TOWN OF WEST BROOKFIELD

 REQUEST FOR PROPOSALS

Emergency Ambulance Services

Three-Year Contract, Start Date to Be Negotiated

 

Due: August 5, 2024, at Noon

 

 

 

Awarding Authority:

The Awarding Authority is the West Brookfield Board of Selectmen, with the advice and counsel of the Town Administrator, Police Chief, and Fire Chief.

 

 

Contact:

Ronald San Angelo

Town Administrator

2 East Main Street

West Brookfield, MA 01585

(508) 867 1421 Ext 329

rsanangelo@wbrookfield.com

 

 

 

 

REQUEST FOR PROPOSALS (RFP) EMERGENCY AMBULANCE SERVICES

 

1. General Information
2. Specifications
3. Proposal Submission Requirements

 

 

The Town of West Brookfield seeks proposals from interested parties for the provision of emergency ambulance services for the Town of West Brookfield. A contract for ambulance service is expressly exempt from the public bidding requirements under M.G.L., Chapter 30B, Section 1(b)(24). Accordingly, proposals shall not be evaluated, nor shall this contract be awarded pursuant to the provisions of M.G.L., Chapter 30B. The Town of West Brookfield reserves the right to award this contract to the ambulance service provider whose proposal is determined to be in the best interests of the Town of West Brookfield. The Town of West Brookfield reserves the right to accept any proposal or to reject any or all proposals if it shall be deemed in the best interest of the Town to do so. The purpose of the proposal process is to determine from the responses received which provider can best ensure that properly trained and certified personnel will provide timely emergency medical care to patients at the scene of their illness or injury, and then transport the patient to an appropriate treatment facility in the shortest practicable time utilizing safe and clean vehicles, and provide the most reliable, safe and effective services to those served.

 

 

I.     General Information

The Town of West Brookfield requests proposals for a 24-hour-per-day/ 7-days-per-week ambulance service covering the Town of West Brookfield.

 

The following data about the Town is from the Massachusetts Division of Loal Services website.

 

Population	3,820
Population Density	186
Land Area 20.49	20.49
Total Road miles	66.42
DOR Income Per Capita	$40,530
State Average Income per Capita	$50,249

 

 

 

 

About West Brookfield

 

Incorporated in 1848, West Brookfield is Rich in Early American History

The New England Town of West Brookfield is located approximately 20 miles west of Worcester, Massachusetts. Situated on the Historic Boston Post Road, the town was the halfway stop on the stage route from Worcester to Springfield. The picturesque Common is the beginning of the Center Historic District. Within walking distance is the Old Indian Cemetery and other locations of historical significance.

West Brookfield has the sites of the first white settlement, the Indian villages, and is the mother town of the Quaboag Plantation. The Quaboag Plantation was deeded in 1660, and thirteen years later this area was incorporated as a town and was called Brookfield. Quaboag is a Nipmuc Indian name meaning "before the pond". The site of the largest of the Quaboag Indian Villages was at Wekabaug, later known as Wickaboag. This site joined the southerly end of what is now Lake Wickaboag in West Brookfield. With the advent of the railroad, West Brookfield was incorporated as a separate Town in 1848.

 

The Town estimates that its current ambulance services provider receives approximately 1,200 calls per year, on average, for service in the Town.

 

II.  Specifications

 

1. Level of Service:

 

The Town of West Brookfield seeks proposals for twenty-four (24 hour per day, seven (7) day per week

 

The Ambulance Service provider:

 

1. will provide Emergency Medical Services for the Town of West Brookfield MA. for the 2025- 2028 fiscal year.

 

2. will provide an immediate 911 ambulance response and have a location in West Brookfield.
3. will provide a call back system for second and third calls for service when needed and will maintain two (2) ambulances at the ALS level and one (1) UTV-Gator with patient carrier for immediate 911 responses.

 

4. will provide Advanced Life Support services when needed at no additional cost

 

5. will be responsible for patient billing and will retain all fees recovered from medical transport.

 

6. will provide Emergency Medical coverage for all town events or requests for services at no additional charge.

