HomeMy WebLinkAbout2026-054' ° INDIAN RIVER COUNTY CLASS "A"
CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY
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WHEREAS, Indian River Shores Public Safety Department has requested authorization to
provide Emergency Pre -Hospital BLS/ALS EMS Transportation Services that originate within
Indian River County; and
WHEREAS, the above named service affirms that it will maintain compliance with the
requirements of the Emergency Medical Act, Chapter 401, Florida Statutes; Florida
Administrative Code, Chapter 64E-2; and Indian River County Code of Ordinances Chapter 304.
THEREFORE, the Indian River County Board of County Commissioners hereby issue a
Class "A" Certificate of Public Convenience and Necessity to said Company to provide
Emergency Pre -Hospital BLS/ALS EMS Transportation Services.
Certificate Type: CLASS A
Date of Expiration: April 15, 2028
(Unless certificate is sooner revoked or suspended.)
Limitations: Primary response service area limited
to the Town of Indian River Shores.
APPROVED AS TO FORM
ANDA FICIENCY
Approved by the Indian River County BY
Board of County Commissioners on CHRI O HER A. HICKS
March 24, 2026 ASSISTA C UNTY ATTORNEY
A V BR CO
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�oMAI Effective Date:
a INDIAN RIVER COUNTY
DEPARTMENT OF EMERGENCY SERVICES
APPLICATION FOR
CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN)
APPLICANT NAME:jlndian River Shores Public Safety Department ` DATE: 02/20!2026
APPLICATION FEE: $100.00 APPLIES TO INITIAL APPLICATIONS ONLY.
If payment applicable, make check payable to INDIAN RIVER COUNTY FIRE RESCUE.
❑ This is a new application; fee is attached.
® This is a renewal of our present COPCN.
❑ This is a renewal of our present COPCN with ownership or classification changes,
CLASSIFICATION OF CERTIFICATE REQUESTED
Please check applicable boxes and options.
Class A ❑ _BLS X ALS
Governmental entities that use advanced life support vehicles to conduct a pre-
hospital EMS ALS/BLS service.
Class B ❑ BLS _ALS
Agencies that provide non -emergency ambulance inter -facility medical transport
at the ALS/BLS level.
Class C ❑ _BLS ALS
Agencies that provide non -emergency ambulance inter -facility medical transports
which require special clinical capabilities and require a physician's order.
Class D ❑ _BLS _ALS
Agencies that provide non -emergency ambulance medical transports limited to
out of county transfers.
UARRE ADMIN ASSISTANTS1Beth\Beth Casano EOC\COPCN\COPCN APPLICATION\COPCN Appfication.dou
H. COMPANY DETAILS
1. NAME OF AGENCY: Indian River Shores Public Safety Department
MAILING ADDRESS: 6001 N. Highway A1A
CITY Indian River Shores COUNTY Indian River
ZIP CODE: 32963
BUSINESS PHONE: 772-231-2451
2. TYPE OF OWNERSHIP (i.e. Private, Government, Volunteer, Partnership,
etc.):
Government
3. MANAGER'S NAME: Theodore Stone
ADDRESS: 6001 N. Highway A1A
PHONE #: 772-231-2451
4. PROVIDE NAME OF OWNER(s) OR LIST ALL OFFICERS, PARTNERS,
DIRECTORS, AND SHAREHOLDERS, IF A CORPORATION (attach a
separate sheet if necessary):
NAME ADDRESS POSITION
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5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL
REFERENCES
NAME ADDRESS PHONE #
UARRE ADMIN ASSISTANTS1Mh\Beth Casano EOCICOPCNICOPCN APPLICATIONTOPCN Application.docx 2
6. FUNDING SOURCE: Tax Based Municipality
7. RATE SCHEDULE ATTACHED? YES 2 NO ❑ N/A ❑
8. LIST THE ADDRESS OF YOUR BASE AND ALL SUB -STATIONS:
Base Only 6001 N Highway A1A Indian River Shores, FL 32963
Ill. COMMUNICATIONS INFORMATION:
TYPES OF RADIOS/EQUIPMENT:
1. RADIO FREQUENCY (ies) 2. RADIO CALL NUMBER(s)
800 mHz Engine 41
800 mHz Quint 41
800 mHz Rescue 41
800 mHz Rescue 42
3. LIST ALL HOSPITALS AND OTHER EMERGENCY AGENCIES WITH
WHICH YOU HAVE DIRECT RADIO COMMUNICATIONS:
FROM AMBULANCE FROM BASE STATION
Cleveland Clinic
Sebastian River Medical Center
First Flight
St. Lucie Air
UARRE ADMIN ASSISTANTS\BethlBeth Cosano EOC\COPCN\COPCN APPLICATION\COPCN Application.docx 3
IV. ADDITIONAL INFORMATION REQUIRED TO BE SUBMITTED
WITH THIS APPLICATION:
RENEWAL APPLICANTS NEED ONLY #'s 4 - 9
1. Factual Statement indicating the public need and services, including studies
supporting the demonstrated demand and feasibility for the proposed
service(s) and deficiencies in existing services, and any other pertinent data
you wish to be considered.
