Item R1# # I I I k 1k I I #
�M M Of 0 IWO I V DI Ji M 1105 1 J4 EV 4
Bulk Item: Yes No X
Public Hearing: Time Certain. 10:00am
Division: EppMengy Servigg __A
Department: Fire Resog ___j
0
ITEM BACKGROUND: Florida Keys Ambulance Service, Inc. submitted an application for the
issuance of a Class A Certificate of Public Convenience and Necessity in order to operate an ALS
ground transport service for pre -hospital and inter -facility transports in all geographical locations of
Monroe County, Florida. A copy of the application submitted by Florida Keys Ambulance Service,
Inc. in August 2012 is attached. Under Monroe County Code 11-173(d), the Board shall schedule a
public hearing to consider the application. The applicant and all current holders of certificates have
been notified by mail as required by this section.
PREVIOUS RELEVANT BOCC ACTION: None
-----------
STAFF RECOMMENDATIONS: None
TOTAL COST: $0.00 INDIRECT COST: N/A BUDGETED: Yes No
INDIRECT COST: BUDGETED: Yes No
COST TO COUNTY: _.$0.00 SOURCE OF FUNDS:
REVENUE PRODUCING: Yes No X AMOUNT PER MONTH - Year
APPROVED BY: County Atty !�F7 &_
OMB/Purchasing - Risk Management M6
DOCUMENTATION: Included X Not Required
DISPOSITIONS
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MONROE COUNTY, FLORIDA
APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN)
CLASS A EMERGENCY MEDICAL SERVICE
(PRINT OR TYPE)
® INITIAL APPLICATION - $50.00 ❑ RENEWAL APPLICATION - $25.00
IF RENEWAL, PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE: #
1. NAME OF SERVICE Florida Keys Ambulance Service, Inc. d/b/a Florida Keys Ambulance
BUSINESS MAILING ADDRESS P.O. BOX 1259 TAVERNIER, FL. 33070
BUSINESS PHONE NUMBER 786-203-6576 EMERGENCY PHONE NUMBER 305-492-9969
2. TYPE OF OWNERSHIP (i.e., Sole Proprietor, Partnership, Corporation, etc.) CORPORATION
DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION AUGUST 6, 2012.
3. LIST ALL OFFICERS, DIRECTORS, AND SHAREHOLDERS (Use separate sheet if necessary):
NAME
AGE
ADDRESS
TELEPHONE #
POSITION/TITLE
EDWARD F BONILLA
44
1154 NE 41 TERRACE
786-203-6576
C.E.O.
HOMESTEAD, FL. 33033
4. LEVEL OF CARE TO BE PROVIDED: El BLS or ®ALS
IF ALS: Z] TRANSPORT or ❑NON TRANSPORT
5. DESCRIBE THE ZONES(S) THAT YOUR SERVICE DESIRES TO SERVE (Use separate sheet if necessary):
Inter facility transports in all geographical locations of Monroe County, Florida.
6. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB-
STATIONS (Use separate sheet if necessary):
BASE STATION 91875 OVERSEAS HIGHWAY. TAVERNIER, FL. 33070
SUB -STATION N/A
Page 1 of 6
7. DESCRIBE YOUR COMMUNICATION SYSTEM (Attach copy of all FCC licenses):
FREQUENCIES
CALL NUMBERS
# OF MOBILES
# OF PORTABLES
N/A
786-203-6576
2
2
8. LIST THE NAMES AND ADDRESSES OF THREE (3) U.S. CITIZENS WHO WILL ACT AS REFERENCES FOR
YOUR SERVICE:
NAME
ADDRESS
DR. Thomas Steed
91500 OVERSEAS HIGHWAY TAVERNIER FL. 33070
Edward T. Child
10 JUDY PL. KEY LARGO, FL. 33037
Susan R. Hems
P.O. BOX 1003, TAVERNIER, FL. 33070
9. ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD.
10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD.
11. ATTACH A COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR.
12. ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR.
13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT, MADE PAYABLE TO THE
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS.
1, THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED SERVICE, DO HEREBY ATTEST MY SERVICE
MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE
COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED IN
THIS APPLICATION, TO THE BEST OF
NOTARY
NOTARY
IS TRUE AND CORRECT.
