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Home My WebLink About20233412.tiff RESOLUTION RE: APPROVE APPLICATIONS FOR VARIOUS AMBULANCE SERVICE LICENSES AND AUTHORIZE CHAIR TO SIGN WHEREAS,the Board of County Commissioners of Weld County,Colorado,pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County,Colorado,and WHEREAS,pursuant to Section 7-2-100 of the Weld County Code,the Department of Public Health and Environment and the Weld County Emergency Medical/Trauma Services Council have reviewed the applications of the below listed applicants for Tier I, II, and III Ambulance Service Licenses and recommend approval,and Tier I Ambulance Service Licenses: 1. Banner Health Paramedic Service / American Medical Response(AMR) 2. Brighton Fire Rescue District 3. Frederick Firestone Fire Protection District 4. Greeley Fire Department 5. Mountain View Fire Protection District 6. North Metro Fire Rescue District 7. Platte Valley Ambulance Service 8. Platteville Gilcrest Fire Protection District 9. Southeast Weld Fire Protection District 10. Thompson Valley Emergency Medical Services(EMS) 11. UC Health Emergency Medical Services(EMS) 12. UC Health LifeLine Tier II Ambulance Service Licenses: 1. Ambulnz CO,LLC 2. American Medical Response of Colorado Tier III Ambulance Service Licenses: 1. Stadium Medical,Inc. 2. Mile High Ambulance Service WHEREAS,after review,the Board deems it advisable to approve said Applications for the above listed Tier I,II,and III Ambulance Service Licenses,copies of which are attached hereto and incorporated herein by reference. NOW,THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County,Colorado,that the Applications for the above listed Tier I,II,and III Ambulance Service Licenses,be,and hereby are,approved. cc•.H(,,,(3CfHS(G�),OfM(RR) 2023-3412 12/2V2-3 HL0056 APPLICATIONS FOR VARIOUS AMBULANCE SERVICE LICENSES PAGE 2 BE IT FURTHER RESOLVED by the Board that the Chair be,and hereby is,authorized to sign said licenses. The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 22nd day of November,A.D.,2023. BOARD OF COUNTY COMMISSIONERS WELD COUNTY,COLORADO ATTEST: did:en/O C.G 1 ;� Mi eman,Chair Weld County Clerk to the Board BC-41=din I, '�tO�UL ff erry L.B ¢k,Pro-Tem R) Deputy Clerk to the Board ,�`� ►�./j� tK.James APP VED A .! ORM: t �•�!�,, SED ItotiV4I1 r D.Ross Cou orney ®I0,�`` ZIP I Z3 ►�ri Saine Date of signature: l 2023-3412 HL0056 1861 Memorandum TO: Mike Freeman,Chair Board of County Commissioners aOUNTY' I FROM: Jason Chessher,Director Department of Public Health&Environment DATE: November 17,2023 SUBJECT: 2024 Applications for Ambulance Service Licensure Enclosed for the Board's review are 16 applications for ambulance service licensing,pursuant to Weld County Code,Chapter 7,Emergency Medical Services,from the ambulance service providers listed below.The Weld County Emergency Medical Trauma Service(EMTS)Council reviewed each application on November 15,2023, and approved all 16 applicants. There are no changes from 2023,other than the addition of Metro One,LLC whose application was submitted and approved earlier this year. Based on the delegated responsibility of the Department,we have reviewed the applications and have deemed all ambulance services,listed below,to have met all applicable licensure requirements,as per Chapter 7.As such,I am recommending the following ambulance service providers for licensure: Tier I Tier II Banner Health Paramedic Service/AMR Platte Valley Ambulance Service Ambulnz CO,LLC 1801 16th St. 1750 E.Egbert St. 3550 N.Academy Blvd. Greeley,CO Brighton,CO Colorado Springs,CO Brighton Fire Rescue District Platteville Gilcrest Fire Protection District American Medical Response 500 S.Main St.3rd Floor 202 Main St. 3800 Pearl St. Brighton,CO Platteville,CO Boulder,CO Frederick Firestone Fire Protection District Southeast Weld Fire Protection District 8426 Kosmerl PI. 95 W.Broadway Ave. Tier III Frederick,CO Keenesburg,CO Greeley Fire Department Thompson Valley EMS Stadium Medical,Inc. 1155 10th Ave. 4480 Clydesdale Pkwy. 695 Canosa Ct. Greeley,CO Loveland,CO Denver,CO Mountain View Fire Protection District UCHealth EMS Mile High Ambulance Service 3561 Stagecoach Rd. 701 Automation Dr. 3251 S.Zuni St. Longmont,CO Windsor,CO Englewood,CO North Metro Fire Rescue District UCHealth LifeLine 101 Spader Way 2450 S.Peoria St.,3rd Floor Broomfield,CO Aurora,CO 80014 2023-3412 t ZZ Una() *141 r WELD COUNTY DEPARTMENT 74 r PUBLIC HEALTH & ENVIRONMENT '41 , r License to Operate Ambulance Service r llTIERIr i . w 1 JL� ,, q _ .7/ BANNER PARAMEDIC HEALTH SERVICE ''lli 4, 1801 16TH STREET , GREELEY, CO 80631 '141 r 1111 IS LICENSED UNTIL DECEMBER 31, 2024, TO OPERATE AN AMBULANCE SERVICE r 1�tet IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . ,:,.,,,„4 r rer.'di. , 1 renji-i, 3 Nov 2 2 2323 _, l8t -, :. Pr ,,,,, ,,,„ 1 T. r CHAIR, BOARD OF WELD COUNTY COMMISSIONERS DATE _ 'COUNTY. .4:113t -7.: '," ' r NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE :, 1 r Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1- 30 of the Weld County Code .-NId *1 t WELD COUNTY DEPARTMENTOF L, PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue , Greeley , CO 80631 www. weldhealth . org Recommendation of the Weld County Emergency Medical/Trauma Servic e Y /T Council for : Banner Health_AMR As required in Section 7 -2- 100 . B . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response g Y p to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location, service area, etc . that are the basis for the Council 's recommendation : FINDING # 1 : We, the council, find that Banner Health_AMR contributes to an efficient, effective, and coordinated service by providing 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies ' areas when requested . FINDING #2 : Banner Health provides service to much of the rural portion of the Weld County. They offer an excellent service in these areas and the agencies they respond with . FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of patient care . FINDING #4 : Banner Health_AMR has a few mutual aid agreements in place, although whenever g a neighboring agency requests their assistance, they do so promptly. Recommended Level of Service : FTier 1 Tier 2 Drier 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application packet. Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve Banner Health_AMR for a Tier 1 License . Recommendation By : Date : H // 5 Matt Concialdi, EMTS Council Chair ! ' . Nk ,,,_. , . i , „ ,,,,8,,,, , \\*,3,./ ir i , t Weld County iv - .0 . I J _ i t Department of Public Health and Environment Ht AMBULANCE SERVICE LICENSE APPLICATION Date of Application : 10- 19 -2023 Name of Ambulance Service : Banner Health Paramedic Service / AMR Owner : Name : American Medical Response Address : 1801 16th Street Greeley Co . 80631 Phone Number : Operations Manager : Name . Robert Schleich Address : 1801 16th st Greeley Co , 80631 Phone Number : 1801 16th st Greeley Co , 80631 Email : Robert . Schleich@gmr. net Medical Director : Name : Shannon Sovndal Address : 1801 16th st Greeley Co . 80631 Phone Number : (970 ) 470-9454 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest ( if applicable ) : Not applicable What area of Weld County will be served by this company ? Please attach a map indicating the service area . 1555 N . 171f, Avenue IMITI * ,, rJ►~tb,,ti. it Greeley, CO 80631 i TA r"' /^ 1 ? = Phone : 970-304-6410 _ _ :13.1- f r l' Public Health �°� `� weldhealth .org . `; Pr�vrnt proa�te- Pn.l..t. Page 1 II How many ambulances do you operate? 11 Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 1801 16th Street Street Number Co Greeley State CO Phone (970)702-3438 Location#2 Street Number 3401 11 th Avenue City Evans State CO Phone 970)302-2833 (additional locations listed on next page) { As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients ✓Yes_No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile °!Yes_No Please read carefully. Sec.7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I•Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II•Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter { Level of Service Requested: t"Tier I Tier II Tier III Page 2 How many ambulances do you opeiate9 11 Stations. How many stations do you have',6 Indicate the location and descnptton of the stations from which these ambulances will operate If there are more than two locations,attach a separate sheet with the above information Ault Fire Station Address Ault-Pierce Fire Department 16680 HWy 14Ault CO 80610 Phone Number 970-834-2838 Galeton Fire Station 2 Address Galeton Fee Department 33535 Hwy 392 Galeton CO 80622 Phone Number 970-454-0681 Ft Lupton Fire Station 2 Address Fort Lupton Fire Department 2999 9.Street Fort Lupton,CO 80621 Phone Number 970-810-2448 I Ft Lupton Fee Station 1 r Address Fort Lupton Fire Department 1121Denver Ave-Fort L1lpfon co Phone Number 303-857-4603 i I Address Phone Number I I I Address i Phone Nu I I I I I { I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION . IN ADDITION , I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7 , INCLUDING , BUT NOT LIMITED TO, SECTION 7 -8 - 10 , WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAI< E A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE . DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION . � .r <� ,{ i o' 2t'2 "�grgnature 4eir--,/tyxeci, � �� /'" c• �� 5-7a �. . � _ 1. of Applicant Tide Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS \ C6 DAY OF Z• cA--06\40-ti , 20 IN THE COUNTY OF elcQ , STATE OF COLORADO . C > e"-__ Signature of Notary My Commission expires : 2-- �� / 2-0�-S p / TARENA RAE FAUBER NOTARY PUBLIC STATE OF COLORADO S NOTARY ID 20134012423 MY COMMISSION EXPIRES FEBRUARY 27, 2025 Page 7 •r•.ri g - r• V l•• , , 11 1 / .. '• r1 . • • etit . - - • I •1 ' V. i _ ..nit '. . . • t C+ • • • • • ., .. I 1 . • `cast •� • • I •; eI.r .� 1� f .VQ . • • iv S. . _ • . .; . . E I • - • • iai 1. • .r .{. .• r f •1 • •• • �tt1 • 1• • Wirt. . 4 f a •' • I /tJtl ' .1.3+1 - . . r .. - - -• • • Ia. . f I ..1.01,attic .f � 1 l„ _ .1 . I • • •r t ¢ • • t • •1. • • I • •i It • • • • • . -:. • • .. • {1.41• - r . - • al r t 'f r 1 • I �s - is, r r„U La. . . • i r sen• •� • • a `2 S • •t t • t• '1 .a•'Z•• I� • •. • 1 • i •. - • ` Lt•t•e I • •' • t ' tI -••• 'a • • I L•. • f••1 •a A- _ lL ate . w . • . . r • • w I • 1 •_ .• •, f +l • ..j• ; rl��.- . . . 1�1j fir • ; .•a` - , { • 1 .. I • • 1♦ i.'I•. •1 1 . 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NCMC Paramedic Services Banner Health R 1801 16th STREET Greeley, Colorado 80631 Phone : (970) 302-2833 Email : Robert.Schleich@gmr. net November 01 , 2023 Gabri Vergara Consumer Protection Manager Weld County Health Department Gabri Vergara: Banner Health NCMC Paramedic Service currently has mutual aid agreements with the following entities and agencies : • Front Range Fire Rescue Authority Cheyenne / Laramie County Emergency Medical Service Joint Powers Board Please contact me with any questions. Sinter ly, Acc)L- Ro ert Schleich Chief Banner Health Paramedic Services 1801 16`x' Street Greeley CO 80631 970 302 2833 Robeli.Schleich@gmr.net Supporting Documents Approval of Quality Control Program Supporting Documents Medical Protocols 1 As required in Section 7-2-80 Part J of the Weld County Code Provide a copy of Medical Protocols adopted by the ambulance service in accordance with standards approved by the Ambulance Services'Medical Director Weld County Protocols wwW ncretac aro Supporting Documents Ambulance Service Training Standards 2 As required in Section 7-2-80 Park K of the Weld County Code Provide a current copy of the Ambulance Service's Training Standards in accordance with requirements approved by the Ambulance Service's Medical Director yeesectiaa 114.Trauma Standards, Colorado 13ME Chaoier 2 Rules ( gmntovee Ceft►fioeSee; Supporting Documents Ambulance Service Vehicle Maintenance&Safety Inspection Protocol 3 As required in Section 7-2-120 of the Weld County Code Provide a copy of the Ambulance Service's vehicle maintenance and safely inspection protocol SOP Section 104.Ambulance Operations SOP Section 137"Vehicle1Ylaintenance&ReOuirS 1 i COLORADO INSURANCE IDENTIFICATION CARD CLAIMS TELEPHONE NUMBER 066-409-2603 COMPANY NUMBER COMPANY 0 COMMERCIAL 0 PERSONAL 22667 ACE American Insurance Company POnCY NUMBER EFFECTIVE DATE EXPIRATION DATE ISA H20090120 3/31/2023 3/31/2024 v. MAKEIMODEL VEHICLE IDENTIFICATION NUMBER FLEET AGENOY(COIAPAINISSUING CARD Aon Riek 9ervieee Central,Inc 100 North 10th Street 15th Floor Philadelphia PA 19103 1030020 (215)255-2000 rAmerican Medical Ree,onee,Inc 6363 9 P>ddlers Green Circle,14th Floor Greenwood Village CO 00111 El and PD Coverage Provided BEE IMPORTANT NOTICE ON REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND _ IN CASE OF ACCIDENT Report all acgldenls to your Agent/Company as soon as posslble Obtain the following 10600021106, i Name and address of each driver,passenger and witness 2 Name of Insurance Company and policy number for each vehicle Involved CLAIMS TELEPHONE NUMBER 866-409-2603 ACORO6o co,a ono, 64ACORD CORPORATION 10463007 All dghhe Noervod J]I 1 4414 .4AJ I I I J I I I I J I I I I J IAL r WELD COUNTY DEPARTMENT OF PUBLIC HEANIRLTH & ENVIRONMENT � r NiguLicense to Operate Ambulance Service r , TIERI r NI r BRIGHTON FIRE RESCUE DIS'TRIC'T 500 SOUTH 4TH AVENUE , BRIGHTON , COLORADO 80601 -11 IS LICENSED UNTIL DECEMBER 31 , 2024, TO OPERATE AN AMBULANCE SERVICE r IN WELD COUNTY IN ACCORDANCE WITH-NilEXISTING WELD COUNTY RULES AND REGULATIONS . r , , -41 tit j,,xx34,- NOV 2 2 2323 �-4 ��b� ,.r� r 1 CHAIR, BOARD OF WELD COUNTY COMMISSIONERS DATE ' I� d /\. ,' 441 NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE r , r Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1 -30 of the Weld County Code . I . LP' r, ; WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT - - -J - 1555 North 17th Avenue , Greeley , CO 80631 www . weldhealth . or g Recommendation of the Weld County Emergency Medical/Trauma g y /T auma Service Council for : Brighton Fire Rescue District As required in Section 7 -2 - 100. B . 