DISCLAIMER FOR ALL CITY OF KISSIMMEE DEVELOPMENT REVIEW APPLICATIONS

Transcription

1 DISCLAIMER FOR ALL CITY OF KISSIMMEE DEVELOPMENT REVIEW APPLICATIONS Important note: The Development Review process associated with this request (as outlined in the attached application) is intended to ensure that the request meets the requirements established in the City of Kissimmee Land Development Code and site development criteria for the City of Kissimmee, and other local, regional and state agencies. It is not intended to constitute approval of building construction or permits as required by external agencies. Other processes, permits, authorizations, and/or fees may be required prior to construction of requested improvements. These may include, but are not limited to: Mobility/Impact Fees (Transportation, Water & Sewer, Recreation, School) Building permits and review fees Right-of-Way Utilization permits South Florida Water Management District (SFWMD) permits Utility permits and/or fees Federal Aviation Administration (FAA) authorizations Business Tax Receipts (BTRs) State Permits and/or Licenses Development Service Agreements (Toho Water Authority) Florida Department of Environmental Protection (FDEP) Permits NPDES Permits (Stormwater permitting) The Agent of record and/or property owner for the attached request is responsible for coordinating with applicable agencies to ensure all requirements for the requested improvements have been met prior to construction. Please read all information above and complete the lower portion of this disclaimer. This document must be signed by both agent and property owner and shall be included with the attached application. Failure to submit this form with the completed application will result in Staff finding the application to be insufficient for review and will delay your request. Project DRC# I Certify that I have read the above and understand/acknowledge the information contained therein. Agent Signature: Date: Agent Name (Print): Property Owner Signature: Date: Property Owner Name (Print):

2 CITY OF KISSIMMEE APPLICATION FOR DEVELOPMENT REVIEW PROJECT Name of Project: Location (Address if possible): Parcel ID#: APPLICANT Firm: Address: Phone: ( ) - AGENT (Contact Person) Firm: Address: Phone: ( ) - OWNER Firm: Address: Phone: ( ) - LEGAL DESCRIPTION/LOCATION Note: Dates are contingent upon previous meeting approval and dependent upon the project type may not require various meetings. For specific processes, please see the project type. Scheduled dates for Public Hearings are subject to notification requirements and may be altered due to advertising requirements. All requests must be accompanied by a completed application, checklist, fee, folded plan(s), a CD containing PDF(s) of any exhibits and/or plans and any other supporting materials. A sufficiency review will be conducted within 24 hours of submittal. If submittal is insufficient, the request will not be scheduled/distributed for review. Unless specifically noted, deadlines for submittals are Friday at 4:00 p.m. on the above listed dates. No late or incomplete submittal will be accepted. FOR OFFICE USE ONLY REQUEST FEE COLLECTED DATE REC D BY DRC # DRC DATE SUFFICIENCY REVIEW (Y/N) PROJECT MANAGER

3 CITY OF KISSIMMEE APPLICATION FOR PAIN MEDICATION LICENSE Pursuant to provisions for pain management clinics and pharmacies outlined in Sections through in the Kissimmee Code of Ordinances, any pain management clinic or pharmacy holding a license duly granted by the State of Florida to prescribe or dispense schedule II controlled substances may apply for a pain medication license. All pain management clinics and/or pharmacies must be approved by the City Commission in a public hearing process, as outlined below. Following consideration of the application for pain medication license by the Development Review Committee (DRC), the committee shall forward its recommendation for approval, denial, or conditional approval of the license to the City Manager or his/her designee and the City Manager or his/her designee shall place the application, with recommendations, on the next available City Commission agenda, for public hearing. Upon approval or conditional approval of an application for a pain management license by the City Commission, based on the criteria of this Article, the pain medication license shall be issued, for a period of one (1) year. This license must be renewed annually, subject to a $200 fee and approval by the City Manager or designee. Mandatory conditions of operation shall apply to all licensed pain management clinics or pharmacies and are outlined on the attached affidavits. The applicable affidavit shall be completed, signed and included with this application. Note: Applicants who feel they may be exempt from the requirements of Sections through must complete and submit an Agreement for Pain Medication License Exemption in lieu of this application. Business Information: Type of business: Pain Management Clinic Pharmacy Phone #: Location of Business (a separate application shall be filed for each location): Mailing Address: Applicant Contact Information: Phone #: Address: Property Owner Information: Phone #: Address: U:\PLANNING\GTR\DRC\Forms\Individual applications\2017 Pain Medication License

