§ 9-356. Application process.

Any pain management clinic must complete an application available from the division which shall at a minimum require the applicant to provide the following information:

(a)

The registration number from the State Department of Health as required by F.S. § 458.3265 or 459.0137, as may be amended, if the pain management clinic must be registered in accordance with state law;

(b)

Proof satisfactory to the division that the applicant is or has been conducting business in the City of Winter Haven as a pain management clinic at the registered location for which the applicant is seeking a city license prior to and up through October 31, 2010;

(c)

Designation of the physician who shall be responsible for complying with all requirements related to registration and operation of the pain management clinic and the physician's DEA number. The designated physician must have a full, active, and unencumbered license under F.S. ch. 456 or 459 and shall practice at the pain management clinic location for which the physician has assumed responsibility. Within ten (10) days after termination or absence of a designated physician, the pain management clinic must notify the division of the identity of another designated physician for the pain management clinic or forfeit the pain management clinic's license;

(d)

A list of all persons associated with the ownership, management or operation of the pain management clinic, whether paid or unpaid, part-time or full time, including all contract labor and independent contractors. This list shall include, but not be limited to, all owners, partners, members, trustees, operators, employees and volunteers. The application shall also designate a contact person who shall be the point of communication between the city and the applicant during the application and license renewal process. For the persons listed, the following additional information must be provided:

(1)

The person's title;

(2)

A current home address, telephone number and date of birth;

(3)

A list of all criminal convictions whether misdemeanor or felony;

(4)

A copy of a current Florida driver's license or a government-issued photo I.D.; and

(5)

A set of fingerprints.

(e)

The property owner's name, address, telephone number and a copy of a Florida driver's license or a government-issued photo I.D., if the property owner is different than the manager or operator.

(f)

A copy of a valid business tax receipt required pursuant to F.S. ch. 205, issued before October 15, 2010;

(g)

Any other information the division director deems necessary; and

(h)

A sworn and notarized statement from the designated physician attesting to the veracity and accuracy of the information provided in the application.

It is the applicant's responsibility to provide full and accurate contact information when submitting the application to the division. If the application for a pain management clinic license is not properly completed in the sole discretion of the division, the division shall notify the designated contact person listed in the application. A completed application must be received by the division within fifteen (15) business days of receipt of the deficiency notice from the division in order to avoid assessment of another application fee. Failure to timely respond within the fifteen (15) business days shall result in a denial of the application as incomplete. A new application must then be submitted that is accompanied by the full nonrefundable application fee. The division shall perform inspection(s) of the facility as necessary to determine whether or not the application submitted is accurate in all respects and to verify a physician licensed under F.S. ch. 456 or 459, as may be amended, is on the premises during all times medications are dispensed or prescribed. In the event that any information provided in the application changes, an amended application must be filed with the division in accordance with section 9-360 below.

(Ord. No. O-10-47, § 1(Exh. A), 10-25-10)