 

7. will provide a subscription service to all residents of West Brookfield at a low cost.

 

8. will provide all necessary training for compliance and certifications to all West Brookfield town employees at no additional cost.

 

9. will provide an Automated External Defibrillator maintenance program for all AEDs in municipal buildings and a Town of West Brookfield designee will notify us when supplies are needed and charged to the Town of West Brookfield.

 

10. will provide monthly reporting data to the town clerk/ administrator or designee and will provide specific call data upon written request at any time.

 

11. will be responsible for maintaining all necessary licensing, certification, compliance with all State and Local laws and regulations.

 

12. will maintain all necessary Mutual Aid, Advanced Life Support agreements.

 

13. will notify the State Department of Emergency Medical Services of the necessary changes to its service zone plan.

 

14. will provide First Responder Training/ Certifications: Covers that covers all current town employees including West Brookfield Police, Fire Department, Highway and/ or any other Town employee designated by the Town of West Brookfield, MA.

 

15. will provide an emergency response to all 911 activations and requests for an EMS response within a minimum of 5 to 10 minutes depending on road conditions/ hazards/ location of call.

 

16. will comply with all current Statewide Treatment Protocols set by the DPH/OEMS and its current Affiliate Hospital Medical Director agreement.

 

17. will cooperate with the West Brookfield Police Department, Fire Department and all other town departments as appropriate.

 

1. Contractual Relationship: It is agreed that in no case shall the ambulance company or ambulance personnel be considered agents or the employees of the Town of West Brookfield in performing services, as the Town of West Brookfield is not providing said service, and the contractual relationship is between the ambulance company and the recipient of said service.

 

1. Indemnification: The ambulance company agrees to hold the Town of West Brookfield harmless from any and all claims, settlements, lawsuits or litigation which may arise from its performance (by itself, an officer, agent, or employee) under the Agreement, the operation of its motor vehicles, its contract with its employees, or damage to any motor vehicles caused while operating under this Agreement. The contractor also agrees to indemnify the Town of West Brookfield from any liability or expense imposed upon it as a result of this Agreement.

 

1. Insurance: The ambulance company shall maintain the insurance coverage listed With the exception of Workers’ Compensation and Professional Liability coverages, the contractor is required by this Agreement to name the Town of West Brookfield as an additional insured and to provide the Town with certificates of insurance coverage indicating that the Town of West Brookfield has been added as an additional insured under all insurance coverages required by this Agreement. Further, the contractor is required to provide the Town of West Brookfield with a copy of the current additional insured endorsement page, reflecting that the Town of West Brookfield has been listed as an additional insured, for each insurance policy to which the Town of West Brookfield has been added.

1. Worker’s Compensation: Workers’ Compensation and Employer’s Liability coverages in the amounts as may be required by Massachusetts General Laws Chapter 152.
2. General Liability: General Liability coverage of at least $1,000,000 Bodily Injury and Property Damage Liability, Combined Single Limit, with a $3,000,000 aggregate limit.
3. Auto Liability: Auto Liability coverage of at least $1,000,000 Bodily Injury and Property Damage per accident.
4. Professional Liability: Professional Liability coverage of at least

$1,000,000 per occurrence and $2,000,000 aggregate.

5. Umbrella Liability: Umbrella liability coverage of at least $2,000,000 per occurrence and $2,000,000 aggregate.

 

The parties acknowledge that the types of insurance and coverage limits listed herein are the minimum necessary for the ambulance company to be awarded this contract. The types of insurance and coverage limits stated herein are not intended in any way to limit the ambulance company’s liability for any damages arising from the ambulance company’s performance under this contract.

 

Further, the policies must contain a notation that the insurer will give thirty

(30) days’ notice to the Town of West Brookfield prior to cancellation, change or non-renewal of the policy. At least thirty (30) days prior to the expiration of any policy, a signed and complete Certificate of Insurance, with all endorsements attached, showing that the insurance coverage has been renewed or extended, shall be filed with the West Brookfield Select Board and Police Chief, via the West Brookfield Town Administrator.