4 Per Section , a list of all owners, operators and/or other parties with a proprietary interest in subject establishment shall be provided below. Each individual shall be subject to a criminal background check in order to confirm that said individuals have no criminal convictions within the last ten (10) years. Names, signatures and other requested information shall be provided below. A copy of each individual s driver s license or other legally recognized form of photo ID shall be provided. Additional individuals to be provided on a separate page. Address: Phone: Nature of affiliation with establishment (i.e. owner, operator, etc.): Signature: Address: Phone: Nature of affiliation with establishment (i.e. owner, operator, etc.): Signature: Address: Phone: Nature of affiliation with establishment (i.e. owner, operator, etc.): Signature: Address: Phone: Nature of affiliation with establishment (i.e. owner, operator, etc.): Signature: Address: Phone: Nature of affiliation with establishment (i.e. owner, operator, etc.): Signature: U:\PLANNING\GTR\DRC\Forms\Individual applications\2017 Pain Medication License

5 I Certify that to the best of my knowledge and belief, all information supplied with this application is true and accurate, and that I am: Owner of the property described herein Party to an agreement for purchase of this property An agent for the owner or purchase of this property Other Applications submitted by an applicant other than the owner of the subject property shall be accompanied by written documentation, suitable to the City Attorney, from the property owner authorizing the applicant to submit this request. Date: Printed Signature: Submittal requirements. Applications will not be accepted unless accompanied by all of the following: 1. Completed Application for Pain Medication License; 2. Completed, signed and notarized Affidavit for Pain Management Clinic and/or Pharmacy; 3. Non-refundable application fee. Note: additional advertising fees may apply. Applicant will be notified of additional fee, to be determined by the cost of advertisement and public notice mailing. NOTE: Incomplete submittals will not be processed. Once an application is submitted, the request will be reviewed by the Development Services Department Planning Division to ensure compliance with the criteria and requirements. If found to be sufficient, the application will be scheduled for the next available City Commission meeting where final determination will be made. Average time for completion of request could take up to 120 days. The length of this process may vary dependent upon time necessary for completion of all criminal background checks and other information needed for the public hearing process. Any application not on scheduled for a City Commission hearing within 120 days of submittal shall be deemed incomplete and rejected. Date: Printed Signature: U:\PLANNING\GTR\DRC\Forms\Individual applications\2017 Pain Medication License

6 Affidavit Mandatory Conditions for Operation of Non-Exempt Pharmacies City of Kissimmee Code of Ordinances, Section The conditions below shall be adhered to by all licensed Non-exempt Pharmacies established after June 30, Note: These conditions shall be in addition to any conditions imposed by the City Commission upon approval of the Pharmacy License. This affidavit must be completed, signed, notarized and submitted with the Application for a Pain Medication License in order to be accepted. All pain medication licenses shall require compliance with the following conditions: 1. Each pain management clinic or pharmacy shall be registered separately for each location within the City regardless of whether each clinic or pharmacy is operated under the same business name or management as another clinic or pharmacy; 2. Each application for a pain management clinic or pharmacy shall disclose each owner and operator of such clinic or pharmacy, and individual principals of any entity that owns such clinic or pharmacy; 3. The pain management clinic or pharmacy shall not limit the form of payment for goods or service to cash only; 4. The pain management clinic or pharmacy shall not accept cash for payment of goods and services associated with the prescribing or dispensing of schedule II substances except for insurance co- pays, coinsurance, or deductibles; and 5. Such other conditions as the City Commission determines are reasonably related to the public health, safety and welfare. Licensed pharmacies shall comply with the following conditions in addition to those outlined above: 1. The pharmacy shall have a State of Florida licensed pharmacist physically on premises at all times during all hours of operation; 2. The pharmacy shall post a copy of all licensed pharmacists' licenses; Page 1 of 3