Page 2 of 6
PERSONNEL - PARAMEDICS
NAME
First Middle Last
EDWARD F. BONILLA
SOCIAL SECURITY#
PARAMEDIC
CERTIFICATION #
PMD 515681
CERTIFICATION
EXPIRATION DATE
12/01/2012
JAMES W. FAKTOR
PMD 514804
12/01/2012
EDWARD T. CHILD
PMD 512934
12/01/2012
DEREK G. RANDOLPH
PMD 522774
12/01/2012
Page 3 of 6
PERSONNEL — EMERGENCY MEDICAL TECHNICIANS
NAME EMT CERTIFICATION
First,_ Middle, Last_ SOCIAL SECURITY# CERTIFICATION # EXPIRATION DATE
EDWARD F. BONILLA EMT 505055 12/01/2012
ROBERT D. HARMAN EMT 539394 12/01/2014
MIGUEL RESENDIZ EMT 518806 12/01/2012
Page 4 of 6
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Florida Keys Ambulance Service, Inc.
P.O. Box 1259 Tavernier, FL. 33070
Ph.: 786.203.6576 - Fax: 305.396.5889 -- Email: Flakeysambulance@aol.com
CLASS A COPCN APPLICATION
ITEM 9: SCHEDULE OF RATES
Transport Base Fee
Transport Base Fee
Transport Base Fee
Transport Base Fee
Mileage Charge
— Basic Life Support (BLS)
— Advanced Life Support (ALS 1)
— Advanced Life Support (ALS2)
- Special Care Transports (SCT)
- Loaded mile
$750.00
$850.00
$950.00
$1,200.00
$13.00
These rates include all medically necessary supplies, equipment, and medications
used during the transport.
!16��� CERTIFICATE OF LIABILITY INSURANCE o8/23t2o12MroDrYYYY,
CATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE n9MFICATE HOLDER.
IS 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 INSURER(S),
AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
e 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 endorsement(s).
PRODUCER
GEICO Insurance Agency, Inc,
1 GEICO Blvd
Fredericksburg, VA 22412
CONTACT GEICO Insurance Agency, Inc.
NAME
PHONE
(A/C, No Ext)
FAQ
(A/C. No)
EMAIL
ADDRESS
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURED
FLORIDA KEYS AMBULANCE SERVICE INC.
PO BOX 1259
TAVERNIER, FL 33070
INSURERA NATIONAL LIABILITY& FIRE INSURANCE
20052
INSURER B
INSURER c
INSURER
INSURER E
INSURER F
1rrJ=At-.1M CERTIFICATE NttM®FR- 97.994
it 9!rISICIN NLILM R•
IS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
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.
INSR
ADDL
SUER
POLICY EFF POLICY EXP
LTIR
TYPE OF INSURANCE
INSD
WVD
POLICY NUMBER MWDDfYY LIMITS
GENERALLIABILITY
EACH OCCURRENCE
S
$
COMMERCIAL GENERAL LIABILITY
CLAIMSMADE ®OCCUR
DAMAGE TO RENTED
PREMISES (Ea oocurrence)
MED EXP (Arty one person)
$
$
PERSONAL & ADV INJURY
$
GENERAL.AGGREGATE
GEN'LAGGREGATE LIMITAPPUES PER.
$
PRODUCTS - COMP/OP AGG
POLICY JECT LOC
S
AUTOMOBILE AUTHORITY
COMBINED SINGLE LIMIT
(Ea accident)
$ WA
ANY AUTO
BODILY INJURY (Per Person)
$ 100,000
A
ALL OWNED SCHEDULED
AUTOS AUTOS
73APGO47689-01 0812312012 08/23/2013 BODILY INJURY (Per acciderd)
$ 300,000
$ 50,000
NON -OWNED
HIRED AUTOS AUTOS
I
PROPERTY DAMAGE
(Per accident)
Covered
PIP LIm it - $10,000
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
$
CLAIMS -MADE
t
EXCESSIAB
AGGREGATE
CEO I I RETENTION $
$
WORKERS COMPENSATION
WC STATU- OTH-
AND EMPLOYERS' LIABILITY
TORY LIMITS ER
$
ANY PROPRIETOR(PARTNER/EXECUTiVE
NIA
E. L. EACH ACCIDENT
CERRAEMBERIXGLUDED? YIN
$
drtory In NIQ
E. L. DISEASE - EA EMPLOYEE
, describe under
fE.�CRIFTION
$
OF OPERATIONS below
E. L. DISEASE -POLICY LIMIT
$
DESCRIP71ON OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remarks Soh W ule, Irm on spade Is required)
Comp or Stated Ptys. Dam,
Year Make, Model, VIN Collision See. Caul. Amount Deductible
2006 FORD E350SO 1FDSS34P86DA21560 WA WA N/A
11
CERTIFICATE HOLDER
SHOULD ANY OF THEABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
MONROE COUNTY FIRE RESCUE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE
490 63RD ST.
POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
MARATHON, FL 33050
ACORD 25 (2010105)
01998-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
M-6652 (112011) 08123/201211:09 6C042348-05E24480-A94E-763BBDF9E550
Florida Keys Ambulance Service, Inc.
P.O. Box 1259 Tavernier, FL. 33070
Ph.: 786.203.6576 - Fax: 305.396.5889 Email: Flakeysambulance@aol.com
This agreement, dated August 21, 2012 by and between Florida Keys Ambulance Service Inc herein referred to as
the Ambulance Service, and Dr. Thomas Steed, Physician, herein referred to as the Medical Director. The
purpose of this agreement is to provide the Ambulance Service with a medical director to enable them to provide
Basic, or Advanced life support to the community they serve.
This relationship may be terminated by written notice served upon the Medical Director at least seven business
days prior to the effective date of said termination. The Medical Director may suspend or terminate the
relationship at will for cause, as defined hereinafter, or upon seven business day notice without cause.
The Medical Director agrees to:
1. Meet regularly with Ambulance Service and providers at least once per quarter or as often as necessary.
2. Be Medical Director of record for the Ambulance Service as required and Pursuant to Florida Statute
Chapter 401, and Florida Administrative Code 64J-1.004, and will perform all duties associated
therewith.
3. Be available to Ambulance service officers when needed to advise on EMS issues.
4. Provide oversight to the agency's pre -hospital quality assurance/quality improvement program.
The Ambulance Service Agrees to:
1. Be responsible for the transmission of all communications from the Medical Director to all Ambulance
Service providers.
2. Take necessary steps to ensure participation by its providers in all programs and courses required by the
Medical Director including but not limited to protocol requirements, continuing Medical Education and
Quality improvement.
3. Monitor the activities of each provider and keep accurate records, which shall be made available to the
Medical Director or designee upon request. An officer shall be appointed to maintain such records.
4. Forward immediately to the Medical director any and all complaints, notifications, summonses,
subpoenas, letters and communication of any nature received which in any way bears on the quality of
service rendered, is suggestive of any possible lawsuit or legal proceeding or in any ways bears on the
competence of any ambulance service provider.
5. Abide by and strictly adhere to all standards and protocols and other requirements by the Medical
Director and agrees to suspend any ALS medical privileges for any "provider" for failure to comply with
this provision.
Signed:
MEDICAL DIRECTOR
NCE SERVICE MANAGER / CEO
112
DATE
t Z1 ILL
DATE
Florida Keys Ambulance Service, Inc.
P.O. Box 1259 Tavernier, FL. 33070
Ph.: 786,203,6576 - Fax: 305.396.5889 — Email: Flakeysambulance@aol.com
CLASS A COPCN APPLICATION
ITEM 12 : PROTOCOLS
Dear Commissioners:
This letter certifies that I, Dr. Thomas M. Steed, acting as Medical director for
Florida Keys Ambulance Service, Inc. approves the Florida Regional Medical
protocols to be used by Florida Keys Ambulance Service, Inc. as standing orders
for interfacility transports and also that at this time there are no changes to these
protocols.
Truly yours,
DR. Thomas M Steed.
MEDICAL DIRECTOR
4
Eb—wa omlla
OPS MANAGER/CEO
Florida Keys Ambulance Service, Inc.
DATE
S 2-
i
DATE
W
KEY LARGo VOLUNTEER AMBULANCE CORPS, INC.
Edward Bonilla was a member in good standing with Key Largo
Volunteer Ambulance Corps from July, 2009 thru May, 2011.
During that time he was willing to extend himself beyond the necessary
limits and complete any assignment in a thorough and professional
manner.
The services he rendered to the community through his involvement with
EMS were a definite asset to members of the community as well as to
Key Largo Volunteer Ambulance Corps.
Sincerely,
a tq J,
Donald Bi
Chief, KLVAC
"Excellence Through Community Service" wwwIlvac.or I'l
Of1011
Flon"da
Keys
reserve
corps
Edward Bonilla
P.O. BOX 1259
Tavernier, Fl. 3307*
mmgmml!��
Thank you for your outstanding dedication and service to the Medical Reserve Corps,
Florida Keys unit.
The Medical Reserve Corps MRC units are community -based and function as a way to
locally organize and utilize volunteers who want to donate their time and expertise to
prepare for and respond to emergencies and promote healthy living throughout the
year. MRC volunteers supplement existing emergency and public health resources.
As a member of the MRC since 2010, we have appreciated your active participation and
willingness to serve your community.
HM=
MTrine Richey Dye. MPH
Coordinator
Florida Keys Medical Reserve Corps
5800 Overseas Highway
Suite 38
Marathon. FL 3' )050
305-743-7111