5 ., the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical g y response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location , service area, etc . that are the basis for the Council's recommendation : FINDING # 1 : we, the council, find that Brighton Fire contributes to an efficient, effective, and coordinated service by providing p ding 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies' areas when requested. FINDING #2 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the le vel of patient care . FINDING #3 : Brighton Fire has mutual aid agreements to ensure service delivery to their service area during call surges . Additionally, Brighton is willing to assist their neighbors when called upon . FINDING #4 : Recommended Level of Service : I1t' kier 1 Etier 2Dlier 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application packet . Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve Brighton Fire Rescue for a Tier I License . • Recommendation By : C- Date : 71/, S /zu L Matt Concialdi, EMTS Council Chair _ 186i { o Nit Weld County v , , Department of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application : 10/02/2023 Name of Ambulance Service : Brighton Fire Rescue District Owner : _.._.. N ame : Brighton Fire Rescue District Address : 500 S. 4th Avenue, Brighton , CO 80601 Phone Number: 3036594101 Operations Manager : N ame : Austin Coleman (Division Chief of EMS) Address : Same Phone Number : 303-654-8050 Email : acoleman@brightonfire .org Medical Director : N ame : Dr. Candace Harrod or Dr. William McNitt Address : Platte Valley @ 1600 Prairie Center Pkwy, Brighton, CO 80601 Phone Number : 303-941 -2012 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest ( if applicable ) : N/A What area of Weld County will be served by this company? Please attach a map indicating the service area . Attached is a map of our District, the areas in Weld that we cover are highlighted in yellow. RD 11 East to RD 35, from RD 2 North to RD 6. 1555 N . 17'^ Avenue ,�N, Greeley, CO 80631 .4w‘, - D fl Phone : 970-304-6410 . 1.O: 11: !f '- 1 C weldhealth .org Pult Health .,f• �.+ Page 1 How many ambulances do you operate?2 Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 Street Number 124 S 40th Ave,Brighton Fire Station 2 City Brighton State CO Phone 3036594101 Location#2 Street Number 425 S Main St,Brighton,CO 80601-BFRD Station 51 City Brighton State CO Phone 3036594101 As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients ✓Yes No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile ✓Yes No Please read carefully: Sec.7-2-10 License for Ambulance Service No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III-Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested. ✓Tier I Tier li Tier Ill Page 2 6/29/22, 12:40 PM brightonfire.org/abouLus/stations_and_apparatustindex,php Stations & Apparatus Click on the location name for more details District Headquarters/City Hall 500 S. 4th Ave. 3rd Floor Brighton , CO 80601 4 Station 51 425 S. Main St. / LitJ/ C-- Brighton , CO 80601 Station 5z NV? L_ L 124 s. 4oth Ave. Brighton, CO 80601 Station 53 16681 E. 12oth Ave. Brighton, CO 80601 Station 54. 15229 Great Rock Rd. Brighton, CO 80603 Station 55 15959 Havana St. Brighton , CO 80602 Medic52— I i t ' 2022 Ram 4500,Arrow Ambulance,Type 1,Patient Capacity—2 Reserve- j, < j 2006 Chevrolet C4500,Type 1,Arrow Ambulance/McCoy Miller,Patient Capacity-2 4, I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION . IN ADDITION , I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING , BUT NOT LIMITED TO, SECTION 7-8 - 10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE . DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION . �-2 • Signature of Applicant Title Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS DAY OF , 20 , IN THE COUNTY OF , STATE OF COLORADO . Signature of Notary My Commission expires : / / MARIA E. KOGER NOTARY PUBLIC - STATE OF COLORADO Notary ID #20094013999 My Commission Expires 5/6/2025 Page 7 Greater Brighton Fire Protection District Street Atlas INDEX FOR INTERNAL USE ONLY w w w w w w w w O This map produced by w w w w w 0 O o o c 0 O o Elroi Consulting , Inc . for GBFPD . O O O a O o 0 0 0 o 0 0 0 0 O O o 0 0 O r N C') v. 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ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND U 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 120TH AVE in \.;_� . _ -_ r_� _ 1 - 120TH AVE w 1 NC NC NC NC NC j NC NC NC NC NC NCam ww w c . . Ilt ._. M_ W w w w w O c wo o Lai o 34 35 36 37 38 39 40 41 42 43 44 f ` o 0 0 O O o c O 0 0 .1 _ ! 1 • - 03 o N M tto I-I NB NB NB g rn o N 112TH AVE w r r l- Ww w w r) M �r Q 0 w o w 37 38 O o a 144 : z I Z Cr QQo 0 C o O 0 4 ow oa) to r 0 , �` . 4 104TH AVE > O CO u we 0 N N N NNA : Cin cc w O NW WW w Z 441 - 44 d z Z w g p = a. ~O Q W 0 0 0 O Q z 1 Q w O °- g we cc?) v a = A A C� >a a 96TH AVE O N N N U a O ,i (n O F- >- m F- Q n 43 44 d O z cn 3 w w EA -,.- --r -z-s t-- _ 88TH AVE 0 0 > CL. >- U Z W W W 0 M 0 O O rn= 0 Cl. 1.- v.) M Z U) Z o Z O o I- o D a m I 2 18 BFRD Overall District Boundary , � 1 - I. • •••• ••• • . • I ...•1 .... - I. 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Mutual Aid— Thornton Fire Department North Metro Fire District South Adams Fire distnct Westminster Fire Department Adams County Fire Department Mountain View Fire District S E Weld Fire Distnct Hudson Fire District Ft Lupton Fire District Frederick/Firestone Fire Distnct Arvada Fire District Bennet Fire District Denver Fire Department Platte Valley Ambulance Service North Glenn Ambulance Service NEAI AAAA A I I I AAAAAA AAAAA___ WELD COUNTY DEPARTMENT OF ill ' r PUBLIC HEALTH 84 ENVIRONMENT "I i r License to Operate Ambulance Service r -\ TIERI r-41 prFREDERICK FIRESTONE FIRE PROTECTION DISTRICT\ . 8426 KOSMERL PLACE , FREDERICK , COLORADO 80504 ' NI I pir Nim IS LICENSED UNTIL DECEMBER 31 , 2024, TO OPERATE AN AMBULANCE SERVICE r IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . I r W , y ��Y*NI $ �� NOV 2 2 2323 \\VNIV -�' � 'H�,-...- -._ r CHAIR . BOARD OF WELD COUNTY COMMISSIONERS DATE ^ • ��' ' ('J .Al: O J• 71 r ivTY J Nil NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE r r Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1 - 30 of the Weld County Code . , 11t• WELD COUNTY DEPARTMENT ,r , OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue , Greeley , CO 80631 www . weldhealth . org Recommendation of the Weld County Emergency Medical/Trauma Service Council for : Frederick Firestone Fire Protection District As required in Section 7 -2 - 100. B . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location, service area , etc. that are the basis for the Council 's recommendation : FINDING # 1 : We, the council, find that Frederick Firestone Fire Protection District ( FFFPD) contributes to an efficient, effective, and coordinated service by providing 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies' areas when reauested . FINDING #2 FFFPD provides service to much of the southwestern part of Weld County. They offer an excellent service in these areas and the agencies they respond with . FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of patient care . FINDING #4 : FFFPD has a few mutual aid agreements in place, although whenever a neighboring agency a requests their Y assistance, they do so promptly. They are certainly a great neighbor to have in providing 911 EMS response during surges . Recommended Level of Service : I trier 1 [ Tier 2 jljlier 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application packet. Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve FFFPD for a Tier I License. Recommendation By : Date : " �'J 4 Z 3 Matt Concialdi, EMTS Council Chair � - -1 Weld County Department of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application : 'D t 12o 2.„3 Name of Ambulance Service : cC Hre s2t0ftt nr2 ?rc4cc}toy\ i' I s41- ' C- � Owner: Name : #-Freder\ ck - e -ires-4-Dne TPO Address : 24tL lç- erttrict C. O $ D S 0 �f Phone Number: 303 - 83 2— Operations Manager, Name : (\SSA • CicX 00 ¼J%j Pni\ t Address : PA 2.142_ •C('jS rvv� � � � I i-nr-ecfAx- ; C �L � co 80 S O Phone Number: 32o - (SI Le Email : ClpcuiNY,..,@.5-C-Cd , v S Medical Director: Name : y Or% O.r Ci' et'C. Address : SCL Good S O4Yn0.r iak- 0. ►'1 Med ; [4.‘ (. Eitr Phone Number: -42.0 - 213 " SO (Qy Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest ( if applicable ) : F�1 tOt What area of Weld County will be served by this company? Please attach a map indicating the service area . AAA Qoi\st 1555 N . 17th Avenue is. � Se71\\ Greeley, CO 80631 ) 1 t . ' = i j Phone: 970-304-6410 Ali? r � � 'c al weldhealth .org sq. .�� Page 1 How many ambulances do you operate ? 5 Location and description of the place ( s ) from which this ambulance service will operate . If there are more than two locations, attach a separate sheet with the above information . Location # 1 : Street Number : Sc_ e_ act LA City : State : Phone : Location #2 : Street Number : City : State : Phone : As required in Section 7 -3 - 30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations , as of the date of the application , are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients : No As required in Section 7 - 3 -40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations, as of the date of the application , are you in compliance with the reporting requirements of the agency profile : e No Please read carefully : Sec. 7 -2- 10 License for Ambulance Service . No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners, except as provided in Section 7 - 2 -80 below . The fee for said license shall be set by separate ordinance . The license shall issue only in the following tiers of service : Tier I : Licensure authorizing for Primary Care, as defined in Section 7- 1 - 30 of this Chapter . Tier II : Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities . This licensure does not provide for primary care, as defined in Section 7 - 1 - 30 of this Chapter . Tier III : Licensure authorizing for Standby Service , as defined in Section 7 - 1 -30 of this Chapter . Level of Service Requested : ier Tier II Tier III Page 2 FREDERICK-FIRESTONE Operations Section FIRE PROTECTION DISTRICT Office. (303)833-2742 ., .�� ` �, �� Fax (303)833-3736 E-Mail: dprunk@fffd us ;17,, !;"4,1 / 1rJ October 1°,2023 The Frederick-Firestone Fire Protection District currently has four fire stations.All Fire stations houses one or two of the District's Ambulances These ambulances arc located at Station#1 - 31 Walnut Drive Frederick,CO 80530 303-833-3727 Station#2- 3991 Rowe Street Frederick,CO 80504 303-651-3104 Station#3- 6800 Tilbury Avenue Firestone,CO 80504 303-833-4458 Station#4- 10706 WCR 7 Frederick,CO 80504 303-710-1720 Resp 11y, uglas J Prank Assistant Chief Physical 8426 Kosmerl Place,Frederick,CO 80504,Mailing P O Box 129,Frederick,CO 80530,www fifcLus I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION IN ADDITION,I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7,INCLUDING,BUT NOT LIMITED TO,SECTION 7-8-10,WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROS TION Ah '(A,, /0//e(2,7,3 Signature of Applicant Title Dote SUBSCRIBED AND AFFIRMED BEFORE ME THIS le- SUMMER D.CAMPOBAY Ur eG7 ,aP ,20___g5,IN THE COUNTY OF NOTARY PUBLIC STATE OF COLORADO G J/.d ,STATE OF COLORADO NOTARY ID 20214002416 MY G0MMI8810PI EXPIRES 011191 o28 .am.,.....„la g4",52„.47_, Signature of Notary My Commission expires al /19/_,a,2_5- Pap 7 f rFrel 'P ' i I ; , PIR= ra- k FI►, yb0 1 / ; 7 '4.-'",-.•••...: _-_:-1-_--- , 41)7i'4 I 1 r►,. ,• ti,,;. 1, a�yw fl r-- ,.•%, FAT . ..,,,, ,i4:16it;'''.''''''''''';',,,:';,..,1,„,,,,,,,,,,.iy-�r{� O,,,iyyyp�•.,n Sgry..--•P".• • '0,,,-:',.1,!t,-,..1 `? f .. 'j 'x.',-r�,S'�riffs'+a 1 u ia.r,.r ,dtrr_ .- _IiiiW ' � FREDERICK-FIRESTONE .REDER --F1>�I_�-1„�1 , � . • Operations Section FIRE PROTECTION DISTRICT Office: (303) 833-2742 tim t '' MI Fax: (303) 833-3736 1j * . h,-Mail: dprunk@fffd.us t IR : October 1st, 202$ The Frederick- Firestone Fire Protection District currently has EMS Mutual-Aid agreements with the following agencies: • Mountain View Fire Protection District • Platteville-Gilcrest Fire Protection District Respectfully, g Prunk Assistant Chief Physical: 8426 Kosmcrl Place, Frederick, CO 80504, Mailing: P. 0. Box 129, Frederick, CO 80530; www.fffd.us „iiiiAAAA1444 .41AAAAAAAA I I J J J A_ WELD COUNTY DEPARTMENT OF NI PUBLIC HEALTH & ENVIRONMENT r , r License to Operate Ambulance Service .11 TIER I r -NI pr GREELEY FIRE DEPARTMENT , or 1155 10TH AVENUE , GREELEY, COLORADO 80631 NI r NI IS LICENSED UNTIL DECEMBER 31 , 2024, TO OPERATE AN AMBULANCE SERVICE r IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . . il r wq, 1 le 1 t‘Q 5Its..°N 13 a l''t a'a I m a e NOV 2 2 2323 CHAIR, BOARD OF WELD COUNTY COMMISSIONERS DATE � . . ,_ , ...: . i r , ,. LE- - lJ ‘Ig NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE .i I , I r Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1 -30 of the Weld County Code . 61 s ', I WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT r - v 1555 North 17th Avenue , ,Greele CO80631 Greeley , www . weldhealth . org Recommendation of the Weld County Emergency Medical/Trauma Service Council /T for : Greeley Fire Department As required in Section 7 -2 - 1OO . B . S . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location, service area, etc. that are the basis for the Council ' s recommendation : FINDING #1 : We, the council, find that Greeley Fire Department (GFD ) contributes to an efficient, effective, and coordinated service by providing 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies' areas when requested . FINDING #2 : GFD Squade provides a specialized service to the City of Greeley, although it will provide transport services in the event of a surge . They offer an excellent service in the City and the agencies they respond with . FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of patient care. FINDING #4 : GFD has a county-wide mutual aid agreement in place, and whenever a neighboring agency requests their g g g Y q ei assistance, they do so promptly. They are certainly a great neighbor to have in providing 911 EMS response during surges. Recommended Level of Service : kkier 1 __.__.Ti r e 2 per 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application packet. Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve GFD for a Tier I License. Recommendation By : - _� Date : / I i$ /zoz Matt Concialdi, EMTS Council Chair ,-;i0.1 Co-, . 1' • ty Department of Public Health and Environment AM=ULANCE SERVICE LICENSE APPLICATION Date of Application 10/04/2023 Name of Ambulance Service Greeley Fire Department Owner Name City of Greeley Address 1000 10th Street,Greeley,CO 80631 Phone Number 970-350-9500 Operations Manager Name Brian Kuznik-Fire Chief Address 1155 10th Ave,Greeley CO 80631 Phone Number 970-350-9501 Email brian kuznik@greeleygov com Medical Director Name Dr Tyler Vaughn Address 1155 10th Ave,Greeley CO 80631 Phone Number 815-252-7049 Name and address of each stockholder of partner owning 10%or more of the outstanding stock of the company of having more than a 10%ownership interest(if applicable). N/A What area of Weld County will be served by this company?Please attach a map indicating the service area City of Greeley/Western Hills Fire Protection District 1555 N 17th Avenue ,,w ,j Greeley,CO 80631 ZiJi ii�'M ; ( , ( ( NH'A Phone 970-304-6410 i.lgl +% weldhealth org yif' r1 ` PW'tnBealth Page 1 1 How many ambulances do you operate? Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 Street Number 2323 Reservoir Road City Greeley State CO Phone 970-350-9500 Location#2 Street Number City State. Phone As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients CD No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile ©e No Please read carefully Sec.7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities.This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier Ill:Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested. (-Tier I-) Tier II Tier III Page 2 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION . IN ADDITION , I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING , BUT NOT LIMITED TO, SECTION 7-8 - 10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE . DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION . Duputy Chief-Administration 10/04/2023 Si4atvide or pplicant Title Date I SUBSCRIBED AND AFFIRMED BEFORE ME THIS DAY OF 00 1c43.ci 2D, 3 , IN THE COUNTY OF LOCr' , STATE OF COLORADO . / . Q ignature of Notary My Commission expires : C2 / OW!) JANICE L PEREKRESTENKO 4 NOTARY PUBLIC - STATE OF COLORADO NOTARY ID 20064032815 + MY COMMISSION EXPIRES AUG 18 , 2026 basorlinnwerrerin Page 7 CDP tilar Cit(L'rof /seiVa."4N\I\ ("H^rado reele l i . ; October 25 , 2023 Greeley Fire Department is part of the Weld County Mutual Aid Contract that allows mutual aid from all Weld County Fire Departments and special districts . This would allow mutual aid ambulances to respond upon request from any neighboring fire district upon request. Respectfully, Jeff Stranahan Deputy Chief — Administration Greeley Fire Department 1155 10th Avenue Greeley, CO 80631 Greeley Fire Department • 1155 10th Avenue, Greeley, CO 80631 • (970) 350-9500 A City Achieving Community Excellence I • I 1 \5 • Fire 1 l • /� pnvua.. .rr w�nma� 41,C' rccicti• tr. �,f.w. fi•11fg1AS • r Reference Mrs MordI 11e ,.o Omer••• lk 1 e 1 l 1 i '-",....i It..11:141116r e_ 1 1 � • Map PNaw1177 14; ik,„,.. VI op . .. _ J• L �,•• wr, �.4_.. r•r� �Tlt� 1 1 . �N ` RAf��rA � - ..• .041° I 111;10 7 'is 1 I glaN. ) L. i , : is, 1 -ter, L ,•:- ..•0 ft • i . D I 4 4,„ IIIr- -m 1 1 ii \ 1 . 4 r • \ I frfa / t 1 a I f 111 \#1N11M ••_ — NM . •••• 13 . . ::: ::\re _ : • '`•I . t '• .t'+: r ; jillirolciiilli::::•'It I 41/4'$► i r 4 =5i w 1 .y•l :,...,SMiJ j JS1' ` • • _ ` �.. sr+ ��{-�Y1• ' • tI�` "'w�yZ_ •- , IV. . 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"Ill r WELD COUNTY DEPARTMENT OF PUB-INLIC HEALTH & ENVIRONMENT P -144License to Operate Ambulance Service r TIERI r -Ni MOUNTAIN VIEW FIRE � DISTRICT 'g . r 3561 NORTH STAGECOACH ROAD , LONGMONT , COLORADO 80504 r NI IS LICENSED UNTIL DECEMBER 31 , 2024 , TO OPERATE AN AMBULANCE SERVICE P IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . 3 nr aa•Le-41.---- ----_____ NOV 2 2 2323 4•,. P,,- _ .CHAIR, BOARD OF WELD COUNTY COMMISSIONERS DATE �,•"� '�� r �� L . �)Nig 1 Dit . .T 1 -r 1 pr ii * it NI NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE r r Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1- 30 of the Weld County Code . It\ f� Z .�IS6I , .r '� � 'I =' WELD COUNTY DEPARTMENTOF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue , Greeley , CO 80631 www . weldhealth . org Si Recommendation of the Weld County Emergency Medical /Trauma Service Council for : Mountain View Fire Protection District As required in Section 7 -2 - 100 . B. 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location, service area , etc . that are the basis for the Council ' s recommendation : FINDING # 1 : We, the council, find that Moutain View Fire Protection District ( MVFPD) contributes to an efficient, effective, and coordinated service by providing 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies' areas when requested . FINDING #2 : MVFPD provides service to a significant portion of southwestern Weld County and ensures timely response to their area . They are willing to assist their neighbors when requested . FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of patient care . FINDING #4 : MVFPD has a robust list of mutual aid agreements in place, and whenever a neighboring agency requests their assistance, they do so promptly. They are certainly a great neighbor to have in providing 911 EMS response during surges. Recommended Level of Service : { ..Tier 1 Tier 2 Lljiier 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application packet. Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve MVFPD for a Tier I License . Recommendation By : Date : / //c Zo z J Matt Concialdi, EMTS Council Chair Weld County 14 1 j r re , fikouNTY Department of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application : 10-5- 2023 Name of Ambulance Service : Mountain View Fire Protection District Owner : N ame : Mountain View Fire Protection District Address : 3561 N . Stagecoach Rd . Longmont, CO 80504 Phone Number : 303-772-0710 Operations Manager : N ame : Paul Johnson Address : 3561 N . Stagecoach Rd . Longmont, CO 80504 Phone Number : 303-902-3243 Email : Piohnson@rnvfpd . org Medical Director : N ame : Adam Rush Address : 3561 N . Stagecoach Rd . Longmont, CO 80504 Phone Number : 303-772-0710 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest ( if applicable ) : What area of Weld County will be served by this company? Please attach a map indicating the service area . 1555 N . 171' Avenue vs I 4. nuns `y Greeley CO 80631 t ' - ti Phone : 970-304 6410 , • " r -7"4"t" // weldhealth . org .,.. _e�' h Page 1 How many ambulances do you operate? 9 _ Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information. Location#1 Street Number See Attached City State. Phone Location#2 Street Number. City State. Phone As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients. Yes No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile Yes No Please read carefully: Sec.7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below.The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I:Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II:Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III.Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter. Level of Service Requested: ✓Tier I Tier II Tier III Page 2 rk`,�eC 1t MOUNTAIN VIEW FIRE RESCUE / nit ' ti ' tt ` 3561 North Stagecoach Road, Unit 200, Longmont Colorado 80504 (303 ) 772 -07 ( 0 FAX (303) 651 -7702 Mountain View Fire- Staffed Sations List and Ambulance Locations Station # 8 Station # 1 400 Bonanza Dr. 10939 CR 5 Erie, CO 80516 Longmont , CO 80504 Station # 9 Station # 2 4390 Eldorado Springs Dr . 7700 Baseline Rd . Boulder, CO 80301 Boulder, CO 80303 Ambulance 2222 Station # 10 5748 Flagstaff Road Station # 3 Boulder, CO 80302 441 3rd Ave . Mead , CO 80542 Headquarters administration building Ambulance 2223 3651 N . Stagecoach Road Longmont, CO 80504 Station # 4 8500 Niwot Rd . Maintenance Facility Niwot, CO 80544 5322 Weld County Road 7 Ambulance 2224 Erie, CO 80516 Reserve Ambulance 1 Station # 5 Reserve Ambulance 2 ( sometimes housed 2701 S . Indiana at station 12 which is an apparatus storage Superior, CO 80027 location and not staffed ) Ambulance 2225 Reserve Ambulance 3 Station # 6 50 Bonanza Dr. Erie, CO 80516 Ambulance 2226 Station # 7 161 Perry Lane Dacono, CO 80514 Ambulance 2227 www. mvfpd .org _ - - I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION . IN ADDITION , I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING , BUT NOT LIMITED TO, SECTION 7 -8- 10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE . DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL I PROSE N . Division Chief of EMS 4 2320 )j Signs ure of Applicant Title Date r� �d AND AFFIRMED .J '- SUBSCRIBED BEFORE ME THIS DAY OF Lth AJE Y , 20 c2 3 , IN THE COUNTY OF f STATE OF COLORA0Ith' .O CYNTHIA L WIBL.E NOTARY PUBLIC STATE OF COLORADO 11:10NOTARY ID 20104009878 ` 4MY COMMISSION EXPIRES ! ES MARCH 25, 2026 Si nature of Notary - .s_--_ My Commissionexpires : 3 & olb 4' / / Page 7 Mountain V] ewF ' I' • . us • • Alp .4 Via 48 sf2 • a 4 VII III 11111. I 1►' #11:11 , all xLMIllgu a ar i_i4 III IF PIO !lir imi•• . via.41 YYCR ri .. N41 I.a s ► NU IR • 1p ".....t.„. , , . . .. ihstp.... „ wry. • • iip ..- r ' im. Illi 0 •' • : . :fir :.; 2 'lIN _ .. •• now J P tag". I illp# -ji hi. 1 RE t, imp ; SI 1°0 1 1351 Aril I Jig . by? 4 7 .P i • , • I i Station 3 • r refflill * via M IN OP EH Ell .• .CI :litiesat IS aii IV e • . ` 1 = = Station 147c1 w • Ir , me I . . 0 • rpiRs gti ala "TA z; saca,....L. , i Li p op . * 4 ,.....11+ oi filiNNLAN:46O .. pa HE w.. RD .4 ." -: . ' .; Is r 1 4 .J P . Star /la it •.i Silt k. libli .• jilt : Le • are tar) a Station 1AcIministration "it : . • _ vir. . Illtaa el -A • wr. , „ . Station 13 Ill i • a % a _ f -ta . . 1 lg. Sin * Matti " .. IP IA. Rpm • I lidi ...„ KV It I P4 Alt e rail• r ',-1 - w- r- - g• 017• 5 RD; . • 15. ii. 0 Station;4 Si . ir " _ y . ' �` 111 ' r 4 le tillP . e 1 _..IS 4MCR mar e r' Maintena1nce Inv 4 . . - ; F P II . Atr i �. Station f7 a 4 " 1 - ' Ilt , k . a _4.llk a r rfa4llkt:. a , Statonn12te . ?FP -al1 Fp • aii Staton 6 is r1 i J I vs A . 11. I Me° vc) Illj ffill s� Ill li 111111E6 !�r 4 St ' I 111111 r .� r••4. r 1 4 II. NI 1� .. 4 - I/ PP 41C w�cA II •► Station 11 . • Lira illip _ stanon 2 , 110r _ ,a C RttE % Ill a •FireAnnex __ • .� 1tkC t . . . '_ , , . . s . sicTi 4 ,.. ?0, • v. 464, j. . gee _ Station 8 I i • - I. ,„ _ _ ,, .4, •• . -b. _._ 4i, . t; , AIN • •+ ea 3 i‘i . . .a. 4 . 0 . 411. ' , � Station 1 oStation9s1 -1r i �r41 •P 6 - E j Station 5 • dlli • aria- . di 941 . - tili 541.• .... .. a 4. ._ . 1 t OCIMUNON A 4, art lo I* al rt tee 4 el • - . .7 ‘: .. g ItsWak,;.:. , ; 4.'444 A ��tallturritorms Vrode1 • . (di aa ASS • . • l{Mit , '`• MOUNTAIN VIEW FIRE RESCUE 3561 North Stagecoach Road, Unit 200, Longmont Colorado 80504 fi' ~r ) (303) 772-0710 FAX (303 ) 651 -7702 October 5 , 2023 To Whom It May Concern: Below is a list of the mutual aid, auto-aid, or IGA agencies Mountain View Fire Protection District has signed with surrounding agencies. Mutual aid or IGA Agencies: • Berthoud Fire • Boulder County • Boulder Fire • Boulder Rural • Boulder OSMP • Frederick Firestone Fire • Front Range Fire • Fort Lupton Fire • Johnstown Fire • Lafayette Fire • Lefthand Fire • Longmont Fire • Lyons Fire • North Metro Fire • Pinebrook Hills Fire • Platteville Ghilcrest Fire • Weld County Mountain View Fire Protection District will respond mutual aid with all fire agencies in both Weld and Boulder Counties if requested . Sincerely, Paul Johnson Division Chief, EMS www.mvfpd.org ;d4 .444 ,414A44 I I I I I I I I I J 1. r -1 WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT r \ ' I License to Operate Ambulance Service r \ 'TIER I I r Nig F-illORTH METRO FIRE � RESCUE DISTRICT r 1O1 SPADER WAY, BROOMFIELD , COLORADO 80020 r .i IS LICENSED UNTIL DECEMBER 31 , 2024 , TO OPERATE AN AMBULANCE SERVICE V IN WELD COUNTY IN ACCO•NRDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . r , _, . . Nil 3 (T n A --k Pr � CHAIR , BOARD OF WELD3...A._............._____ CO eTV COMMISSIONERS DATE 1 tatsi: _ 1 I r lig NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1 - 30 of the Weld County Code . R61 .�..s. WELD COUNTY DEPARTMENT OF PUBLIC ri HEALTH AND ENVIRONMENT 1555 North 1 7th Avenue , Greeley , CO 80631 www . weldhealth . org Recommendation of the Weld County Emergency Medical/Trauma Service Y /T Council for : North Metro Fire Rescue District As required in Section 7-2 - 100 . B . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency response onse p to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location, service area , etc . that are the basis for the Council ' s recommendation : FINDING #1 : We, the council, find that North Metro Fire Rescue District (NMFRD) contributes to an efficient, effective, and coordinated service by providing 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies ' areas when requested . FINDING #2 : NMFRD serves a small portion of southern Weld County and ensures timely response to their area . They are willing to assist their neighbors when requested . FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of pati ent ent care . FINDING #4 : NMFRD has a list of mutual aid agreements in place, and whenever a neighboring agency g g requests their assistance, they do so promptly. They are certainly a great neighbor to have in providing 911 EMS response during surges. Recommended Level of Service : I 'Tier 1 ...Tier e 2jjTier 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application packet . Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve NMFRD for a Tier I License. Recommendation By : Date : // it /Z6 z 3 Matt Concialdi, EMTS Council Chair , ... , ,. ,- - 186.1 _ EU sr-) uNT ' Department of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application : October 9th , 2023 Name of Ambulance Service : North Metro Fire Rescue District Owner : Name : Dave Ramos , Fire Chief Address : 101 Spader Way Broomfield , CO 80020 Phone Number : 303-452-9910 Operations Manager : Name : Mark Daugherty , Division Chief-EMS Address : 101 Spader Way Broomfield , CO 80020 Phone Number : 303-349-7686 Email : mdaugherty@northmetrofire . org Medical Director : Name : Dr. Jason Roosa , M . D . Address : 101 Spader Way Broomfield , CO 80020 Phone Number : 303-452-9910 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest ( if applicable ) : N/A What area of Weld County will be served by this company? Please attach a map indicating the service area . Attached 1555 N . 