7 3. The pharmacy shall require a valid State or Federal photo identification, or passport, to identify the patient or, in the case of a minor, his/ her parent or legal guardian's similar identification, prior to the dispensing of any schedule II substances; 4. The pharmacy shall only dispense any schedule II substances as defined in Section between the hours of 9: 00 a.m. to 7: 00 p.m.; 5. The pharmacy shall not dispense more than a thirty (30) day supply of any schedule II substance provided the patient's valid identification is from the State of Florida. For any patient whose valid identification is outside the State of Florida, the pharmacy shall not dispense more than a seventy two (72) hour supply of any schedule II substance except that a pharmacy may dispense up to a thirty (30) day supply of any schedule II substance provided the patient presents a valid photo identification, in accordance with this section, and a utility bill that is not older three (3) months, that is in the name of the patient or the patient' s spouse, and that shows a City of Kissimmee address. 6. The pharmacy shall maintain a legible copy of the prescription for schedule II substances as defined by section the patient's photo identification for each prescription dispensed or delivered; and the utility bill, if applicable. The records must be maintained for a minimum of two (2) years. Such records shall be available for inspection and copying by the law enforcement agencies, as permitted by Section , Florida Statutes, for a minimum of two (2) years; 7. The delivery, including mail order delivery, of all schedule II substances shall be prohibited except (i) to any facility licensed under Florida Statutes Chapters 400 or 429, or (ii) while fully complying with this Article to any address located within the Kissimmee City boundaries and listed on the patient's valid photo identification, or (iii) while fully complying with this Article to the address listed within the Kissimmee City boundaries on the utility bill for the patient or the patient' s spouse, if applicable; 8. Provide a monthly summary report to the Police Department for all schedule II substances as defined in section that have been dispensed by this facility. The monthly report shall be provided by the seventh day of each month for the previous month. At a minimum, the report shall include the following: a) A list of all physicians that have prescribed schedule II substances and the business address of the prescribing physician; b) The number of prescriptions written by each physician or physicians' office; c) The number of prescriptions associated with each type of schedule II substances; d) Certification from the applicant that the pain management clinic or pharmacy is in compliance with all provisions of the pain medication license; and, e) A current listing of all suppliers/ wholesalers for all schedule II substances. Page 2 of 3

8 AFFIDAVIT OF AGREEMENT I have read the above mandatory conditions for Non-exempt Pharmacies. I clearly understand these conditions must be adhered to at all times during the operation of the business licensed at the address below. I am also aware of my responsibilities for the operation of a pharmacy on the property. I further understand that any violation of this affidavit and/or other conditions imposed by the City of Kissimmee for the operation of the business licensed at the address contained in this affidavit may result in code enforcement action and/or revocation of the license to operate said facility. Applicant Business Business Address: Suite: Signature of Applicant: Date: NOTARY PUBLIC INFORMATION: STATE OF FLORIDA The forgoing instrument was acknowledged before me this day of, 20 by (Name of person acknowledging). He/she is personally known to me or has produced (type of identification) as identification. Notary Public State of Florida at Large My Commission Expires: Page 3 of 3