 

 

1. Compensation: The ambulance company shall bill the users of its services directly. Respondents must clearly detail any additional monetary compensation to be provided by the Town of West Brookfield for establishing an ambulance service within the town borders of West Brookfield.

 

 

 

1. Patients Experiencing Financial Hardship: Respondents must clearly state their policy for billing patients who cannot pay for an ambulance transport due to financial hardship.

 

 

1. Rates: The contractor agrees to provide the Town with a current rate

 

 

1. Cost of Operations: After payment of any agreed upon monetary compensation provided by the Town of West Brookfield, the ambulance company must assume all remaining costs of its supplies, telephone, gasoline, oil, maintenance, materials, communications systems, and equipment, etc. in order to adequately provide ambulance service to the Town.

 

I.           Personnel:

1. Training: All ambulance company personnel shall be trained and re- trained in compliance with M.G.L., Chapter 111C. The ambulance company will assign personnel to attend training and orientation sessions as prescribed by the standards established by the Medical Director. These sessions will be arranged and scheduled at times which are mutually agreed upon by the contractor and the Medical
2. Personnel Roster: The contractor shall furnish the Town of West Brookfield at contract execution and henceforth semiannually with a roster of currently employed personnel, which shall include the following information on each person: name, home address, date of certification, license, and registry numbers. The Town of West Brookfield shall retain the right to verify these with the Massachusetts Office of Emergency Medical Services.
3. Background Checks: The contractor will conduct criminal background checks on all ambulance personnel prior to being assigned to work in West Brookfield, and at least annually thereafter, in order to determine the person’s suitability and character. The contractor will comply with all laws and regulations of the Commonwealth of Massachusetts pertaining to criminal background checks.
4. Minimum Staffing: The ambulance shall be staffed in accordance with the Department of Public Health - Office of Emergency Medical Services regulations effective at the time of this contract.
5. Conduct and Appearance: All employed personnel responding to EMS calls in West Brookfield shall maintain a professional appearance to include a nametag, neat uniform (distinctly different from West Brookfield Police & Fire Department uniforms) and good All personnel shall conduct themselves in a professional manner at all times and shall show appropriate courtesy and respect towards all people with whom they come in contact.
6. Non-Discrimination: It is understood and agreed that it shall be a material breach of any contract resulting from this proposal for the Contractor to engage in any practice which shall violate any provision of Massachusetts General Laws, Chapter 151B, relative to discrimination in hiring, discharging, compensation, or terms conditions or privileges of employment because of race, color, religious creed, ancestry, handicap, national origin, sex, age, or sexual
7. Supervision: The ambulance contractor shall provide on call twenty- four (24) hours per day, seven (7) days per week a lead supervisory person(s) that the West Brookfield Fire Chief, Police Chief, or Hospital Medical Director can contact to handle all operational issues. The ambulance company shall also provide an accessible senior management liaison to the Town.
8. Labor Disputes/Work Stoppages:

In the event that the ambulance company is involved in a labor dispute, and as a result of such dispute the service is interrupted, the ambulance company agrees to provide substitute services and to reimburse the Town of West Brookfield for any and all costs the Town incurs for interruption of service by the ambulance company.

 

1. Subcontracting: The ambulance company shall not subcontract any services under the resulting agreement and shall not assign the contract without written consent by the Town of West Brookfield. This contract is not assignable, except with the express written permission of the Town of West Brookfield and only then upon compliance with any conditions required by the Select Board.

 

K.       Training

A.i.1.         Re-Certification Training for West Brookfield Personnel: If requested, the contractor will conduct or otherwise make available, at a minimum, annual re-certification classes for Police and Fire department EMT and First Responder personnel at a location determined by each respective Chief. Classes shall be held on a group rotation schedule.

 

1. Community Support: In the RFP response, the proposer shall outline any community benefits offered.

 

 

M.      Reporting

 

        Monthly service reporting: The contractor will keep statistical monthly reports, in a form acceptable to the Town. Each monthly report shall be completed no later than the 15th day of each month following the month reported. These reports shall be sent to the West Brookfield Select Board, and Police Chief and/ or Fire Chief upon request.