17th Avenue °s"."~°� Greeley, CO 80631 \tag t • PHA5 • C►'f Phone : 970-304-6410 ;.‘,/ r J . .�� _» ; ° " ' PublicHealth vveldhealth . Org ,-= Yr .ci,r PS note. ,'Mcc, Page 1 How many ambulances do you operate?9 Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 Street Number See attached City State Phone Location#2 Street Number City State Phone As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients /Yes No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile ✓Yes No Please read carefully. Sec 7-2-10 License for Ambulance Service No person shall provide or operate an ambulance , service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II.Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III.Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested. 1 Tier I Tier II Tier III Page 2 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION . IN ADDITION, I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING , BUT NOT LIMITED TO, SECTION 7 -8 - 10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE . DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION . ile2----- �S C � IEt� k0 / q .� Z- ZS nat of App! ' '� Title Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS art- DAY OF obloLers-- , 20 2.3_ , IN THE COUNTY OF 3l7QJvvfM , k , STATE OF COLORADO . Sig Notary My Commission expires : l'"] te / 20 HEATHER W. BROWN NOTARY PUBLIC STATE OF COLORADO ARY 4b MY CONOT#ASI0N EXP1O1997IRES 07118!212875025 Page 7 North Metro Fire Rescue District Ambulance Locations October 2023 LOCATION Primary Ambulances Reserve Ambulances Station 61 2015 Ford E - 450 2011 Ford E - 450 1275 W . Midway Blvd . Type III (M - 12 ) QJY - 233 Type III (M- 7 ) ORU - 064 Broomfield , CO 80020 Patient Capacity - 3 Patient Capacity - 3 ALS Bariatric Station 62 2022 Ford F- 450 2012 Ford E -450 10550 Huron St . Type III (M - 15 ) Temp Type III (M- 10 ) ORU - 067 Northglenn , CO 80234 Patient Capacity - 3 Patient Capacity - 3 ALS ALS Station 63 2015 Ford E - 450 None 10941 Irma Dr. Type III (M- 13 ) QJY- 234 Northglenn , CO 80233 Patient Capacity - 3 ALS Station 64 2022 Ford F - 450 None 13515 Lowell Blvd . Type III (M - 16 ) Temp Broomfield , CO 80020 Patient Capacity - 3 ALS Station 65 None 9900 W . 120th Ave . Broomfield , CO 80020 Station 66 2019 Ford E - 450 None 1750 W . 160th Ave . Type III (M - 14 ) BHJ - L90 Broomfield , CO 80020 Patient Capacity - 3 ALS Station 67 None None 13875 S . 96th Street Broomfield , CO 80020 Station 68 2011 Ford E -450 2011 Ford E - 450 1006 WCR 11 Type III ( M - 8 ) ORU - 065 Type III (M - 9 ) ORU - 066 Northglenn , CO 80602 Patient Capacity - 3 Patient Capacity - 3 ALS ALS North Metro Fire Rescue District—Mutual Aid Agencies 2023 -Adams County Fire Protection District -Brighton Fire Protection District -Federal Heights Fire Department -Lafayette Fire Department -Louisville Fire Protection District -Mountain View Fire Rescue Protection District -South Adams County Fire Department -Thornton Fire Department -Westminster Fire Department I 4 ►r1 - in • tn• ?Every !` Z V flnon t Rd v r Z *sabot!, Rd Z • a w Arcata* ltd _.-.: Z t. . ... -- -J - t • • setine Rt. W Baseline Rd -- - _ -E fisa witl�- T - - _ ._ -- - - -- _ — i • u • ithi . z Lalay.etle Ai? - 3 ••. , _ ii -te0wylrra PQd'° Louisville ,,I. st ►esn L• II • � - '� _ '.liter Vir I i Empit. Rd ": • ' t _ , iii,well • fi i at—-.. - l 44 t • r� u A o s. • .... � • I ; �� O41 on Re w "'"'" W twei Ar• Superior t� - • • , i r _ r 8 4 frill ' _�', L..I Cl, ♦ir �- evii&J 1Ei Its r t,, ]b. 10 a3 a q_ ND L 11 z M d ii as codton Rol _ , � re mss . _ 6 1211th Ave • , • rit E �+I i dN'�t » 0 l „ ,. E 124th j = tt?ata�eW Sisson a aid - !► E 1Z0� Av '-A ,.- •- ,;. - Nart�Blinn . � " 1 • „s .• to • tx.Pk ' .t4- A s. C- ',att. A v • • „ ....:c • -tin d4� —l it sit ri -00 • ' sip.3 6j 4 , . �4 r • _ e / lig In , • _ - �� v - •. 10414 1rf - @._ X . 4 76 - --- • = W 100d! wa Ili ` � Q a :ill E �90n Ava 6.$tardey yaks a �" , Thornton a t'hosn�cQ, Pkgrj� Of E ti '0 ' egu�ui Pfer�, y 5 in IIP Pd a �, \ - , w rind A • Westm insist I ..... y o r` [ M Vi sifl 1 — . ra , / I ' . , r County Road 8 r !* I �%� ' 1 r — 1 r Weldtaelliairboaisaibbilli I 8coonInfzeId "I‘ ~ ' / I I ' x I 1 . . : 11 : t6- 11 4 ' ► ;. I I hi I i. el I MVO I I 1Jis , .. , ~ .S . l ti '' pr . • •i s . • , .. L . .. . y y „r 7 1 { k ' [ I t C i' t E a c s h U NMFRD 66 • - I i t I a7 .�,. I • .._ i, v set I _' I _. I II ti Lila „. I ` fa a' W- '444th A _ - - 9,3 v r i f 'at i CO W Y, TFD 0 V.S 'im1 W I l b tti A v • - -- - ! it, t!i Ala. City and County of Broomfield , Bureau of Land Ma . . . rs,ailZIIII. http://nmfrd . maps .arcgis .com/apps/Embed/index . html?webmap = e0ebf79d ... rue&previewlmage = false & scale = true&disable_scroll = true&theme = light „41 .4444444 .44 .44 .444444A4AL p Pr WELD COUNTY DEPARTMENT OF , , r PUBLIC HEALTH 8c ENVIRONMENT -NI p Fr License to Operate Ambulance Service , T TIERI I ir -4 i m i r PLATTE VALLEY AMBULANCE SERVICE Nu! r 1750 EAST EGBERT STREET , BRIGHTON , COLORADO 80601 -4 r NI IS LICENSED UNTIL DECEMBER 31, 2024, TO OPERATE AN AMBULANCE SERVICE IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . , I r , , Nil ii mi.P.4. 3,....„..„. NC? 2 2 2323 • • ;N MLA;i I ' !..)-4 -t-y r--Li Ii''\ - p Pr I, , , CHAIR . BOARD OF WELD COUNTY COMMISSIONERS DATE , l' ; , " , J!. :It'T 1: k •Lif�if Y1. - rr NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE r Tier I : Licensure authorizing for Primary Care, as defined in Section 7- 1-30 of the Weld County Code. re = WELD COUNTY DEPARTMENT ti; p , OF PUBLIC HEALTH AND ENVIRONMENT Y - 1555 North 17th Avenue , Greeley , CO 80631 www .weldhealth . org Recommendation of the Weld County Emergency Medical/Trauma Service y /T Council for : Platte Valley Ambulance Service As required in Section 7 -2 - 100 . B . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County . Please include any findings related to response time, coordination with other ambulance services, location , service area, etc . that are the basis for the Council ' s recommendation : FINDING # 1 : We, the council, find that Platte Valley Ambulance Service ( PVAS) contributes to an efficient, effective, and coordinated service by providing 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies ' areas when requested . FINDING #2 : PVAS serves areas in the southern portion of Weld County and ensures timely response to their area . They are willing to assist their neighbors when requested . FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of patient care . FINDING #4 : PVAS follows the mutual aid that is in place with their contract agencies. Whenever a neighboring g g ng agency requests their assistance, they do so promptly. They are certainly a great neighbor to have in providing 911 EMS response during surges . Recommended Level of Service : ✓ Tier 1 LTier 2 jjlier 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application packet . Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve PVAS for a Tier I License. Recommendation By : - Date : J1 /if he, Mat to i, EMTS Council Chair r . ' =RH k Weld County i- IN ars Department of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application : 10/26/2023 Name of Ambulance Service : Platte Valley Ambulance Service Owner: Name : Platte Valley Medical Center Address : 1600 Prairie Center Parkway, Brighton, CO 80601 Phone Number : 303-498- 1600 Operations Manager : Name : Chris Mulberry, NR-Paramedic (Chief Paramedic) Address : 1750 E. Egbert St. Brighton, CO 80601 Phone Number : 303-304-2017 Email : christopher.mulberry@imail.org Medical Director: Name : Candace Harrod, MD Address : 1600 Prairie Center Parkway, Brighton, CO 80601 Phone Number: 303-498- 1600 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest ( if applicable ) : Platte Valley Ambulance Service is a department of Platte Valley Medical Center, community hospital a part of Intermountain Health. As such we have no stockholders. Attached is current list of the board of directors. What area of Weld County will be served by this company? Please attach a map indicating the service area . We provide service for the Hudson Fire Department and the Southeast Weld Fire Department. We cover the towns of Lochbuie and Wattenburg with the Brighton Fire Department. a^ 1555 N . 17'r' Avenue ,* , ebb Greeley. CO 80631 1 j .se g Phone: 970-304-6410 0U F weldhealth.arg Public Health . Page 1 How many ambulances do you operate?16 Location and description of the place(s)from which this ambulance service will operate.If there are more than two locations,attach a separate sheet with the above information Location#1• Street Number 1750 E Egbert St City.Brighton State CO phone.303-981-8740 Location 82 Street Number-PVAS Station#2.on Platte Valley Medical Center Campus City.Brighton State CO Phone.303-498-1600 As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients ✓Yes No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile J Yes No Please read carefully: Sec 7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service. Tier I.Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II'Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This Licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III:Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested: /Tier 1 Tier II Tier III Page 2 Platte Valley Ambulance Service Locations (Sept 1,2023) Amb 55 15959 Havana St 7 days/24 hrs (Brighton Fire Stn 55) Amb 51 425 S Main St 7 days/24 hrs (Brighton Fire Stn.51) Amb 57 1606 Prarie Center Parkway 7 days/24 hrs (PVMC CUP Station) Amb 2825 702 Cedar St Hudson 7 days/24 hrs (Hudson Fire Stn 1) Amb 3921 65 E Gandy Ave Keenesburg 7 days/24 hrs (Southeast Weld Fire Stn 1) EMS 53 1750 E Egbert St 7 days/24 hrs (ALS Battalion Chief in fly car) Amb 22 5650 Holly Street 7 days/24 hrs (South Adams Stn 22) Amb 23 6550 E 72nd Ave 7 days/24 hrs (South Adams Stn 23) Amb 24 8600 Rosemary St. T days/24 hrs (South Adams Stn 24) Amb 27 11200 E 112th Ave. 7 days/24 hrs (South Adams Stn 27) Amb 28 10326 Walden St 7 days/24 hrs (South Adams Stn 28) EMS 23 6550 E 72nd Ave 7 days/24 hrs (ALS Battalion Chief in fly car) I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION . IN ADDITION , I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING , BUT NOT LIMITED TO , SECTION 7 - 8- 10 , WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE. DETERMINF►'ION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORM ,If ON , CONSTITUTE $ GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PR SECUTO . k, ati -� h i f Paramedic 1 C e iyo ? 3 Sigbtti MIApplicant Title Dote r2 ,41. 1 SUBSCRIBED AND AFFIRMED BEFORE ME THIS DAY OFrerni3e9-- 20 IN THE COUNTY OF %/ d aDiAT �� , STATE OF COLORADO . NICKIE MAILLET • NOTARY PUBLIC L � STATE OF COLORADO 1 NOTARY ID 20074020287 MY COMMISSION EXPIRES MAY 23. 2027 Signature of Notary ; Z My Commission expires : C", ,�a/ / Page 7 _ ______ _____ _ Brighton Fire Department 11 ........ ...... , _ , . - . .. ..L..._ ____A___ ,,A ______i L ___L _ _ _____ Brighton, Co. .._ A , , . , • -- saiirtain. .. ir k i :I t_d int 1 re :. 1 911 RESPONSE ZONES i , ,. . ; LI tate.Illeell i rise sae e ' • ii 117 1 a ktr 00;12,i 133: 402 Platte Valley Ambulance, Aug. 2012 I 5 a 115 ) . r 6 • I •LFj' 136 ' , III ` f « / ._ 155 1142 ,� ��l.� ,;,.� • r • - s s Pranar ` �'" _ I j 12i�1' ' ,aC .r*.� T j r— 140 T i1 111 { tea . : ( —+— 1 f ii I.I�.� t 434 4. *.."-- . v. Pp— I # ,_., d • . H. 4 . X132 i 134 .. ti 9 Wain" r ( 1 � ; e 11� 1--..--4•-‘,......: rall all r I — c - i 1s� X33 7 4 Li Y. I A .1 , 3 i ., . 135 327 Or"� 141 r 1 el ..L ti ,l /1 121 i ill ' t i i w - r. a .. ^ • A 1311 N 111. .E wanC.r f"rM . s ' a% • in 71 Os 1 3 • - _ 1 Rarer V Platte Valle1 Ambsa a+ce Untie Brlghlon Fire Rescue Department Ant 25 2012 Hudson Fire Protection District Fire Southeast Weld County re till 4: K tCR 40I _' at It CR II .. w ,� . i - — .• w aw a a aaI 17 4 ` It Z I ; i 1 hr rte Jt 1-s Il -x �.iks. - ' ' Cp 24 d W. l'' I C 3:r a CAR 2t _ , 1 r 1 , e ntl « . L. • ape c O`4� Sall. £; U1-., I I COI 22 y ~ ' ( SE WELD FIRE so — — is MO a . . OA SIII Ink. .+EG _ PROTECTION c�Ginn a1 Iit :� " 1 r I DISTRICT 1 ar ICS I8 t - - ._r 7. 1 ` 1 1 1 1 I i4 MP 1 •Ifillir Jai..1.1 • t 4 ' I I I .:I 4 �. • I I ' 1 r s laA • .1 •'► .. (il I ' w w 4. •. 1. w J C • - v-- �', I' _ T_- ' .1 _ NUDSON 'FIREagei I. 1 f 1 - I Li :. ; i ti cli a Silli PROTECTION 1 i 1 : I Y E Xt tide'DISTRICT. I� 1 N4 • _ 1 ► ' 1 { CS I L 1 1 I 1 I I t t I i 1 1 ' - C11 I 3 Ik . a t` — T , J i : �.. -. 4- _ 4P _ i _ + _ ._ IS _ .1 - 1 I . 0. L. -I I . + rl I a l 1 1 1 - t a - R a , 6 IS V I - r 1 1 I I i it �Ka'! r - - '`v u vL. _ .t.. - s; -..t ,1. a1 _ J. _• .�.. _ 1� _ — . I L I I ,e1 I 1 1 f _ I I C - , ( 1 1 1 I I I ( I I I aanru.........maim a/issiaisalseaa.us uof•a.•.al.. .:.im..rsiwn. iaslit ant ins ...—...I.r...«...,..,i.........«......