9 Affidavit Mandatory Conditions for Operation of Non-Exempt Pharmacies City of Kissimmee Code of Ordinances, Section The conditions below shall be adhered to by all licensed Non-exempt Pharmacies established after June 30, Note: These conditions shall be in addition to any conditions imposed by the City Commission upon approval of the Pharmacy License. This affidavit must be completed, signed, notarized and submitted with the Application for a Pain Medication License in order to be accepted. All pain medication licenses shall require compliance with the following conditions: 1. Each pain management clinic or pharmacy shall be registered separately for each location within the City regardless of whether each clinic or pharmacy is operated under the same business name or management as another clinic or pharmacy; 2. Each application for a pain management clinic or pharmacy shall disclose each owner and operator of such clinic or pharmacy, and individual principals of any entity that owns such clinic or pharmacy; 3. The pain management clinic or pharmacy shall not limit the form of payment for goods or service to cash only; 4. The pain management clinic or pharmacy shall not accept cash for payment of goods and services associated with the prescribing or dispensing of schedule II substances except for insurance co- pays, coinsurance, or deductibles; and 5. Such other conditions as the City Commission determines are reasonably related to the public health, safety and welfare. Licensed pharmacies shall comply with the following conditions in addition to those outlined above: 1. The pharmacy shall have a State of Florida licensed pharmacist physically on premises at all times during all hours of operation; 2. The pharmacy shall post a copy of all licensed pharmacists' licenses; Page 1 of 3

10 3. The pharmacy shall require a valid State or Federal photo identification, or passport, to identify the patient or, in the case of a minor, his/ her parent or legal guardian's similar identification, prior to the dispensing of any schedule II substances; 4. The pharmacy shall only dispense any schedule II substances as defined in Section between the hours of 9: 00 a.m. to 7: 00 p.m.; 5. The pharmacy shall not dispense more than a thirty (30) day supply of any schedule II substance provided the patient's valid identification is from the State of Florida. For any patient whose valid identification is outside the State of Florida, the pharmacy shall not dispense more than a seventy two (72) hour supply of any schedule II substance except that a pharmacy may dispense up to a thirty (30) day supply of any schedule II substance provided the patient presents a valid photo identification, in accordance with this section, and a utility bill that is not older three (3) months, that is in the name of the patient or the patient' s spouse, and that shows a City of Kissimmee address. 6. The pharmacy shall maintain a legible copy of the prescription for schedule II substances as defined by section the patient's photo identification for each prescription dispensed or delivered; and the utility bill, if applicable. The records must be maintained for a minimum of two (2) years. Such records shall be available for inspection and copying by the law enforcement agencies, as permitted by Section , Florida Statutes, for a minimum of two (2) years; 7. The delivery, including mail order delivery, of all schedule II substances shall be prohibited except (i) to any facility licensed under Florida Statutes Chapters 400 or 429, or (ii) while fully complying with this Article to any address located within the Kissimmee City boundaries and listed on the patient's valid photo identification, or (iii) while fully complying with this Article to the address listed within the Kissimmee City boundaries on the utility bill for the patient or the patient' s spouse, if applicable; 8. Provide a monthly summary report to the Police Department for all schedule II substances as defined in section that have been dispensed by this facility. The monthly report shall be provided by the seventh day of each month for the previous month. At a minimum, the report shall include the following: a) A list of all physicians that have prescribed schedule II substances and the business address of the prescribing physician; b) The number of prescriptions written by each physician or physicians' office; c) The number of prescriptions associated with each type of schedule II substances; d) Certification from the applicant that the pain management clinic or pharmacy is in compliance with all provisions of the pain medication license; and, e) A current listing of all suppliers/ wholesalers for all schedule II substances. Page 2 of 3

11 AFFIDAVIT OF AGREEMENT I have read the above mandatory conditions for Non-exempt Pharmacies. I clearly understand these conditions must be adhered to at all times during the operation of the business licensed at the address below. I am also aware of my responsibilities for the operation of a pharmacy on the property. I further understand that any violation of this affidavit and/or other conditions imposed by the City of Kissimmee for the operation of the business licensed at the address contained in this affidavit may result in code enforcement action and/or revocation of the license to operate said facility. Applicant Business Business Address: Suite: Signature of Applicant: Date: NOTARY PUBLIC INFORMATION: STATE OF FLORIDA The forgoing instrument was acknowledged before me this day of, 20 by (Name of person acknowledging). He/she is personally known to me or has produced (type of identification) as identification. Notary Public State of Florida at Large My Commission Expires: Page 3 of 3