 

1. Number of Calls
   • Daily
   • Weekly
   • Monthly

 

1. Calls to be segregated (as appropriate) by:
   • Basic Life Support
   • Advanced Life Support
   • Specific note made of ALS calls responded to by non- dedicated units
   • Specific note made of any call that required use of back up

 

1. Dispatching Log:
   • Sequential listing of all emergency responses to include dates, time of call, time of arrival on scene, point of entry (or refusal of care, no patient, DOA, and chief complaint).
   • Names, dates of birth, addresses, and reason for
   • Amount billed per patient for service
   •  

N.        Additional Reporting:

1. The contractor shall establish a mechanism to collect data (i.e. run sheets) regarding the Town of West Brookfield employees assisting in an EMS This is to ensure timely communications regarding any clinical infectious disease exposure. The contractor shall notify the personnel involved as well as their supervisors in the Fire or Police Departments of the Town.
2. Whenever the contractor files a Serious Incident and Accident Report with the Department of Public Health pursuant to 105 CMR 170.350, the contractor shall at the same time submit copies of said report to Town of West Brookfield’s Board of Health, Police Chief, and Select
3. The provider will notify the Police Chief of any personnel on the

provider’s roster that are involved in any investigations, motor vehicle

accidents or any criminal activities, whether or not the incidents were in West Brookfield or other locations. Said incidents should be reported in timely fashion.

4. The provider shall immediately notify the Town of West Brookfield if at any time during the term of the contract, the provider’s license to operate an ambulance service is modified, suspended or revoked, or been refused renewal by the Commonwealth of Massachusetts Department of Public This requirement for notification shall include the issuance of a provisional license pursuant to 105 CMR

170.235. The provider shall forward to the Town all copies of the correspondence received relative to the above matters, should they occur during the term of the contract. Any such action outlined above, (or application or proceeding to effect such, may, at the option of the City, be considered just cause for immediate termination hereunder. Said notification and copies of all such correspondence shall be provided to the West Brookfield Police Chief and Select Board.

5. If response time to any call exceeds forty (40) minutes, the ambulance provider must notify the West Brookfield Select Board in writing, providing a full explanation of the date, time, location of the call, the nature of the emergency service(s) provided, the actual response time, and a full and complete explanation as to why that response time exceeded forty (40) minutes.
6. If, for any one-month period of the contract, response times do not meet the standard of twenty (20) minutes, for ninety-percent (90%) of incidents, the ambulance provider must notify the Select Board in writing, providing a full explanation of the situation, and a plan of corrective action.

 

1. Inspection Reports: The ambulance company must forward, upon request, to the respective Town Select Boards, a copy of all inspection reports issued by the Department of Public Health, Office of Emergency Medical Services and/or the Ambulance Regulations Program, as they pertain to West Brookfield. Any deficiencies noted therein must be corrected in accordance with the findings and recommendations of OEMS.

 

1. Termination: The Town of West Brookfield, acting through its Select Board or its designee, shall have the right to terminate the Agreement at any time if in their sole judgment the ambulance company is not performing satisfactorily. Should the contractor, at any time during the life of the

 

agreement, fail to provide ambulance service under the terms and conditions set forth, or continue to default in the performance of the agreement, then, and in such case the Town, through its authorized agent, shall have the right to terminate the agreement between the contractor and the Town, and secure services from others, and charge the cost thereof to the contractor, which shall be liable for all costs incidental thereto.

 

The Town of West Brookfield shall have the right to terminate this agreement at any time if, in its sole discretion, the Town should decide to provide any portion of or all ambulance services through employees of the Town, by providing the contractor with six (6) months advance written notice by certified mail to the address stated herein. The provisions of this paragraph shall not alter or interfere with the Town’s rights to terminate this agreement pursuant to any other provision of this agreement.

 

This contract may be terminated by either party upon receipt of six (6) months’ advance written notice by certified mail to the Designated Representative identified on the contract for ambulance services. In case of such written notice of termination, all services under this contract shall cease with the exception of such work as may be necessary to bring the work in progress to a reasonable and safe condition. There shall be no penalty for termination for the convenience of the Town.