__ 1 --- - -I , X Platte Valley Ambulance Service Ambulance Licensing Mutual Aid 2023 Platte Valley Ambulance Service is the designated 911 ALS Transport for the Hudson Fire Department, Southeast Weld Fire Department, Brighton Fire Department, and the South Adams County Fire Department. Under the terms of our agreements, we service the terms of each of the Fire District's mutual aid agreements. Medical MI Platte Valley Ambulance Service conducts a CQI program under the oversight of its medical directors, whose features include the following: - A peer-based employee selection process, by means of which crews determine their own selection criteria , conduct skill assessments and interview their own future colleagues. - A peer-based equipment selection process, by means of which crews choose or design their own disposable and non-disposable equipment, including everything from suction devices to ambulances . - A 100% general chart audit daily by Battalion Chiefs and lieutenants to review for clinical and operational accuracy, with support from Medical Directors, Chief Paramedic and Training Captain . Other quality improvement projects completed by Training Captain, Chief Paramedic and Medical Directors as need for maintain Key Performance Indicators. Results from chart audits help drive the education process for staff. - Monthly reports to Medical Directors. - An aggressive ongoing education process that includes small-group presentations and workshops. When opportunity is presented, national speakers will be utilized for some of the education presented . Education is presented with Evidenced Based Care as a primary focus. A4AAAAAAAAAAAAAA444L AA_ � WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT r NIILicense to Operate Ambulance Service r "NI TIERI rr .i PLATFEVILLE GHCREST FIRE PRO'TECTIOI�i DISTRICT � 202 MAIN STREETilo , PLATTEVILLE , COLORADO 80651-41 r -44 IS LICENSED UNTIL DECEMBER 31, 2024, TO OPERATE AN AMBULANCE SERVICE r IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . -4r NO I 2 2 2323 .,. , r .i Perttat-- :-L4.... WNWCHAIR , BOARD OF WELD COUNTY COMMISSIONERS DATE '��°' ; A fj �J COUNTY -lig or \ l NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE r Pry Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1-30 of the Weld County Code . lk 1. 11861,, �•.►•' t I r r 2 WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT f- ) � -� r 1555 North 17th Avenue ,, ; . ,, , r Greeley , CO 80631 www .weldhealth . org Ni Recommendation of the Weld County Emergency Medical/Trauma Service Council for : Platteville-Gilcrest Fire Protection District As required in Section 7-2 - 100. B . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location, service area, etc. that are the basis for the Council's recommendation : FINDING # 1 : We, the council, find that Platteville-Gilcrest Fire Protection District ( PGFPD) contributes to an efficient, effective, and coordinated service by providing 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies' areas when reauested . p FINDING #2 : PGFPD serves areas in the south-central portion of Weld County and ensures timely response to their area . They are willing to assist their neighbors when requested . FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of patient care . FINDING #4 : PGFPD has mutual aid that is in place with their neighboring agencies. Whenever a neighboring agency requests their assistance, they do so promptly. They are certainly a great neighbor to have in providing 911 EMS response during surges. Recommended Level of Service : killer 1 LiTier 2 Her 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application g PP packet. Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve PGFPD for a Tier I License. cV2Recommendation By : Date : i i ic ./2-0 Z T �D Prunk, EMTS Council Vice Chair 1 .1 04., Weld County i r, ..„ 7 ! H . �-t ''� �. Department of Public Health and Environment n: AMBULANCE SERVICE LICENSE APPLICATION Date of Application : 10/2/2023 Name of Ambulance Service : Platteville Gilcrest Fire Protection District Owner : Name : Platteville Gilcrest Fire Protection District Address : PO Box 407/202 Main Street, Platteville , CO 80651 Phone Number : 970-785-2232 Operations Manager : Name : Matt Concialdi Address : PO Box 407/202 Main Street, Platteville , CO 80651 Phone Number : 970-785-2232 Email : mconcialdi@pgfpd .org Medical Director : Name : Kristen Knowles Address : 3228 N Clay Street, Denver CO 80211 Phone Number : 970-389-0495 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest ( if applicable ) : NA What area of Weld County will be served by this company ? Please attach a map indicating the service area . Platteville and Gilcrest - South Central Weld County - 144 square miles M►u ih 1555 N . 17th Avenue 1861 ' ay Greeley, CO 80631 tj ; , Phone: 970-304-6410 tiri) weldhealth .org - � " PubiicHPatth 'ts44; 'i ` ficvtet ftu,nutr Floral ��-_ Page 1 How many ambulances do you operate?4 Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 Street Number 202 Main Street City Platteville State CO Phone 970-785-2232 Location#2 Street Number 14679 CR 42 City Gllcrest State CO Phone 970-785-2232 As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients ✓Yes No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile Yes No Please read carefully Sec.7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I:Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II.Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This lcensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III:Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested- 6/Tier I Tier II Tier III Page 2 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION IN ADDITION,I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7,INCLUDING,BUT NOT LIMITED TO,SECTION 7-8-10,WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION EMS Chief 10/2/2023 Signature of r Title Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS O DAY OF O O"069-- ,20�- ,IN THE COUNTY OF W ,STATE OF COLORADO Signature of Notary My Commission expires / / VANESSA KOOPS1ABS WADER NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20164012698 MY COMMISSION EXPIRES 4-1-2024 Page 7 ,.cj r nv }`. . ' _ . . .�lF.,�.. Platteville- Gilcrest Fire Protection District . i• PGFPD • ! P. O . Box 407 202 Main Street • �!! ,�\�- Platteville, CO 80651 s G s.,, os' 970 . 785 . 2232 • FAX 970 . 785 . 0139 G The Platteville-Gilcrest Fire Protection District is apart of the Weld County Mutual Aid Contract and currently has specific EMS Mutual -Aid and contract agreements with the following agencies : • Mountain View Fire Protection District • Frederick Firestone Fire Protection District • LaSalle Fire Protection District • Front Range Fire Rescue Respectfully, rode CondaQt Matt Concialdi EMS Division Chief I_ C' F /f L. % - Evans I FR2D i. AS /..: 6A4i5---� -ti-t,— .S R-15 :.a,.a r.— • I 7 FR2A � •F r t S a / X Johnstown • Milliken if ye — .i. /,,,.. t. I Gilcrest y' - f .or PLFRL ! k�,• _ .0-4S i ;.3•y — "�___` t X :• PLMFL ( I Y , , /„.; ,�t — \ • PLMFA\ y kr -. . .4-'a- PLL I r — -- 1• 3 �»_ yyc PL•FFR PLFRA PL1.1VA i Platteville ' f I ca-3: > l i ` PLLFF i____� i _ . ✓: ! / '; re PL PLFFA-7--------1 --- ye / / 1 /a4 s "• GA-212-0--\:\i' • ---- - , i. a .L tY 3 GIVie — • 41 PLATTEVILLE - GILCREST FIRE DISTRICT \\Ns Firestone ( RESPONSE AREAS ) 71 L. Hudson — Lo Rose I FILM•Frant Rang►Money IMO D.wnd NOM of Ns Pla OF ewoaanl Auto Aj C. R FRL•Front Range La Salle Auto Aid LOW — Cony ROM FR2D•Frail Rage Angry una DMlnd Noth of Ron PItw$.-Glaeat Enna Auto N0 ;ILL La Sale Auto Ad _- •-..- r tinNpllwfy _ . PL -DYOne6Uaf �IF d O No Aida Ad 1- PUFF-Fedaek FMeno La SAO Auto Aid I ' _ N LIKES and RIVERS _ PLC •Ffeeent*Ironton*Auto h0 1..i-r 1 P WA•Fort Range Mourean New Auto NO A D nae oe-c .S Fee Foloclon Papua —_I PLFFR-Nodal.*FL..lar Front Range Ls SAN Auto A d III R1AFL•Frau Range La SW Uo.ewsn Vivo Auto Aid • J PLFM-Not*Rang*Auto A4 M RANA-Alovnan Vow Auto Ad Frederick - .211-1 4-S - J A A J I I I I I J I I / III / / J I J WELD COUNTY DEPARTMENT ' OF r PUBLIC HEALTH & ENVIRONMENT vr License to Operate Ambulance Service r "I TIERI r -4 SOUTHEAST WELD FIRE PROTECTION DISTRICT � r 95 WEST BROADWAY AVENUE , KEENESBURG , COLORADO 80643 \ r Nil IS LICENSED UNTIL DECEMBER 31 , 2024, TO OPERATE AN AMBULANCE SERVICE r IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . r c , -4 3 � NOV ‘ ,, .10., •. . _ Is() , : ..ar Pr , , 9 CHAIR , BOARD OF WELD COUNTY COMMISSIONERS DATE jjf NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE r -go r Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1 -30 of the Weld County Code . r ' WELD COUNTY DEPARTMENT OF PUBLIC HEALTH r AND ENVIRONMENT � - 1555 North 17th Avenue , Greeley , CO 80631 www . weldheolth . org Recommendation of the Weld County Emergency Medical/Trauma Service g Y /T Council for : Southeast Weld Fire Protection District As required in Section 7 -2 - 100. B . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location , service area, etc. that are the basis for the Council's recommendation : FINDING #1 : We, the council, find that the Southeast Weld Fire Protection District (SEWFPD) contributes to an efficient, effective, and coordinated service by providing 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies' areas when reauested . FINDING #2 : SEWFPD serves areas in the southeast portion of Weld County and ensures timely response to their area . They are willing to assist their neighbors when requested . FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of patien t t care . FINDING #4 : SEWFPD has mutual aid that is in place with their neighboring agencies . Whenever a neighboring g g g agency requests their assistance, they do so promptly. They are certainly a great neighbor to have in providing 911 EMS response during surges. vimmer Recommended Level of Service : ✓ Tier 1 ____Tier 2 nTier 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application packet. Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve SEWFPD for a Tier l License . Recommendation By : �. - D /457-1) Z- 3 Date : Matt Concialdi, EMTS Council Chair • Weld county 1/2 - <<: you_NTH Department of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application : 8/14/2023 Name of Ambulance Service : Southeast Weld Fire District Owner : Name : Southeast Weld Fire District Address : 95 W . Broadway Avenue , Keenesburg 80643 - Phone Number : 303-732-4203 Operations Manager : Name : Torn Beach Address : 95 W . Broadway Avenue , Keenesburg 80643 Phone Number : 303--732-4203 Email : tbeach@seweldfire . org Medical Director : Name : Candace Harrod , MD Address : 1600 Prairie Center Parkway, Brighton 80601 Phone Number : 303-498- 1600 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest ( if applicable ) : N/A What area of Weld County will be served by this company? Please attach a map indicating the service area . Southeast Weld County ks-_ii 1555 N _ 17th Avenue Greley, CO 806314 PHAa Phone : 970-304-6410 yo u -� Public Health V2 weldhealth .org re � i I Ptent Promote Pt• ttct Page 1 How many ambulances do you operate?2 Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 Street Number 4910 Highway 79 City Keenesburg State CO Phone 303-732-4203 Location#2 Street Number 65 E Gandy Avenue City Keenesburg State CO Phone 303-732-4203 As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients Yes No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile v Yes No Please read carefully Sec 7-2-10 License for Ambulance Service No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I.Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III.Licensure authorizing for Standby Service,an defined in Section 7-1-30 of this Chapter Level of Service Requested t/Tier I Tiei II Tier III Page 2 AMBULANCE VEHICLE PERMIT LIST Name of Ambulance Service Southeast Weld Fire District Vehicle# Year 2002 Make Chevy Model K3500 4 Wheel Drive(Y/N) Y Ambulance Type* Primary ALS_ Primary BLSX Reserve_ Vehicle Identification Number(V I N) 1 GBJK34182F136948 Colorado State License Number(Registration No) 03P110944 Motor Vehicle Chassis Number CK36403 Registered with the State of Colorado as an emergency vehicle YESX NO N/A Date Ambulance placed in service 10131/2012 Normal Location of Ambulance 4910 Highway 79,Keenesburg 80643 Vehicle# Year 2019 Make Ford Model F-450 4 Wheel Drive(Y/N) Y Ambulance Type* Primary ALS_ Primary BLSX Reserve Vehicle Identification Number(V I N) 1 FDUF4HY8KDA27049 Colorado State License Number(Registration No) L0034036939 Motor Vehicle Chassis Number 19OF25155G Registered with the State of Colorado as an emergency vehicle YESX NO N/A Date Ambulance placed in service 1/2/2020 Normal Location of Ambulance 4910 Highway 79,Keenesburg 80643 Vehicle# Year Make Model 4 Wheel Drive(Y/N) Ambulance Type* Primary ALS_ Primary BLS_ Reserve_ Vehicle Identification Number(V I N) Colorado State License Number(Registration No) Motor Vehicle Chassis Number Registered with the State of Colorado as an emergency vehicle YESX NO N/A _ Date Ambulance placed in service Normal Location of Ambulance *Refer to Weld County Code Section 7-1-30 Definitions(Ambulance) Please make additional copies as necessary Page 6 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION IN ADDITION,I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7,INCLUDING,BUT NOT LIMITED TO,SECTION 7-8-10,WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION Fire Chief 8/14/2023 Signature of Applicant Title Date R 1 SUBSCRIBED AND AFFIRMED BEFORE ME THIS 14th DAY OF August 2023 ,IN THE COUNTY OF Weld ,STATE OF COLORADO P . IRENE M BURKE-HYBERG Notary Public State of Colorado 411 4-2 nn ,4/27; Notary io N 20174003247 A'I My Commission Expires 03247 025 Signature of Notary My Commission expires 01 /20 X2025 Page 7 i . r[- i i1 �,5 J.:,I 'i'"J'i,;..1LI • 7..i �. { C� 1 _ t'1l:`-- ..1").-'.t .e t L. [.f l'_a1t vt.:.s. 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I:siSit. lI !.11 ` ' it:Mill:Sy ::.: .lit- .5 Taal.: . �.tm. %j�-z3•t at,. • 1uu•ctR fr al t� l�S]�+d r "ilig4. .F. ) UY�-l1 wytnxrlR _ r.e;w._. .: l� t( a it'}�s3! S:. >S?�dL 1••LyLS • i•41'-LZI;I'...IS: t. .. 1/• L t a to ' Ira:CE -• ..I 1 2 � �� •f•�J{1!if..J. EyS1L..t1L•- i!SL1lT1t —_—� [r':1..ti'• t • t air L.T."•\cis 'IlLt.�.t'[�4____ _:lL1. SOUTHEAST WELD AMBULANCE 1 Legend IMIN :•,...:<<:I, a....3n EMS DISPATCH ZONES E1.1$ Dispatch Zones tY- t, r----0-; „� L. Zone Code ;`4io 4 ni f ' ; \Jct. i l� 1 11-11 1 t 1R'..'J a:.ill -•� ia . �'ii �l Pi • T U .•a I 1 .�1 g — L!;>: G:• i I i•.4 G •.r) ':X14 • ' - . .•. . a 1I . ' r- S. .., - HONORS • ($IEI WELD 4:11 (19 „z, FIRE apaE - BR4`ear 8/ 14/2023 To Whom It May Concern : Southeast Weld Fire District has mutual aid agreements with Platte Valley Ambulance Service, Bennett Fire District, Strasburg Fire District and Morgan County Ambulance . Sincerely, om each Fire Chief Southeast Weld Fire Protection District 95 W . Broadway Avenue - Keenesburg, Colorado 80643 - 303 - 732 -4203 www .seweldfire . org -4N1 r WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT , r License to Operate Ambulance Service , r "I TIERI NI r THOMPSON VALLEY EMERGENCY MEDICAL f 4480 CLYDESDALE PARKWAY, LOVELAND , COLORADO 80838 -4 r Nu IS LICENSED UNTIL DECEMBER 31 , 2024, TO OPERATE AN AMBULANCE SERVICE r IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . -N4 r iql 1 n g ,-,, ,- .