12 2018 CITY OF KISSIMMEE SCHEDULE Development Review Committee (DRC) Planning Advisory Board (PAB) & City Commission (CC) SUBMITTAL DEADLINE (4:00 P.M.) PAB PUBLIC HEARING (6:00 P.M.) CC PUBLIC HEARING (6:00 P.M.) DRC MEETING (8:30 A.M.) October 20, 2017 November 7, 2017 December 6, 2017 January 2, 2018 November 3, 2017 November 21, 2017 December 20, 2017 January 16, 2018 November 17, 2017 December 12, 2017 January 3, 2018 February 6, 2018 November 22, 2017* December 12, 2017 January 3, 2018 February 6, 2018 December 8, 2017 December 27, 2017** January 17, 2018 February 20, 2018 December 22, 2017 January 9, 2018 February 7, 2018 March 6, 2018 January 5, 2018 January 23, 2018 February 21, 2018 March 20, 2018 January 19, 2018 February 13, 2018 March 7, 2018 April 3, 2018 January 26, 2018 February 13, 2018 March 7, 2018 April 3, 2018 February 9, 2018 February 27, 2018 March 21, 2018 April 17, 2018 February 23, 2018 March 13, 2018 April 4, 2018 May 1, 2018 March 9, 2018 March 27, 2018 April 18, 2018 May 15, 2018 March 23, 2018 April 10, 2018 May 2, 2018 June 5, 2018 April 6, 2018 April 24, 2018 May 16, 2018 June 19, 2018 April 20, 2018 May 8, 2018 June 6, 2018 July 3, 2018 May 4, 2018 May 22, 2018 June 20, 2018 July 17, 2018 May 18, 2018 June 12, 2018 July 18, 2018*** August 21, 2018 May 25, 2018 June 12, 2018 July 18, 2018*** August 21, 2018 June 8, 2018 June 26, 2018 July 18, 2018 August 21, 2018 June 22, 2018 July 10, 2018 August 1, 2018 September 11, 2018 July 6, 2018 July 24, 2018 August 15, 2018 September 11, 2018 July 20, 2018 August 7, 2018 September 5, 2018 October 2, 2018 August 3, 2018 August 21, 2018 September 19, 2018 October 16, 2018 August 17, 2018 September 11, 2018 October 3, 2018 November 6, 2018 August 24, 2018 September 11, 2018 October 3, 2018 November 6, 2018 September 7, 2018 September 25, 2018 October 17, 2018 November 20, 2018 September 21, 2018 October 9, 2018 November 7, 2018 December 4, 2018 October 5, 2018 October 23, 2018 November 21, 2018 December 18, 2018 October 19, 2018 November 13, 2018 December 5, 2018 January 15, 2019**** October 26, 2018 November 13, 2018 December 5, 2018 January 15, 2019**** November 9, 2018 November 27, 2018 December 19, 2018 January 15, 2019**** November 21, 2018 December 11, 2018 January 2, 2019 February 5, 2019 December 7, 2018 December 26, 2018** January 16, 2019 February 19, 2019 December 21, 2018 January 8, 2019 February 6, 2019 March 5, 2019 January 4, 2019 January 22, 2019 February 20, 2019 March 19, 2019 * Submittal deadline has been moved to Wednesday 4 p.m. due to holiday. ** DRC Meeting date has been moved to Wednesday due to holiday. *** July 4, 2018 Planning Advisory Board meeting has been canceled due to holiday. **** January 1, 2019 City Commission meeting has been canceled due to holiday. Note: Dates are contingent upon previous meeting approval and dependent upon the project type may not require various meetings. For specific processes, please see the project type. Scheduled dates for Public Hearings are subject to notification requirements and may be altered due to advertising requirements. All requests must be accompanied by a completed application, checklist, fee, folded plan(s), a PDF of any exhibits and/or plans and any other supporting materials. A sufficiency review will be conducted within 24 hours of submittal. If submittal is insufficient, the request will not be scheduled/distributed for review. Unless specifically noted, deadlines for submittals are Friday at 4:00 p.m. on the above listed dates. No late or incomplete submittal will be accepted.