 

1. Compliance: Any and all regulations promulgated by any department, agency, or division of the Commonwealth, and any general laws relative to supplying ambulance service, are hereby incorporated in this specification as if fully written out, and the ambulance company covenants to meet at all times such requirements and laws presented. Should any provision of this Agreement be in conflict with said regulations and laws, then said regulations and laws shall govern except when the Agreement calls for a higher standard.

 

 

1. Additional Documentation: The contractor, in the RFP response, will provide evidence of the following:
   1. Drug and Alcohol Testing Policy and Program
   2. Compliance with Health Insurance Portability and Accountability Act
   3. Ability to maintain sufficient inventory on hand to provide for Mass Casualty Incidents (MCI) and/or extended operations (100 victims)
   4. Ability to meet computerized reporting requirements of MDPH/OEMS
   5. Quality Assurance Program to include all First Responders on a quarterly basis.
   6. Orientation and Training Guidelines for employees
   7. Written standard operating procedures for emergency operations, dispatch, additional staff call-in, ambulance inspections, and sick call-in.
   8. Vehicle Maintenance Program
   9. Criminal Background Check Policy

S.                              Periodic Reviews of Provider’s Performance:

1. The Select Board may, at its discretion, appoint a West Brookfield Ambulance Service Review Committee, consisting of the following persons, or their designees:
   1. The Select Board of West Brookfield
   2. West Brookfield Town Administrator
2. The Police Chief of West Brookfield
3. The Fire Chief of West Brookfield

 

The Committee will have the authority to review the provider’s

performance.

 

2. Performance Review: Managers and supervisors assigned by the provider to West Brookfield shall be required to attend performance review sessions held by the West Brookfield Ambulance Service Review Committee. The review sessions will be held on an “as-needed” basis

for the following purposes: a) to ensure the provider’s continued compliance with the provisions of the Agreement; b) to review response times and certain ALS calls; c) to review paramedic ALS skill performance; d) to address and resolve specific issues/problems; and e) to generally coordinate EMS operations in the Town of West Brookfield.

 

 

1. Medical Waste: The provider shall accept all medical waste generated at the EMS scene as well as accept medical waste collected by the Town of West Brookfield employees who may act as first responders to an EMS The provider will supply Bio Bins and Sharp containers to first responders as required.

 

170. Vehicles: Providers proposing to furnish the Ambulance Service shall supply with a detailed inventory of their transportation vehicles and equipment to be provided for the performance of the contract, showing each type by model, year of manufacture, anticipated remaining useful life, and certificate of compliance with all applicable State Standards. All leased equipment shall be separately listed and show the time remaining on each leased machine and any options of renewal. All new equipment to be acquired in fulfillment of this contract must be available on the effective date when service operations start. All ambulances in service to the Town of West Brookfield must meet the requirements of both state and federal law, and particularly all the requirements in 105 CMR of the Massachusetts Department of Public Health. If at any time the service provider fails to meet state requirements or federal requirements the Town of West Brookfield may terminate the contract. Vehicles shall have equipment and supplies as required by 105 CMR 170.

 

The provider shall maintain and keep all ambulances required under this contract in good mechanical and operating condition. The vehicles must be inspected every ninety (90) days by a certified automobile mechanic to ensure that they are in proper mechanical condition and comply with all safety regulations. All inspection and maintenance records shall be furnished to the Town Administrator or his designee immediately upon their completion. All vehicles utilized by the ambulance provider must be properly insured and registered and must display a valid motor vehicle inspection sticker and Massachusetts Ambulance Regulations sticker during the life of the agreement. All drivers/emergency personnel must at all times hold all professional, regulatory and administrative certifications required

 

Ambulance vehicles, State-mandated garaging facilities, and staff must be available at all times for inspection by an agent or designee of the Town of West Brookfield.