---7-1, , , c .ThAs.4„ , _ _ 7 ! r. - 2 I cl 23234,..,tom 18��1_� � CHAIR , BOARD OF WELD COUNTY COMMISSIONERS DATE +i I '' I e�'i. i'i3' (‘ ,_ i r NNOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE -411 p Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1-30 of the Weld County Code . lit�� ' � � WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT • 101rI 1555 North 17th Avenue , Greeley , CO 80631 www . weldhealth . org ' fir Recommendation of the Weld County Emergency Medical /Trauma Service Council for : Thompson Valley EMS As required in Section 7 -2 - 100 . B . 5 ., the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location, service area , etc. that are the basis for the Council' s recommendation : FINDING # 1 : We, the council, find that Thompson Valley EMS (TVEMS) contributes to an efficient, effective, and coordinated service by providing 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies ' areas when requested . FINDING #2 : TVEMS serves areas in the central-western portion of Weld County and ensures timely response to their area . They are willing to assist their neighbors when requested . FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of patient care . FINDING #4 : TVEMS does not have mutual aid in place with their neighboring agencies. However, whenever a neighboring agency requests their assistance, they do so promptly. They are certainly a great neighbor to have in providing 911 EMS response during surges. Recommended Level of Service : reirTier 1 ETier 2 Hrier 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application packet. Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve TVEMS for a Tier I License . Recommendation By : Date : / 1 /C /Z,; 2 ) Matt Concialdi, EMTS Council Chair i (A,L1(o ( • nt `, Department of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application 10/30/2023 Name of Ambulance Service Thompson Valley EMS Owner Name Thompson Valley Health Services District Address 4480 Clydesdale Pkwy,Loveland,CO 80538 Phone Number 970-663-6025 Operations Manager Name James Robinson Address 4480 Clydesdale Pkwy,Loveland,CO 80538 Phone Number 970-663-6025 Email lrobinson@tvems org Medical Director Name Dr Jasiot Johar Address.5606 Willow Springs Court,Fort Collins,CO Phone Number 970-481-0742 Name and address of each stockholder of partner owning 10%or more of the outstanding stock of the company of having more than a 10%ownership interest Of applicable) Title 32 Special District _ Jon Smela-Board Chairman What area of Weld County will be served by this company?Please attach a map indicating the service area. Western Weld County within the geographic boundaries of TVHSD,Windsor,Berthoud&Johnstown fire districts • 1555 N 17th Avenue Greeley,CO 80631 �1f�`re,8' i• �f 3l" Phone 970-304-6410 weldhealth org zx- P�tblic..,Heatth a"° Page 1 How many ambulances do you operate?1S Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 Street Number See attached City State- Phone _ Location#2 Street Number _ City State* Phone. As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients 1 Yes No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile /Yes No Please read carefully. Sec 7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I.Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II:Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested. ✓Tier I Tier II Tier III Page 2 Thompson Valley EMS Location#1 2100 N Boise Ave Loveland,CO 80538 970-669-7256 Location#2 380 N Wilson Ave Loveland,CO 80537 970-776-8474 Location#3 740 N 2nd St Berthoud,CO 80513 970-344-7158 Location#4 2750 N Taft Ave Loveland,CO 80537 970-775-7351 Location#5(Headquarters) 4480 Clydesdale Parkway Loveland,CO 80538 970-663-6025 Location#6 4645 Sunview Dr Loveland,CO 80538 970-685-4808 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION . IN ADDITION , I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING , BUT NOT LIMITED TO, SECTION 7-8- 10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE . DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION , Chief, Thompson Valley EMS 10/30/2023 Sign ore of Applicant Title Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS DAY OF0Q,WAA _ 120a 3 , INTHECOUNTYOF L_ rrL .. , STATE OF COLORADO . \-\\AJP•-)%tA.CAS-Qact\ii•-• Signature of Notary (Y3-. I MARVI CELESTE Dl m s1on expires : / itRoc2.3-- NOTARY PUBLIC . STATE OF COLORADO Notary ID #19914010442 My Commission Expires 7/31 /2027 Page 7 `i ‘re alai . ■ Co ivaa ■ IP Sr �g Ilit to, .. aril''WSJ t 4 sN� C' FORT H ' • rii COL'L' INS ' t . .. ■� i_ • • WINDSOR 2 jLOArIt \ i _: m.L... i 31 0 I IS 1 — - — ' Isc i , „ �JaHNSTOWN s A I ESTES PARK -) r-.1\NNN. : y �, 1 1 . I 36 i 4 O , 60 i El L, N ' ` BERTHOUDI HHI THOMPSON VALLEY BLERGENCY MEDICAL SERVIC-FS 4480 Clydesdale Pkwy . . Loveland , CO Main 970-663-6025 Fax 970-667- 0172 Mutual Aid Agreements Since we are licensed in both Weld County and Larimer County we don 't have any official mutual aid agreements in place . We are dispatched as needed and respond when surrounding EMS agencies are in need of EMS support services . Chief James Robinson 4AAAAAAAAAAAAAAAAAAAa __ . „IfilA pr , WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT � Nig r -4 License to Operate Ambulance Service r -NI TIERI r RC H Y MEDICAL � UGHEALTH EME � C SERVICES NI r 7O1 AUTOMATION DRIVE , WINDSOR , COLORADO 80550 NI pr- -11 IS LICENSED UNTIL DECEMBER 31 , 2024, TO OPERATE AN AMBULANCE SERVICE r IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . r , , , _.? „... _ , , . \ 3 M1/4--Cci--„ ;L.. 4. n 2 2 2323 .. . #4 CHAIR , BOARD OF WE--11) CnIINIY COMMISSIONERS DATE E � 'I'NI I . • pr NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE r ‘41 r Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1 - 30 of the Weld County Code . • 1 . I r=i WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT fr; r : 1555 North 17th Avenue , Greeley , CO 80631 www . weldhealth . org Recommendation of the Weld County Emergency Medical /Trauma Service Council for : UCHealth EMS As required in Section 7 -2 - 100 . B . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location, service area , etc . that are the basis for the Council' s recommendation : FINDING # 1 : We, the council, find that UCHealth EMS ( UCHEMS) contributes to an efficient, effective, and coordinated service by providing 911 EMS service to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area and into their neighboring agencies ' areas when requested. FINDING #2 : UCHEMS serves significant areas in the central -western portion of Weld County and ensures timely response to their area . They are willing to assist their neighbors when requested FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of patient care . FINDING #4 : UCHEMS does not have mutual aid in place with their neighboring agencies. However, whenever a neighboring agency requests their assistance, they do so promptly. They are certainly a great neighbor to have in providing 911 EMS response during surges . IIMENIMMOV Recommended Level of Service : Y' iier 1 .___.Tier 2Liner 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application pplication packet . Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve UCHEMS for a Tier I License . Recommendation By : TT9„ � Date : /� 2y ��"� J 3 Matt Concialdi, EMTS Council Chair ,r Weld County . ... • t I / } sty Department of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application : 10/24/2023 Name of Ambulance Service : DBA - UCHealth EMS Owner : Name : Poudre Valley Healthcare inc. Address : 701 Automation Drive , Windsor, Colorado 80550 Phone Number : (970 ) 495-7000 Operations Manager : Name : Kevin Waters Address : 701 Automation Drive , Windsor, Colorado 80550 Phone Number : (970 ) 495-7000 Email : Kevin .Waters@uchealth . org Medical Director : Name : Darren Tremblay, D . O . Address : 701 Automation Drive , Windsor, Colorado 80550 Phone Number : ( 970 ) 495-8006 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest ( if applicable ) : N / A What area of Weld County will be served by this company ? Please attach a map indicating the service area . Windsor, Severance , Johnstown , Milliken , Hill-n-Park , Evans , Kersey, LaSalle , Greeley, Western Hills 1555 N . 17th Avenue ,w,, Greeley, CO 80631 stja r ,; IP PHAB Phone : 970-3046410 ,. '`� . r Pt weldhealth . org % Public Health Page 1 { How many ambulances do you operate?38 Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 Street Number See Attached Form City State Phone Location#2 Street Number _ Ji City State Phone As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients ✓Yes No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile Yes No Please read carefully: Sec 7-2-10 License for Ambulance Service No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested: R'Tier I Tier II Tier III Page 2 I Location#1 701 Automation Dr,Windsor,CO 80550 Location#2 181 Timber Ridge Pkway,Severance,CO 80550 Location#3 100 N 7th,Windsor,CO 80550 Location#4 2100 37th St,Evans,CO 80620 Location#5 27128 Co Rd 53,Kersey,CO 80644 Location#6 , 118 Main St,La Salle,CO 80645 Location#7 100 Telep Ave,Johnstown,CO 80534 Location#8 101 S Irene Ave,Milliken,CO 80543 Location#9 Front Range Fire Rescue Station 3/UCHealth 4225 Yosemite Dr,Greeley CO 80634 Location#10 5881 W 16th St,Greeley,CO 80634 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION . IN ADDITION , I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING , BUT NOT LIMITED TO, SECTION 7 -8- 10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE . DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION . I/ // Y(/' /7" f � Serev ; . ELL / 0 30 2 013 Signa e o Applicant Title Dote SUBSCRIBED AND AFFIRMED BEFORE ME THIS V.) 1-4 ‘ DAY OF a 4-0 kir , 20 .23 , IN THE COUNTY OF lAk k , STATE OF COLORADO . f 11/411414k `-O-Mar Signature of Notary My Commission expires : ay / 05 NAKEESHA ROMERO NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20174014813 MY COMMISSION EXPIRES APRIL 5, 2025 Page 7 N.-11J r �,,` 1 I \ 1 I i C\ r SE \ M. 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Ill A�' � WCR 418iriVirrill.°)r-1 City of Evans and Vicinity tY _rail , , March 2010 C a, tiQ r, A" Xu ,..., Legend U x 3 Evans Urban Evans City Limits Growth Boundary WCR 46 Miles 0 0 .5 1 1 .5 2w, rei u 1 :48,000 3 Disclaimer ��Nff- T his map was designed and intended for City of Evans use only; it is not guaranteed to survey accuracy This map is based on the best information available on the dale shown on this map The City of Evans W E makes nn warranties or guarantees. either expressed or implied, as b the completeness, accuracy or Ifras•- correctness of this map, for accepts any liability arising from any incorrect. incomplete, or misleading 60 nformaton contained therein My reproduction or sale of this map, or portions thereof. is prohibited 3 withoul the express written authorization by the City of Evans __. - ---�_ .�_. k _ :fir►.a•�..►r,•.a.r►i... .+Y•^R�.-• • r.,..............r ............_ .' . s tY'••. ii 1 l 1 ...4 e j lu• Z • I SIM •, • 1 1 . • t . • Y . _. 4 - ;, [..— t ' 1 I, ana • 1ar...`.(( 1 1 I yam+... ,' _ 4144144404 • I = tJ40#4,.....0 •..•.w• I 1- -...k.i t ., S . _,. f. . �.*-� - I 1 _ •.-Miesri.;.- r I ! .`_ • _ ebk fA I .w... 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'!> � ; set � i .rpf • 0) 30 i a rte•- Jr: r V� it LO AA4AAAAAAAAAAA4AAAA4A Nil , N img WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONM-1ENT � P r •N iLicense to Operate Ambulance Service r Nii 9 TIER I r ` IJCHEALTH LIFELIN � E 2, 450 SOUTH PEORIA STREET 3RD FLOOR , AURORA , COLORADO 80014-9 'Ng Pr ‘44 IS LICENSED UNTIL DECEMBER 31, 2024 , TO OPERATE AN AMBULANCE SERVICE r IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . r -1 3 /in:,-k z ;L a s-, Mg 2 2 2323 ..,t , , - ;. ., igoi .. ,. _ ___ _„ . P r CHAIR, BOARD OF WELD COUNTY COMMISSIONERS DATE N ,_ , - - NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE I ' -1 4 4 r Tier I : Licensure authorizing for Primary Care, as defined in Section 7 - 1 - 30 of the Weld County Code . di — t4 .4 ,j WELD COUNTY • • 01 r, 1 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT -- 1555 North 17th Avenue , Greeley , CO 80631 wvvvv . weldhealth . org Recommendation of the Weld County Emergency Medical/Trauma Service Council for : UCHealth Lifeline As required in Section 7-2- 100. B . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County . Please include any findings related to response time, coordination with other ambulance services, location, service area, etc. that are the basis for the Council' s recommendation : FINDING #1 : we, the council, find that UCHealth Lifeline ( UCHLL) contributes to an efficient, effective, and coordinated service by providing specialized EMS services to the citizens of Weld County. As a Tier I service, they respond timely to calls for assistance within their service area . FINDING #2 : UCHLL serves all of Weld County and ensures timely response. They are willing to assist their neighbors when requested . FINDING #3 : The EMTS Council is unaware of any concerns with timely responses for service or issues with the level of patient care. FINDING #4 : UCHLL does not have mutual aid in place. However, whenever an agency requests their assistance, they do so promptly. They are a great asset in providing 911 EMS response during surges . Recommended Level of Service : Tier 1 ETier 2 Tier 3 Recommended Service Area : The EMTS Council members recommend the coverage area indicated in the application packet. Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve UCHLL for a Tier I License . Recommendation By : L- ''� Date : i � ' Y /2-t, z 3 S Matt Concialdi, EMTS Council Chair Health Administration Public Health & Environmental Health Communication, Emergency Preparedness rridi Vital Records Clinical Services Services Education & Planning & Response Tete: 970-304-6410 Tele: 970-304-6420 Tele: 970-304-6415 Tele: 970-304-6470 Tele: 970-304-6470 Fox: 970-3046412 Fax: 970-304-6416 Fax: 970-304-6411 Fax: 970-304-6452 Fax: 970-304-6452 Public Health ? ' •4 1 r� q. WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Mtn- 1555 North 1 th r . �:. cr, .iM 7 Avenue , Greeley, CO 80631 www.weldheafth . org AMBULANCE SERVICE LICENSE APPLICATION Date of Application: 09/06/2023 Name of Ambulance Service : UCHealth LifeLine Owner: Name : PVHC d/b/a UCHealth LifeLine Address: 2450 S . Peoria St, 3rd Floor, Aurora, CO 80014 Phone Number: _844 . 