLA 52 917 RED BIRD RD. 786-203-6576 CEO / OPS MANAGE
KEY LARGO, FLA. 33037
4. DESCRIBE THE GEOGRAPHIC AREA(S) THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if
necessary):
All geographical locations in Monroe County , Florida. .2
5. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB-
STATIONS (Use separate sheet if necessary):
BASE STATION 91421 OVERSEAS HIGHWAY SUITE #102. Tavernier, FL. 33070
SUB-STATION
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6. DESCRIBE YOUR COMMUNICATION SYSTEM(Attach copy of all FCC licenses):
FRE21JENCIES CALL NUMBERS OF MOBILES #OF PORTABLES
CELL PHONES 3 5-9 31
7. LIST THE NAMES AND ADDRESSES OF THREE( )U.S.CITIZENS WHO WILL ACTREFERENCES
YOUR SERVICE:
NAME ADDRESS
W
r. THO AS STEED 91500OVERSEAS HIGHWAY, TAVERNIER, L. 33070
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DGARD MIRANDA 2205 SE 27 DR. HOMESTEAD, L. 33030
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JAMES W FA TOR 18720 SW 296 ST. HOMESTEAD, FL. 33030 ca
SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD.
9. PROVIDE VERIFICATION ADEQUATE SU NCE COVERAGE DURING THE C'OPCN PERIOD.
. ATTACH A STATEMENT INDICATING I ETHOD OF SCREENING THAT WILL BE USED TO ASSURE
THAT ALL CALLS RESPONDED TO REQUIRE ONLY TRANSPORTATION AS MAY BE PROVIDED BY c
NON-EMERGENCY MEDICALTRANSPORTATION SERVICE AND VEHICLE.
11. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT, Y LE TO THE
MON OE COUNTY BOARD OF COUNTY COMMISSIONERS.
12. ATTACH A COPY OF AUDIT REPORT AS REQUIRED BY THE MONROE COUNTY NON-EMERGENCY
MEDICAL SERVICES ORDINANCES, U
I,THE UNDERSIGNED REPRESENTATIVE ABOVE NAMED SERVICE,DO HEREBY ATTEST MY SERVICE
MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF A NON-EMERGENCY MEDICAL TRANSPORTATION
SERVICE IN MONROE COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE
INFORMATION CONTAINED IN THIS APPLICATION, KNOWLEDGE,IS TRUE AND
CORRECT. c
SIG OAF LI NiT I AUTHORIZED REPRESENTATIVE
NOTARY r s `
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NOTARY SIGNATURE aDATE
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VEHICLES
ideal¢Provide tine E�iira�ina IafmraiiAea faa Eachehi�le pprat�d Bar Yer Seesie�{Idxe Seurat Si# t If sari
LICENSE
PASSENGER CAP URS TAG CJ
TYPE OF VEHICLE MODEL YEAR MILEAGE WHEELCHAIR I LITTER PERNHT# VIN NUMBER NUMBER BER
DODGE MINIVAN CARAVAN 2018 68,000.00 6PASSENGER /A 2C4RDGBG9JR160190 DDJQ86
DODGE MINIVAN CARAVAN 2018 45,000.00 6 PASSENGER /A 2C4RDGBIJR167914 EXMN19y
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Florida Keys Ambulance Service,
P.O. Box 1259 Tavernier,
FL. 33070
Ph.: 305.414.8136-Fax: 305.396.5889—Email: Flakeysambulance@aol.com
REF: CLASS B COPCN APPLICATION
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ITEM 8-. SCHEDULE OF RATES ca
MMA REGISTERED CUSTOMERS
AMBULATORY T T : $40.00
WHEELCHAIR TRANSPORT : $65.00
STRETCHER TRANSPORT : . 0
LOADED MILE2.00
PRIVATEPAY CUSTOMERS
LOADED MILE : 5.00
Packet Pg. 153
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FLO KEY-01 �C_ _- UILL
DATE(MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE /16/2020
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 BETWEEN THE ISSUING ISURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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 rlhts tO the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
-NAME---- --
JAG Insurance Grou ,LLC PRONE FAX
999 Ponce De Leon Ivd (Arc,No,Ext):(305)542-3600 (Arc,No):(35)542-3600
Suite 600 a-AIL
Coral Gables,FL 33134 DREas-
INSURER s AFFORDING COVERAGE NALC s
_---- INSURER A:National Interstate Insurance Co.