 

 

III.        Proposal Submission Requirements

 

2024. Time and Place of Submission Time and Place of Submission: Proposals are to be submitted by mail or in person to Ronald San Angelo, Town Administrator, Town of West Brookfield, 2 East Main Street, West Brookfield, MA 01585 until 12:00 PM on August 5, 2024. Postmarks will not be considered. The Town shall not be responsible for proposals arriving late due to couriers, deliveries to wrong locations, express mailing service errors, etc. If, at the time that proposals are due, the Town Hall is closed due to uncontrolled events, bids will be accepted until 12:00 PM on the next day that Town Hall is open. For the purposes of determining whether a proposer has met the deadline, the clock in the office of the Town Administrator shall indicate the official time. No individual extensions of this deadline will be

 

1. Contents of Proposal Package: Each proposer must submit one proposal package, marked with the proposer’s name and address, and “West Brookfield Ambulance ” One original and three (3) copies of the proposal must be in the package. A separate envelope with the Price Proposal must be in the package.

 

1. Proposal Modifications: A Proposer may correct, modify, or withdraw a proposal by written notice received by the Town prior to the proposal due date and time. A modification package is to be marked with the proposer’s name and address and “West Brookfield Ambulance Service, Modification #1., Each modification package must be numbered in sequence.

 

1. Contract Award: The contract will be awarded by the Town of West Brookfield within 45 days after the proposal due date. Contracted services will commence as soon as possible. The time for the award may be extended by mutual agreement between the Town and successful proposer.

 

1. Questions: Questions concerning this request for proposals (RFP) must be made in writing no later than July 25, 2024 ­­­­­­at 12:00 Questions may be delivered, mailed, or e-mailed to:

Ron San Angelo, Town Administrator Town of West Brookfield

2 East Main Street

West Brookfield, MA 01585

rsanangelo@wbrookfield.com

 

Questions should not be directed to any other person.

 

1. Addenda: If necessary to maintain a fair and equal proposing environment, the Town will issue addenda to all Proposers who have requested bid packages. Addenda will be mailed, faxed, or e-mailed to all vendors on record as having requested the Nevertheless, Proposers shall be responsible for ensuring that all addenda are in receipt prior to the proposal deadline. The Town will require acknowledgement of any addenda issued to be included on the proposal form. No addenda will be issued later than five days prior to RFP due date.

 

1. Finality of Proposal: After the proposal due date, a proposer may not change any provision of the proposal in a manner prejudicial to the interests of the Town or fair competition. Minor informalities will be waived, or the Proposer will be allowed to correct them. If a mistake and the intended proposal are clearly evident on the face of the proposal document, the mistake will be corrected to reflect the intended correct proposal, and the Proposer will be notified in writing.

 

1. Contact Prohibition: With the exception of the Town Administrator, all contact with Town of West Brookfield personnel concerning this RFP are prohibited. This prohibition shall apply to all prospective proposers from the date of release of the RFP until an ambulance company is Violation of this condition may be considered sufficient cause by the Town to reject the response and/or selection of an ambulance company.

 

1. Minimum Requirements: Any proposal which is not according to prescribed form, incomplete, not properly signed, or contrary to the instructions and requirements contained in the Request for Proposals may be rejected by the Town of West Brookfield.

 

1. Town’s Reserved Rights: The Town may cancel this RFP or reject in whole or in part any and all proposals, if the Town determines that the cancellation or rejection serves the best interests of the Town of West Brookfield.

 

1. Signatures: Proposals must be signed as follows: 1) If the Proposer is an individual, by her/him personally; 2) If the Proposer is a partnership, by the name of the partnership, followed by the signature of each general partner; and 3) if the Proposer is a corporation, by the authorized officer.

 

1. Contract: By submitting a proposal, the vendor agrees that if chosen, the vendor will enter into a contract with the Town of West Brookfield under the terms and conditions described in the Town of West Brookfield contract (Appendix A).

 

1. Contents of Proposal (Please provide information in the following order):

 

Note: One (1) original and three (3) copies of the Proposal must be in the Proposal envelope. The Price of the proposal must be in a separate envelope marked “Price Proposal. Do not put the price in the Proposal Envelop. The Town will have a three-member committee made up of the fire chief, police chief, and town administrator who will evaluate all proposals first and then look at the price separately to evaluate the best overall proposal. The committee will then make a recommendation to the Board of Selectmen.