867. 4590 Operations Manager: Name : Doug White Address : 2450 S . Peoria St, 3rd Floor, Aurora, CO 80014 Phone Number : _970 . 388 .2677 Email : Doug. White@ucheal . org Medical Director: Name : __Leslie Moats Address: 2450 S . Peoria St, 3rd Floor, Aurora, CO 80014 Phone Number: J44 . 867. 4590 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest (if applicable) : What area of Weld County will be served by this company? Please attach a map indicating the service area. Entire County Page 1 ,:10E-141 2TJ:+ciry'� Tian5 Company Information&Ownership Company Name PVHC d/b/a UCHealth Lifeline 2450 S Peoria Street,3rd Floor,Aurora,CO 80014 844-867-4590 Ownership 100%University of Colorado Health Authority Owner Information PVHC d/b/a UCHealth Lifeline 2450 S Peoria Street,3rd Floor,Aurora,CO 80014 720-848-0000 Manager or Responsible Individual.Doug White 2450 S Peoria Street,3rd Floor,Aurora,CO 80014 970-388-2677 Insurance information Insurance Company:Beecher Carlson Insurance Services 1500 Broadway,215i Floor,New York,NY 10036 646-358-8500 Insurance Point of Contact: Steph Upton,Risk Management Specialist 1400 E Boulder St,Bldg 7,RM 105,Colorado Springs,CO 80909 719-365-8480 Stephanie Upton@uchealth org Health Administration Public Health & Environmental Health Communication, Emergency Preparedness Vital Records Clinical Services Services Education & Planning t Response Tele: 970-304-6410 Tele: 970-304-6420 Tele: 970-304-6415 Tele: 970-304-6470 Tele: 970-304-6470 Fax: 970-304-6412 Fax: 970-304-6416 Fax: 970-304-6411 Fax: 970.304-6452 Fax: 970-304-6452 Public Health How many ambulances do you operate? 4 Location and description of the place(s) from which this ambulance service will operate. If there are more than two locations, attach a separate sheet with the above information. Location # 1 : Street Number: _5881 W 16th St City: Greeley State: CO Phone: 844 . 867 . 4590 Location #2 : Street Number: _ 1713 -2 Quentin St City: Aurora State : CO Phone: 844. 867.4590 Location #3 : Street Number: _ 1400 Boulder St City: Colorado Springs State : CO Phone : 844. 867. 4590_ Location #4 : Street Number : _2450 S . Peroia St City: Aurora State: CO Phone: 844. 867. 4590_ As required in Section 7-3 -30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations, as of the date of the application, are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients: XYes ❑ No As required in Section 7-3 -40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations, as of the date of the application, are you in compliance with the reporting requirements of the agency profile : XYes ❑ No Please read carefully: Sec. 7-2- 10 License for Ambulance Service. No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners, except as provided in Section 7-2-80 below. The fee for Page 2 said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I:Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier lIII:Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier Hi:Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested:X Tier I Tier II Tier Ill I have attached the following documents to this application: A list of ambulance agencies,fire departments,special districts,and other EMS providers with which the applicant has mutual aid agreements,or Currently,our agency does not have mutual aid agreements with other ambulance agencies,fire departments,special districts or EMS providers XA map of the service area x If ambulance service/ambulances have been licensed/inspected by another County in Colorado,within the most recent licensure period,attach the current license,and either the vehicle permits or other proof of recent inspection(not to exceed twelve months)for each vehicle to be operated m Weld County A current copy of the ambulance service's pharmacological agents and delivery devices per medical director protocol This only needs to be provided if your ambulances are to be inspected by the Weld County Depat invent of Public Health and Environment If your Page 3 Normal Location of Ambulance: Please make additional copies as necessary. I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN TH IS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION. IN ADDITION, I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING, BUT NOT LIMITED TO, SECTION 7-8- 10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE. DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION. 1242/ece3 soel ar'neectok. co' ft£gn atii e o pp nt Tide Date 2 111— SUBSCRIBED AND AFFIRMED BEFORE ME THIS I DAY OF SQfkfll >er 2023 , IN THE COUNTY OF LiLn rvt,e.Y , STATE OF COLORADO. A_ his Signature of Notary My Commission expires: / / f b / Z026- LINDA M DISNEY NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20014030011 MY COMMISSION EXPIRES OCTOBER 16, 2025 Page 7 N ��fi xsYJ� „"�c9tuc�cc�. .4472 Operations,Locations,Service area,Personnel&Ambulances Service Area See attached map. Locations: Business Office/Main Location 2450 S Peoria Street,3rd Floor,Aurora,CO 80014 844-867-4590 Business Office/Secondary Location Main Dispatch Center 2450 S Peoria Street,3rd Floor,Aurora,CO 80014 844-867-4590 Backup Dispatch Center 2450 5 Peoria Street,Building 3,Aurora,CO 80014 Vehicle Locations 5881 W 16th St,Greeley,CO 80634 1713-2 Quentin Street,Aurora,CO 80045 1400 E Boulder St,Colorado Springs,CO 80909 Sedgwicit La rimer Logan Weld MoffatPrullips Jackson ..,. Routt ` organ Rio Blanco Grand in 1 Yuma 44 , it Adams Washington Garfield Eagle , Eti rirsh Arapahoe Kit Elbert Mesa Pitkin Park Dou Carson Lake . . El Delta Gunnison �a� I . Cheyenne Paso incoln Montrose ' Fremont Kiowa ItovvIey San Miguel is �. Saguache Lc-Titer Pueblo g Bent Provers Dolores San o. "' atero Hue �► Juan • N e? Montezuma ,C%°1- Grande �° c'� La Baca Plata Archuleta conejos comma Las Animas 41AAAAAAA _AAAAAAAAAAAAAL, r WELD COUNTY DEPARTMENT OF PUBLIC -4 & ENVIRONMENT I r License to Operate Ambulance Service TIERII Ill -14 r -14AMBIJLNZ I ..il3550 NORTH ACADEMY BOULEVARD , COLORADO SPRINGS , CO 80917 pr -14 IS LICENSED UNTIL DECEMBER 31 , 2024, TO OPERATE AN AMBULANCE SERVICE IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . III r Nil i tinetiect , 2 NOV 2 2323 z\z_ 1861 /›..-:0; . Vall,1).1 CHAIR , BOARD OF WELD COUNTY COMMISSIONERS DATE I ' 1 IiitiaLt ° 13NTY , c NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE.1441 Tier II : Licensure authorizing for transports of patient ( s ) to and from licensed medical facilities . This licensure does not provide for Primary Care, as i r defined in Section 7 - 1- 30 of the Weld County Code . ti ri = L) WELD COUNTY DEPARTMENT • r; r . OF PUBLIC HEALTH AND ENVIRONMENT - - 1555 North 17th Avenue , Greeley , CO 80631 www . weldhealth . org Recommendation of the Weld County Emergency Medical/Trauma Service Y /T Council for : Ambulnz As required in Section 7 -2 - 100 . B . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location , service area , etc . that are the basis for the Council 's recommendation : FINDING # 1 : We, the council, find that Ambulnz contributes to an efficient, effective, and coordinated service by providing g inter-facility transport services to the citizens of Weld County. As a tier II service, they allow 911 response units to remain available in their service areas. FINDING #2 : Ambulnz timely responds to calls for providing interfacility transport of patients. They coordinate with Medical Facilities to provide service . FINDING #3 : As a Tier II agency, they rarely interact with 911 agencies, although they work well with other IFT agencies . FINDING #4 : Recommended Level of Service : ier 1 ✓ Tier 2 ier 3 Recommended Service Area : The EMTS Council members are not concerned with the Ambulnz area they serve . Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve Ambulnz for a Tier II License . Recommendation By : Date : / i 11 // t.; z� Matt Concialdi, EMTS Council Chair - '` County Department of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application 1O/2S/2023 Name of Ambulance Service AIAO ue..ndz EY 0o.cs0 Owner Name A"Bo Utz HoCDipms 1.Lc Address 3s WEST 3s,o ss 5.,rings tin,.Yalu< ill I000l Phone Number (212.)M-9994 Operations Manager Name Rovcg Davis , D aEcToR of oPEaAsioNs co Address 3Sso N ACADOISY BLVD,COLODADo SPkItV6S C.0 IS0919 Phone Number. (612)q46-%96S Email' 2DAiISO DoCC70.Cora Medical Director Name Da ANCvCLA wD16HT M 0 Address 12606 E 16TH Ave, AuR®RA co tsao4S Phone Number 1920)1348-6 � Name and address of each stockholder of partner owning 10%or more of the outstanding stock of the company of having more than a 10%ownership interest(if applicable) AVABVLNz F1o1.D1rd1,S LLc So./. , 3S w 3Szq sT STa Roos NEW YORK ivy 1000 Juivensti- of Ca.oCADO dPALTH SO/. 124n1 Avs..nwn.sra c i ,AaRonA Go gov4S What area of Weld County will be served by this company?Please attach a map indicating the service area. Esriec coo.,Y , SAE A1TAiiit)AAAP 1555 N 17th Avenue ( Greeley,CO 80631 -19 j 'E Phone 970-304-6410 ' weldhealth org s"�s.:=� M tat as R - Page 1 How many ambulances do you operate? 21 Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 Street Number 3SS0 N AcAotMY SLV0 City COLORADO SPRINGS State. Co Phone (866)2SS-76f t Location#2 Street Number 2i4o 5.Ao.Lv ST City 'DENVER State co Phone (g66)2SS-7•67I As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients es No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile es No Please read carefully: Sec.7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I.Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II:Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III.Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested Tier I ler Tier III Page 2 edicai Director Medic& 'oectors Dr.Leslie Moats M.D 1400 E Boulder Ave,Colorado Spnngs,Co 80909 (719)357-2060 Teske.mo atsWcuanschutz.edu Dr Angela Wright M D. 12606 E 16th Ave.Aurora,CO 80045 (720)848-6777 angels wnghtWcuanschutz edu Cis mpg oy Information t,Ownership Company Name:Ambulnz Ct,LLC 3550 N Academy Blvd,Colorado Spnngs,CO 80909 866-255-7671 Ownership 50%Ambulnz Holdings,LLC 50%University of Colorado Health Owner Information:Arnbulnz Holdings,LLC 35 West 35th Street,5th Floor New York,NY 10001 212-273-9774 Owner Information:University of Colorado Health 12401 E 17th Avenue Mail Stop F415,Aurora,CO 80045 720-848-0000 National Responsible Individual:Lee Beinstock,CEO 35 West 35th Street,5th Floor New York,NY 10001 212-273-9774 Authorized Co tact Personnel:Royce Davis,CO'Irector of Operations 2140 S Holly St 2nd Floor,Denver,CO 80222 612-946-8965 Daily Responsible Party:Royce Davis,CO Director of Operations 3550 N Academy Blvd,Colorado Spnngs,CO.80909 612-946-8965 "anagement:Ambulnz Holdings,LLC: 35 West 35th Street,5th Floor New York,NY 10001 212-273-9774 Locations: Business Office/Main Location. 3550 N Academy Blvd,Colorado Springs,CO.80909 Business Office/Secondary Location: 2140 S Holly St Denver,CO 80222 Vehicle Locations. 3550 N Academy Blvd,Colorado Spnngs,CO 80909 16990 Village Center Dr East,Parker,CO 80134 9475 S University Blvd.Highlands Ranch,CO 80126 2140 S Holly St Denver,CO 80222 11820 Destination Dr Broomfield,CO 80021 913 E.Myrtle St Fort Collins,CO 80524 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION IN ADDITION,I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7,INCLUDING,BUT NOT LIMITED TO,SECTION 7-8-10,WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION cy'e-1,+..--\,,, 6/2-5-/z,,03- Signature of Applicant Title Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS .Z DAY OF (}(' - ,20≥> ,IN THE COUNTY OF — ,STATE OFCOLORADO c- 12%":: - c r;I 7"-Ijo� Signature of Notary My Commission expires /0 -�r�-�- J Page 7 Operations, Locations,Service area,Personnel& Ambulances Service Area: Weld ogan Moffat Ja�c5\anmer ,,,,,,,,,9-T toutt •rgan Grand ,, ;�.�., C Rio r Blanco � . Yuma Adams .'Tprcem Garfield Eagle 5�� a Elb- Kit Mesa Pltkin Park •,� Carson Delta Gunnison �,� E' Cheyenne % Pas• In —Montrose Fremont c. 1<IOWa oGf San Miguel ° ; Saguache Custer' ebl' Bent Pr°" Dolores "'" �, ••1--------- Huerfano Otero Rao 4i4n.eauma 5 ,1 Grando Baca P ata Aruurie+a�canelos c*"' Las Animas f Ambulnz currently operates in the following counties • Adams • Arapahoe • Broomfield • Denver • Douglas • Elbert • El Paso • Jefferson • Lanmer • Pueblo • Weld NEAAAAAAAAAAAAAAAAAAAAAL r N 4 iWELD COUNTY DEPARTMENT OF PUBLIC HEALTH 8c ENVIRONMENT License to Operate Ambulance Service NII T I ER I I , r- AMERICANMEDICAL 3800 PEARL STREET , BOULDER , COLORADO 80301 •, r "Ill IS LICENSED UNTIL DECEMBER 31 , 2024, TO OPERATE AN AMBULANCE SERVICE r IN WELD COUNTY IN ACCORDANCE WITH EXISTING WEL-NID COUNTY RULES AND REGULATIONS . r / 1 -1 I 3 ii\d\S -a—ts— \ _ -_ ., NOV 2 2 232 \.k i8 ., eA n -t-sr5* r CHAIR , BOARD OF WELD COUNTY COMMISSIONERS DATE )it r I , i e____J \ \_ 2 u ,_ . _ , . . r Nill NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE NI Tier II : Licensure authorizing for transports of patient ( s ) to and from licensed medical facilities . This licensure does not provide for Primary Care, as defined in Section 7 - 1-30 of the Weld County Code . WELD COUNTY DEPARTMENT �� r; ARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue , Greeley , CO 80631 www . weldhealth . or g Recommendation of the Weld County Emergency Medical/Trauma Servic e Y /T Council for : American Medical Response (AMR ) As required in Section 7-2 - 100 . B . 