2. Factual statement of the proposed services to be provided, including type of
service, hours and days of operation, market to be served, geographic areas
to be serviced, and any other pertinent data you wish to be considered.
3. Factual Statement indicating the ability of the applicant to manage and
provide the proposed services, including the management plan, maintenance
facilities, insurance program, accounting system, system for handling
complaints, system for handling accidents and injuries, system for providing
the county monthly operating reports and any other pertinent data you wish to
be considered.
4. Copy of Standard Operating Procedures.
5. Copy of Medical Protocols.
6. Copy of your insurance policy — must show coverage limits —
7. Vehicle Information. For each vehicle provide the following:
a. Make, Model, Year, Manufacturer
b. Mileage
c. VIN #
d. Tag Number
e. Passenger capacity (E/E1 classification)
f. Indicate ALS/BLS (A -D classification)
8. Personnel Roster. For each employee provide the following:
a. Name — Last, First and Middle Initial
b. Driver's License # (if commercial, specify class) & Expiration Date
ADDITIONAL INFO REQUIRED FOR A -D classifications
c. Emergency Medical Service Certification and # (EMT or Paramedic)
d. Expiration date of Certification
e. Whether or not has an Emergency Vehicle Operation Certificate.
9. Fee Schedule Incl: Service Type, Base Rate, Mileage, Waiting & Special Charges
UARRE ADMIN ASSISTANTS\Beth\Beth Casano EOC\COPCN\COPCN APPLICATION COPCN Appllcation.docx 4
V. NOTARIZED STATEMENTS
l� Theodore Stone , the representative of
Applicant Name
Indian River Shores Public Safety Department , do hereby attest that
Business Name of Service
the above named service will provide continuous service on a 24-hour, 7 -day
week basis. 1 do hereby attest that the above named service meets all the
requirements for operation of an ambulance service in the State of Florida as
provided in Chapter 401, Part III, Florida Statutes, Chapter 64E-2, Florida
Administrative Code, and that I agree to comply with all the provisions of Chapter
304, Life Support Services.
ALL APPLICANTS
I further acknowledge that discrepancies discovered during the effective
period of the Certificate of Public Convenience and Necessity will subject
this service and its authorized representatives to corrective action and
penalty provided in the referenced authority and that to the best of my
knowledge, all statements on this ap lic tion are trualdind correct.
APPLICANT SIGNATURE DTE
Before me personally appeared the saidThf,cbm_2lit , who says
that he/she executed the above instrument of his/her own free will and accord, with full
knowledge of the purpose thereof. 5 rn a subscribed in my presence thisQ-Jday of
My commission expires: AM
NOTA Y PU
KIMBERLY WALL
MY COMMISSION # HH 476032
EXPIRES: December26, 2027
U:\FIRE ADMIN ASSISTANTS\BeftSeth Casano EOC\COPCN\COPCN APPLICATION\COPCN Application.docx