13 CITY OF KISSIMMEE DEVELOPMENT REVIEW FEE SCHEDULE Selection Annexation $0 Land Use Map Amendment Review* Land Use Plan Amendment (Small) $2, Land Use Plan Amendment (Large) $3, Land Use Plan Amendment (Text) $3, Zoning Map Amendment* $2, Plan Unit Development (PUD) Review PUD Zoning/Preliminary Plan $4, PUD Amendment (Minor) $ PUD Amendment (Major or Moderate) $3, PUD Site Plan $4, PUD Name Change $ Conditional Use Review Conditional Use $1, Conditional Use/Site Plan $2, Conditional Use/Site Specific Redevelopment Plan (CRAO) $3, Site Plan Review Minor Site Plan $2, Site Plan (Full) $2, Site Specific Redevelopment Plan (CRAO) $2, Site Plan Extension $ Site Development (Construction) Plan Review Preliminary & Final Site Development (Construction) Plan $5, Resubmittal of a Final Site Development (Construction) Plan $4, Switch out pages (Developer Initiated) $ Final Site Development (Construction) Plan Amendment after issuance of $1, Development Order Subdivision Review Preliminary Plat $5, Preliminary Plat Amendment $4, Final Plat $1, Lot Combination Agreement $1, Development of Regional Impact (DRI) Review Application for Development Approval $12, $5 per acre Non-Substantial DRI Amendment $2, Substantial DRI Amendment $4, Annual Report $ Rescission $2, Special Event Review Without Sales $ With Sales $1, In Right-of-Way $ Renewal $ Late Submittal $1, Page 1 of 2 See other side of page for continuation of fee schedule U:\PLANNING\GTR\DRC\Forms\Individual applications\fee schedule doc 10/27/2017

14 Abandonment Vacation of Right-of-Way/Easement $2, Right-of-Way Review Temporary Sign in the Right-of-Way $ Outdoor Use Agreement in Right-of-Way $ Sidewalk Permit in B-1 District $ Street Name Change Variance/Waiver Review City Commission Variance $2, Buffer Waiver $1, Board of Adjustments $2, City Commission Extension of a public hearing item $1, City Manager Extension of a public hearing item $ Administrative Waiver/Variance $ Transportation Request for Alternative Mobility Fee Analysis Request for Mobility Fee Estimate with Credits $ Request for Mobility Fee Estimate without Credits $0 Transportation Studies/Reviews Zoning & State Funding Letter Standardized $47.01 Customized $ Tree Inspection 1-10 Trees $ Trees & Greater $ Miscellaneous Authorization of True Work of Art $1, State Application for Alcoholic Beverage License $ Pain Medication License $1, Developer s or Annexation Agreement $ Community Development District $ Folding Fee (Plans that are unfolded) $ Resubmittal (Upon 3 rd Submittal of any DRC Request) Applicant Requested Continuance of an Advertised Request $ Appeal of Staff, Planning Advisory Board and/or City Commission $1, Cost to be of advertisement and notifications to be paid for by the applicant Cost of consultant to be paid for by the applicant Cost of consultant to be paid for by the applicant Review fee of original request *A fee waiver can be approved at the discretion of the City Manager when a Small Scale Land Use Plan Amendment and Zoning Map Amendment request are submitted concurrently with the annexation request. NOTE: Fees shall increase annually on October 1, in accordance with the Consumer Price Index for All Urban Consumers (CPI-U), U.S. city average, percentage change from the previous year as determined by the U.S. Department of Bureau of Labor Statistics (BLS). Fees were amended by City Commission on December 15, 2015 by Resolution # All requests must be accompanied by a completed application, checklist, fee, plan(s) and any other supporting materials. A sufficiency review will be conducted with 24 hours of submittal. If submittal is insufficient, the request will not be scheduled or distributed for review. Deadline submittal is 4:00 p.m., Friday, in accordance with the City of Kissimmee Schedule for DRC, PAB & City Commission. Late or incomplete submittals will not be accepted. DRC meets every other Tuesday at 8:30 a.m. Page 2 of 2 U:\PLANNING\GTR\DRC\Forms\Individual applications\fee schedule doc 10/27/2017