5 ., the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response g Y p to residents of the County . Please include any findings related to response time, coordination with other ambulance services, location, service area , etc . that are the basis for the Council 's recommendation : FINDING # 1 : We, the council, find that AMR contributes to an efficient, effective, and coordinated service by providing inter-facility transport (IFT) services to the citizens of Weld County. As a tier II service, they allow 911 response units to remain available in their service areas . FINDING #2 : AMR timely responds to calls for providing inter-facility transport of patients. They coordinate with Medical Facilities to provide service . FINDING #3 : As a Tier II agency, they rarely interact with 911 agencies, although they work well with other IFT agencies .g s AMR operates as IFT within Northern Colorado, which can benefit the citizens of Weld County in the event of an MCI . FINDING #4 : Recommended Level of Service : I ITier 1 ✓ Tier 2 Drier 3 Recommended Service Area : The EMTS Council members are not concerned with the AMR area Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve AMR for a Tier II License. Recommendation By : f� � 1 /zuDate . S Zi Matt oncialdi, EMTS Council Chair pm\186,1 Weld County L _C o U NT Y Department of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application : a I15 12.. "3 Name of Ambulance Service : flr rLcan Ma:iL'cc:L1 12a_sp Th a of ' tc ac4O Owner : Name : etiOLO_ &ed cal Qerence, Address : to3to S . Ft:c Ube `es CO Fl k Phone Number : Pap--3 -, 1 -- 12OO Operations Manager : Name : ?> 44anj 1-2- tsss Address : -� o 1,. x ( S e,Qt 11-330kcigir , C ap 1 Phone Number : '1ao ,- arc-i — &Vow Email : 1 -k . , ` net Medical Director : Name : r cAnco .cv ccU Address : , tst St ent . cr S Phone Number : 12_x, Name and address of each stockholder of partner owning 1O% or more of the outstanding stock of the company of having more than a 1O% ownership interest ( if applicable ) : Cal HIciL'CCU sts P t exx t 4 , tor3t.03 S . Ftc -4 t e v ' EireQ-n __a`_' r - • Y x % What area of Weld County will be served by this company? Please attach a rnap indicating the service area . `Kinney - can'tt c s ',Amp E ci l� 1 1555 N . 17th AvenueS7P (7 Greeley, CO 80631 ' •` PHAB • Phone : 970-304-6410 weldhealth org � ou � tY � ,PublicHealth '' ' . �,uc+ • Page 1 • How many ambulances do you operate?.3 Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 Street Number'3Zm P�xvl St ree�� City 1jouicas- State CO Phone O 1 Location#2 Street Number City• State Phone As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients a No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile. 462) No Please read carefully. Sec.7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I:Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II:Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III:Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested: Tier I422) Tier Ill Page 2 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION IN ADDITION,I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7,INCLUDING,BUT NOT LIMITED TO,SECTION 7-8-10,WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION r ...-,... ,20„,,,,Lb,o A.,cn ...k...s.firvt. ,,,,2,(0k2...5 gna re of App cant Title Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS 24 DAY OF ©l/a'I W ,20 z3 ,IN THE COUNTY OF Zoo id,-Sr ,STATE OF COLORADO ,,,Z4 -- /--' ,e------ Signature of Notary My Commission expires 3 /Z 6 /ZOZ% ROBERT HUNE-KALTER NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20184013629 MY COMMISSION EXPIRES 03/26/2026 Page 7 Map of Service Area- Working as a Tier 1I licensed ambulance Provider we will transport patients for Banner Health from their facilities. The Map below shows the locations of the Banner Hospitals. fS l) aii‘cise , (Thj} : ii • r• IF lT ftnnntI) • Severance i Eaton J . • - ; •. • _ I.ticerne (39 7) ,09?) Winthor 1397 (i_ zi. I ae-0 iti. . 4 4 Ilil3 _ ^} ' \ t : .*'7� Grey • 4:rtr ! t• finA ;(2j} 'eland 0-4) Garden City (40M) I:vnfns • 25 if ' i ' vim f la Salle • • • • • . — a • e• •• • — DJ • a• 1 t. N • • i is 1 1 ' • • 1 1 • 1 -1 r OUNTY DEPARTMENT ;1444 .44AAAAAAAIAAAAAAAA___ r WELD OF PUBLIC HEALTH & ENVIRONMENT I License to Operate Ambulance Service , r -NII TIER III , r STADIUM MEDICAL r 696 CANOSA COURT , DENVER , COLORADO 80204 NI r go IS LICENSED UNTIL DECEMBER 31 , 2024 , TO OPERATE AN AMBULANCE SERVICE IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . -.I r c m _._.7_ _______ . :_____Th 3 e. , tnAc -r-3 ,,........_ , 4 f4 2tCC / 32 aIKol tar A is. i CHAIR , BOARD OF WELD COUNTY COMMISSIONERS DATE J NI a l kji 1 Nig NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE NI Pr Tier III : Licensure authorizing for Standby Service, as defined in Section 7 - 1 - 30 of the Weld County Code . 'per . I86Ji'r re ' ` WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT ` • V 1555 North 17th Avenue ,.. Greeley , CO 80631 www . weldhealth . org Recommendation of the Weld County Emergency Medical /Trauma Service Council for : Stadium Medical As required in Section 7 -2 - 100 . B . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location , service area , etc . that are the basis for the Council ' s recommendation : FINDING # 1 : We, the council, find that Stadium Medical contributes to an efficient, effective, and coordinated service by providing EMS Standby services to the citizens of Weld County at various venues. As a tier III service, they allow 911 response units to remain available in their service areas. FINDING #2 : Stadium Medical provides standby EMS services at events throughout the county and timely responds to emergencies . Having them at the event allows them to react immediately to a patient requiring medical attention . FINDING #3 : As a Tier III agency, they occasionally interact with 911 agencies . The EMTS Council membership is unaware of any negative interactions with Stadium . FINDING #4 : Recommended Level of Service : !Tier 1 ..Tier 2 IVITier 3 Recommended Service Area : The EMTS Council members have no concerns with Stadium Medical service area as a Tier III agency. Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve Stadium Medical for a Tier III License .6-7--PRecommendation By : Date : 11 5 Matt Concialdi, EMTS Council Chair .:,. L ��,,,:„ 86'1 ,�' la h • Weld County I A. C Li N 7 YDepartment of Public Health and Environment AMBULANCE SERVICE LICENSE APPLICATION Date of Application : October 31 . 2023 Name of Ambulance Service : Stadium Medical Owner : Name : Rodger Ames Address : 695 Canosa Ct Denver, Colorado 80204 Phone Number : 303 . 549 . 7914 Operations Manager : Name : Meghan Adas Address : 695 Canosa Ct Denver. Colorado 80204 Phone Number : 720 . 384 . 3189 Email : madas@stadiummedical . com Medical Director : Name : Sam Smith Address : 34 Van Gordon Lakewood , Colorado 80228 Phone Number : 501 . 339 . 3082 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest ( if applicable ) : Rodger Ames 695 Canosa Ct . Denver, Colorado 80224 What area of Weld County will be served by this company? Please attach a map indicating the service area . Event based Weld County 1555 N . 17th Avenue �y a��°�`�' °-� Greeley, CO 80631 Si; • PHA& /// Phone : 970-304-6410 :z-� .; J Y PublicHealth h, � { weldhealth .org _ � I r.., ,.,t «, tidam, Page 1 How many ambulances do you operate?25 Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information Location#1 Street Number 695 Canosa Ct City Denver State CO Phone 80204 Location#2 Street Number City State Phone As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients yes No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile Yes No Please read carefully. Sec 7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier III Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested Tier I Tier II Tier III Page 2 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION . IN ADDITION , I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING , BUT NOT LIMITED TO , SECTION 7- 8- 10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE . DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION . C ft I cep c 13&- vfFIo z--- c o /221 ( L-3 Signature of plican Title Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS 31 DAY OF Oc--4 GC) ex- , 20 e- , IN THE COUNTY OF C Cstis 0 , STATE OF COLORADO . SCOTT A . PHILLIPS .... NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20094016691 Signature of Notary MY COMMISSION EXPIRES JULY 14, 2025 My Commission expires : / / AI / Z Z> Page 7 carpenter 0 II�I�N111111-N-N1M1 NWel/410100.0.0 - 1� IiI1NN1-� NINIINNIIIIIINII ese .. _171w!•1-N__S- -�I�NY YMY -�NYIIN \1/�YYI'I�NIIYI�N -• V. Soapstone : • Prairie • PHereford )ale Natural Area • - Norfoll4 Carr O3 . Grover Pawnee az ® National Buckeye Grassland 0 Livermore , ,Wellington Nunn Keota 9, 0 Ted s Place O Pierce Briggsdale 0 Bellvue e 39? 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Boulder = Hoyt .•-- Lochbuie Lafayette Louisville Brighton Woodrow GI 170 Superior 0 . { • r-• - - -i.► I. ..-.- - -_ En - _ - . 4AAAAAAAAAAAAAAAAAA44 . , - - - r mli WELD COUNTY DEPARTMENT OF PUBLIC HEA-4LTH & ENVIRONMENT � r License to Operate Ambulance Service r TIER III r MNilILE HIGH AMBULANCE � 32. 51 SOUTH ZUNI STREET , ENGLEWOOD , COLORADO 80110 r r NI IS LICENSED UNTIL DECEMBER 31 , 2024, TO OPERATE AN AMBULANCE SERVICE r IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS . , , , i __ _ _ l*. NI :fin ' fftCe3tNOV 2 2 2323 • i% , 86, ,,,::. , i .., _ . ,. , 4,014 ) CHAIR , BOARD OF WELD COUNTY COMMISSIONERS DATE � t-47: J_- ,-, �I V y r � J-NI NOT TRANSFERRABLE / POST IN A CONSPICUOUS PLACE r r Tier III : Licensure authorizing for Standby Service, as defined in Section 7 - 1 - 30 of the Weld County Code . tree WELD COUNTY DEPARTMENT= r OF PUBLIC HEALTH AND ENVIRONMENT c �; Y - 1555 North 17th Avenue , Greeley , CO 80631 www . weidhealth . org Recommendation of the Weld County Emergency Medical/Trauma Service Council Y /T for : Mile High Ambulance As required in Section 7-2- 100 . 8 . 5 . , the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. Please include any findings related to response time, coordination with other ambulance services, location , service area, etc . that are the basis for the Council 's recommendation : FINDING # 1 : We, the council, find that Mile High Ambulance contributes to an efficient, effective, and coordinated service by providing EMS Standby services to the citizens of Weld County at various venues. As a tier III service, they allow 911 response units to remain available in their service areas. FINDING #2 : Mile High Ambulance provides standby EMS services at events throughout the county and timely responds to P emergencies during the event. Having them at the event allows them to react immediately to a patient requiring medical attention . FINDING #3 : As a Tier III agency, they occasionally interact with 911 agencies. The EMTS Council membership is unaware of any negative interactions with Mile High . FINDING #4 : Recommended Level of Service : LTier 1 E`Tier 2 Tier 3 Recommended Service Area : The EMTS Council members have no concerns with Mile High Ambulances service area as a Tier Ill agency. Other EMTS Council recommendations or comments : The EMTS Council voting members unanimously recommend that the Weld County Board of County Commissioners approve Mile High Ambulance for a Tier III License. Recommendation By : :- /jam Date : 1r �� 2 Matt Concialdi, EMTS Council Chair I 'ilk. n u t , U"�7 Department of Public Health and Environment :La.! ...LANCE SERVICE LICENSE APPLICATION Date of Application 10/19/2023 Name of Ambulance Service Mile High Ambulance,LLC Owner Name Leo Abrashevich and Igor Balaban Address 3251 S Zuni St Englewood,CO 80110 Phone Number 303-564-6636 Operations Manager Name Peter Reschenberg Address 3251 S Zuni St Englewood,CO 80110 Phone Number 720-584-0773 Email Peter@Milehighambulance corn Medical Director Name Dr JP Brewer _ Address 4567 E 9th Ave Denver,CO 80220 Phone Number 740-707-2755 Name and address of each stockholder of partner owning 10%or more of the outstanding stock of the company of having more than a 10%ownership interest(if applicable) Armada Management(Leo Abrashevich)50%22047 E Rowland Ave Aurora,CO 80016 Global Management and Consulting(Igor Balaban)50%4218 Greenfinch Dr Highlands Ranch,CO 80126 What area of Weld County will be served by this company?Please attach a map indicating the service area. Dacono,CO(Colorado National Speedway) 1555 N 17th Avenue ,,,,,, cro, Greeley CO 80631 Phone 970-304-6410 ,;' t W if weldhealth org $ �� Public Health .,' Page 1 How many ambulances do you operate?'24*""cow,i Location and description of the place(s)from which this ambulance service will operate If there are more than two locations,attach a separate sheet with the above information. Location#1 Street Number 3251 S Zuni St City Englewood _ _ State Co _ ____ Phone 80110 Location#2. Street Number _ City. State. Phone. As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations,as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients ✓Yes No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations,as of the date of the application,are you in compliance with the reporting requirements of the agency profile ✓Yes No Please read carefully: Sec.7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below The fee for said license shall be set by separate ordinance The license shall issue only in the following tiers of service Tier I:Licensure authorizing for Primary Care,as defined in Section 7-1-30 of this Chapter Tier II.Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities This licensure does not provide for primary care,as defined in Section 7-1-30 of this Chapter Tier Ill:Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter Level of Service Requested: Tier I Tier II er Tier III Page 2 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION . IN ADDITION, I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING, BUT NOT LIMITED TO, SECTION 7-8 - 10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE . DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUT _ s'Accolion s ALI atkl_</` 20 igna of pplicant Title D e r O 15z r SUBSCRIBED AND AFFIRMED BEFORE ME THIS Z I c7) Q � z m w 1 z DAY OF Ocefc) beir , 20 23 , IN THE COUNTY OF -5 "7-1Vr9-i5 z — O > ��' �-eT STATE OF COLORADO . 01 2 O Imses31 - zoo J p o C� Signature of Notary < " w My Commission expires : Ni / o 7 / ao a S cn Page 7 calcrnaps.com Radius: 702 . 56 m I 0. 70 km 10 .44 ml ( 2305 ft Circle Area: 1550650 m21 1 .55 km2 ( 0. 60 mi21 16691057 ft2 Puritan • Ith ay • I n I i 4il1v.4j S;' Etch Dwane High • s. $ . In • a - 3 • sr.simdlob sir I ' 7 t r , • i I Erse ►`H .v, - tun Ned S! �/fi -r • s � ra lin i r • Sit Vain 1 . Disk t Hello