HomeMy WebLinkAboutAgreement_General_01/22/2015 Palm Heach, Coast
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AFFILIATE AGREEMENT
To ensure continuity of care and support to clients, 211 Palm Beach/Treasure Coast enters into the
following agreement with
Village of Tequesta CICS1317
(Print ortype your agency name here.)
211 Palm Beach /Treasure Coast agrees:
1. To refer callers, who meet the eligibility requirements) of the Affiliate, to the Affiliate without
regard to race, color, creed, disability, national origin, age, sex, sexual orientation or economic
status for assessment/on -going services.
2. To be available as a resource to the Affiliate's clients 24 hours a day for telephone counseling and
information and referral to community resources.
3. To be available to the affiliate's staff for information about and referrals to community resources.
The Affiliate agrees
1 . To receive clients, who meet the eligibility requirement(s), without regard to race, color, creed,
disability, national origin, age, sex, sexual orientation or economic status who are referred by 211
Palm Beach /Treasure Coast.
2. To advise clients of the 24 -hour availability of 211 Palm Beach/Treasure Coast services.
3. To advise staff of the availability of 211 Palm Beach /Treasure Coast as a resource.
4. To inform 211 Palm Beach/Treasure Coast when changes arise within the Affiliate.
5. That information provided is true and accurate to the best of their knowledge and that this
information may be included in published materials and in local or statewide databases.
6. To provide 211 Palm Beach/Treasure Coast a yearly formal update when requested beginning at
the start of each calendar year for accuracy, deletion and new content. Agencies can update
formally during the year using the online update process proactively on the website.
This letter of agreement will remain in force until terminated by either party contingent upon thirty (30)
days written notice.
211 PALM BEACH/TREASURE COAST: AFFI LI ATE:
Susan K. Buza,'Executive Director
January 2 2015
Date Signed Date Signed
11/10/2014 Page 5 of 5
211 Palm Beach Treasure Coast Information from 211 Community Resource Database
211 Database Update
211 Palm Beach/Treasure Coast
PO Box 3588
Lantana, FL 33465
To: Judi Hechtman
Phone: (561) 383 -2162
Email: judi.hechtman @211 pbtc.org
Fax: (561) 383 -2172
Date: 1 — 01 —� Pages: 5
From:
Agency Name: 1 Ik03-e- QC no a si - r,
Contact Name: Cu)i
Phone Number: rj to ) -- - - d --- L-A LI p
I have reviewed the details of our agency/site(s)/service(s), and:
The information is correct
We are enclosing corrections D A, y i
Village of Tequesta Agency #: CICS1317
345 Tequesta Drive Last Formal Update: 2/25/2014
Tequesta, FL 33469 Record Owned By: CICS
Date Entered: 11/5/2010
Mailing Address:
345 TEQUESTA DR Affliliate Agreement Date: 2/25/2014
Tequesta, FL 33469
Phone Number EXT Dept/Contact Agency Fax
(561) 768 -0460 (561) 768 -0697
Agency County: PALM BEACH Year Incorporated:
Also Known As: IRS Status:
Agency Type: Municipal Government Agency FEIN:
Person In Charge: Michael R. Couzzo, Jr. License /Accred.:
In Charge Title: Village Manager Annual Budget: $0.00
Email: mcouzzo @tequesta.org Source of Funds:
Website: www.tequesta.org /
Hours of Operation: Monday- Friday / 8:30 am -5 pm
Notes /Description: Municipal government. Council meets 2nd Thursday / 6 pm.
Site (Location)
Site Name: Tequesta Fire Department Site ID: CICS1317AC
357 Tequesta Drive Last Formal Update: 2/25/2014
Tequesta, FL 33469
11/10/2014 Page 1 of 5
211 Palm Beach Treasure Coast Information from 211 Community Resource Database
Site Mailing Address:
357 Tequesta Dr
Tequesta, FL 33469
Phone Number EXT Dept/Contact Site Fax
( ) -911 TO REPORT A FIRE (561) 768 -0693
(561) 768 -0550
Please Complete this section and include /send a copy of your AHCA License if this site provides:
Adult Day Care, Family Care Home, ALF, Nursing Home, Home Health Agency, Homemaker and Companion Service, Nurse Registry
Facility/Provider Type:
License Number: License Expiration Date:
Also Known As:
Person In Charge: James Weinand
In Charge Title: Fire Chief Site Accessibility:
Site Email: J LU2i�411c 4-qoe -s'fL• O(?) Site Bus Access:
Site Website: www.tequesta.Q-@*t44
Site Hours: 24 Hours A Day / 7 Days A Week
Notes /Description: Local number to contact an individual fire department.