INSURED INSURER2: _-- — --
Florida Keys Ambulance,Inc. _INSURER C: -�-
91421 Overseas Highway INSURERD:
Tavernier,FL 33070 4-
_INSURER E: e, _ CL
_ INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE. LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 100
INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS N
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE. AFFORDED BY THE. POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. �
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
kNSR -- TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR Y _
A X COMMERCIAL GENERAL LIABILITY 1,000,00
EACH OCCURRENCE S _ _
-,CLAIMS-MADE �OCCUR LJG 0000161-01 7f1612020 7116/2021 DAMAGE TO RENTED �100,QQ W arr 5
MED EXP Arr one erson S 5,00
PERSONAL&ADV INJURY S 1,000,00
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,00 U
X POLICY ❑ PRO- LOC 3,000,0 ®
-- JECT PRODUCTS-COMPIOP AGG S
OTHER S _
A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00
a accident
_ ANY AUTO AAL 0000148-Ql 7/16/2020 711612021 BODILY INJURY Per erson
OWNED SCHEDULED N
AUTOS ONLY X AUTOS BODILY INJURY Per aavdent $ _
HIRED NON-OWNED PROPERTY DAMAGE _ C�
AUTOS ONLY AUTOS ONLY Per accident S W
S �
MDELDR!ETENTION
OCCUR EACH OCCURRENCE S _
CLAIM
AGGREGATE $
......... .. ... . $ $
WORKERS COMPENSATION ...._.._.._......~.W_.._.._._ __...�.. PER OTH-
AND EMPLOYERS'LIABILITY T U E
YIN
ANY PROPRIETORIPARTNERIEXECUTIVE E E.L.EACH ACCIDENT $
OFFICER(MEMBER EXCLUDED? NIA -
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes.describe under
DESCRIPTION OF OPERATIONS below I EL.DISEASE-POLICY LIMIT :2
A Professional Liabili LPL 0000137-01 7116/2020 7116/2021 Each Claim 1,000,00 -
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A Professional Liabili LPL 0000137-01 711612020 7116f2021 Aggregate 3,000,00
DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If snore space is required)
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE N DATE THEREOF,
Monroe County Fire Rescue ACCORDANCE WITH THE POLICY PROVIS ONSCE WILL BE DELIVERED IN.
90 63rd Street
Marathon,FL 33050
AUTHORIZED REPRESENTATIVE
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ACORD 25(2016103) v 196 -2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD Packet Pg. 154
C.3.a
Florida Keys Ambulance Service, .
P.O. Box 1259 Tavernier, FL. 33070
Ph.: 305.414.8136-Fax: 305.396.5889—Email:Flakeysabulance@aol.com
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F: CLASS B COPCN APPLICATION
ITEM 10: SCREENING METHOD ca
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Dear Commissioners:
e require 24 hrs notice to schedule a non-emergency transportation through a
Medicaid Management Agency. In the event that a customer needs transportation
the same day, we evaluate the reason for transfer, and determine the type of service
required, therefore, dispatching the right personnel and the right vehicle. y
Sincerely yours,
'Edward F Bonill Date
C / Ops Manager
Florida Keys Ambulance Service, inc.
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u n .. BOARD OF C"O SIv�
Mayor heather Carruthers,District 3
The Florida Keys Mayor Pro Tern Michelle Coldiro ,District
Craig Cates,District I
David Rice,District 4
� Sylvia I Murphy,Disttict
Monroe County Fire Rescue
490 631Street Ocean
Marathon,Ft, 33050
Phone(30 ) 9-60 8
MEMORANDUM
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Nicole Rhodes
FROM: Caitlin Bourassa
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SUBJECT: for Deposit
DATE: 07/20/2020
Attached please find Check#1008 dated / , in the amount of$25,00,to be depositedin the
General Fund.Thisas been issued for the renewal application of a Class B Certificatef Public
Convenience and Necessityr Florida Keys Ambulance. 75
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Thank you, U-
Cat in Bourassa
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