 

1. Name and Address of
2. Contact Information for Proposal, including: Name, Address, Telephone, and E-Mail Address.
3. Acknowledgement of Addenda, if
4. Executive Must be signed by company officer authorized to sign contracts for the company.
5. List all of the specifications given in Section II of this RFP, with the company’s plan for Also, list any exceptions taken to any portion of any specification listed in Section II of this RFP.

 

6. List of all municipal contracts held by the company in the Commonwealth of Massachusetts. This list shall include the name and current telephone number of the contact person. Any omissions from this list may be grounds for rejection of the proposal.

 

7. Complete and current name, address, and telephone number of at least one financial reference, one municipal official reference, and one hospital official reference.
8. A disclosure of any conditions (bankruptcy or other financial problems, pending litigation, planned closures, impending merger) that may affect Proposer’s ability to perform contractually.
9. Disclosure of whether or not the Proposer (or one of the joint venture partners) has been dismissed or disqualified from a bid/contract within the past five years, and if yes, the reason(s) why.
10. List of personnel by type and length of service who work for the company in the western Massachusetts area.
11. List of ambulances presently owned or leased by the company and used in the western Massachusetts area. This list should include year, make and
12. The company’s present complete rate

 

CERTIFICATE OF CORPORATE AUTHORITY

 

At a duly authorized meeting of the Board of Directors of the ______________________

                                                                                                                        (name of corporation)

 

held on __________ Directors were present or waived notice, it was voted that ________________

                (date)                                                                                                                               (name and title)

 

 

__________________of this company be and hereby is authorized to execute contracts and bonds

 

in the name and behalf of said company, and affix its Corporate Seal thereto, and such execution

 

of any contract or bond of obligation in this company's name on its behalf of such ______________

                                                                                                                        (officer)

under seal of the company shall be valid and binding upon this company.

 

A TRUE COPY,

 

ATTEST:    _____________________________

                                                            Place of Business:

 

                                                            ______________________________

 

 

I hereby certify that I am the ___________________ of the ______________________________                                                                        (title)                                 (name of corporation)

 

that ______________________________ is the duly elected ______________________ of said

                 (name of officer)                                                                   (title)

company, and the above vote has not been amended or rescinded and remains in full force and effect as

 

of the date of this contract.

                                                            Signature:         ______________________________

 

                                                            Name/Title:      ______________________________

 

                                                            Date:                ______________________________

                                                                                                    (corporate seal)

 

COMMONWEALTH OF MASSACHUSETTS, SS. ______________________, 20__

 

 

Then personally appeared the above named ______________________and acknowledged the foregoing

 

instrument to be his/her free act and deed before me.

 

                                                                        Notary Public _____________________________

                                                                        My commission expires________________________

 

 

 

 

Attestation Of Tax Compliance

I certify under the penalties of perjury that, to the best of my knowledge and belief, I am in compliance with all laws of the Commonwealth relating to taxes, reporting of employees and CONSULTANTs, and withholding and remitting child support.

 

_______________________                          ______________________________

*Signature of Individual or                             **Social Security Number or Federal

Corporate Name (Mandatory)                                   Identification Number (Mandatory)

 

By: _____________________                                   Date: __________________________

      Corporate Officer

      (Mandatory)

*Approval of a contract or other agreement will not be granted unless this certification clause is signed by the applicant.

**Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing and tax payment obligations.  Providers who fail to correct their non-filing or delinquency status will not have a contract or other agreement issued, renewed, or extended.  This request is made under the authority of Mass. G.L.C.62c, Sec.49A.

 

 

 

Certificate of Non-Collusion

 

The undersigned certifies under penalties of perjury that this bid or proposal has been made and submitted in good faith and without collusion or fraud with any other person. As used in this certification, the word “person” shall mean any natural person, business, partnership, corporation, union, committee, club, or other organization, entity, or group of individuals.

 

 

                                                            (Signature of Person Signing Bid)