TO REPORT A FIRE, DIAL 911.
Site Service ID: CICS010709
Program Name:
Taxonomy Code Site Service Use Reference Terms
JR- 1900.2000 Fire Control /Extinction
Fire Extinction
Fire Protection
Fire Response
Fire Suppression
Target Terms:
In Charge: Title:
Service Phone: Ext: Phone 2: Fax:
Site Service Email:
Site Service Website:
Site Service Fees: No fees charged.
Site Service Hours: 24 Hours A Day / 7 Days A Week
Service Area: Village of Tequesta
Service Intake Process: Contact by phone.
Service Eligibility: No restrictions.
Documents Required:
Language(s): English.
Notes /Description: Local number to contact an individual fire department.
TO REPORT A FIRE, DIAL 911.
11/10/2014 Page 2 of 5
211 Palm Beach Treasure Coast Information from 211 Community Resource Database
Site (Location)
Site Name: Tequesta Police Department Site ID: CICS1317AA
357 Tequesta Drive Last Formal Update: 2/25/2014
Tequesta, FL 33469
Site Mailing Address:
357 Tequesta Dr
Tequesta, FL 33469
Phone Number EXT Dept/Contact Site Fax
(561) 768 -0500 (561) 768 -0695
Please Complete this section and include /send a copy of your AHCA License if this site provides:
Adult Day Care, Family Care Home, ALF, Nursing Home, Home Health Agency, Homemaker and Companion Service, Nurse Registry
Facility/Provider Type:
License Number: License Expiration Date:
Also Known As:
Person In Charge: Christopher Elg
In Charge Title: Police Chief I ,, Site Accessibility:
Site Email: C 1° 4
15 @ -e- jL),5i 0, 3 Site Bus Access:
Site Website: www.tequesta.org
Site Hours: 24 Hours /7 Days A Week
Notes /Description: Local law enforcement agency.
— – - -- -- — -- — — — — --
Site Service ID: CICS010707
Program Name:
Taxonomy Code Site Service Use Reference Terms
FL -6500 Municipal Police
City Police
Local Police
Police Departments
Township Police
Village Police
Eviction Notice
Target Terms:
In Charge: Title:
Service Phone: Ext: Phone 2: Fax:
Site Service Email:
Site Service Website:
Site Service Fees: No fees charged.
Site Service Hours: 24 Hours /7 Days A Week
Service Area: Tequesta
Service Intake Process: Call.
Service Eligibility: No restrictions.
Documents Required:
Language(s): English.
Notes /Description: Local law enforcement agency.
11/10/2014 Page 3 of 5
211 Palm Beach Treasure Coast Information from 211 Community Resource Database
Site (Location)
Site Name: Village of Tequesta Site ID: CICS1317AB
345 Tequesta Drive Last Formal Update: 2/25/2014
Tequesta, FL 33469
Site Mailing Address:
345 TEQUESTA DR
Tequesta, FL 33469
Phone Number EXT Dept/Contact Site Fax
(561) 768 -0700 (561) 768 -0697
Please Complete this section and include /send a copy of your AHCA License if this site provides:
Adult Day Care, Family Care Home, ALF, Nursing Home, Home Health Agency, Homemaker and Companion Service, Nurse Registry
Facility/Provider Type:
License Number: License Expiration Date:
Also Known As:
Person In Charge: Michael R. Couzzo, Jr.
In Charge Title: Village Manager � Site Accessibility:
Site Email: mcc%�..�� C �`� -1 �"' 0r 3 Site Bus Access:
Site Website: www.tequesta.org
Site Hours: Monday- Friday / 8:30 am -5 pm
Notes /Description: Municipal government. Council meets 2nd Thursday / 6 pm.
— — — — - — — — — --- —
Site Service ID: CICS010708
Program Name:
Taxonomy Code Site Service Use Reference Terms
TD- 6600.4500 Local Officials Offices
City Government Offices
City Officials Offices
County Government Offices
County Officials Offices
Municipal Government Offices
Town Government Offices
Target Terms:
In Charge: Title:
Service Phone: Ext: Phone 2: Fax:
Site Service Email:
Site Service Website:
Site Service Fees: No fees charged.
Site Service Hours: Monday- Friday / 8:30 am -5 pm
Service Area: Village of Tequesta
Service Intake Process: Contact by phone.
Service Eligibility: No restrictions.
Documents Required:
Language(s): English.
Notes /Description: Municipal government. Council meets 2nd Thursday / 7 pm.
11/10/2014 Page 4 of 5
211 Palm Beach Treasure Coast Information from 211 Community Resource Database