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| 43668 | 2020/Sargent,_Ronald_1.22.20_CMR_6.07.pdf | The Commonwealth of Massachusetts Executive Office of Health & Human Services Department of Developmental Services Central/West State Operated Community Services 184 Freight Shed Road Charles D. Baker Jane F. Ryder Governor Baldwinville, MA 01436 Commissioner Karyn E. Polito Phone: (978) 939-2161 Anthony Keane Lieutenant Governor FAX: (978) 939-8273 Regional Director Marylou Sudders Patricia Lyons Secretary Director C/W State Operated Community Services To: T. Michael McDonald Assistant General Counsel From: Patricia Director Lyons y CW State Operated Community Services Re: Corrections to the 930 CMR 6.07 Disclosures Barbara DiVito and Ronald Sargent Date: January 15, 2020 Enclosed you will find the corrected 930 CMR 6.07 Disclosures for Barbara DiVito and Ronald Sargent. The information regarding payment has been added and the section entitled "Approval by Agency that Made the Contract (If Different)" has been deleted as it was not necessary. Please let me know if you should have any additional questions. I may be reached at 978-652-4048. Thank you for your assistance with this process. 2020 JAN 22 PM 2:05 2: 05 R i. SINHORE RECEIVED DISCLOSURE BY STATE EMPLOYEE OF FINANCIAL INTEREST IN A CONTRACT TO PROVIDE SOCIAL SERVICES PURSUANT TO 930 CMR 6.07 STATE EMPLOYEE INFORMATION Name of state employee: Ronald Sargent Title/ Position: Physician Assistant DDS- Templeton Community Services 2019 DEC 16 AM11:57 RECEIVED Agency/Department: Agency Address: 184 Freight Shed Rd Baldwinnille, MA 01436 Office phone: 918-657-4073 Office e-mail Ronald, Sergente MassMall. State. MA. US I am a state employee, and I seek to have a financial interest in a contract or agreement made by a state agency listed below, or by a provider or organization funded by a state agency listed below: A state agency within the following Executive Offices: Executive Office of Health and Human Services, including the Human Service Transportation Office; Executive Office of Public Safety and Security, Executive Office of Elder Affairs, Executive Office of Veteran's Services, or A sheriff's office. The purpose of the contract is: To provide personal services to a person or persons who receive services from, or have services paid for by, these state agencies; or - To provide educational services to people who work for these state agencies or for providers or organizations funded by these state agencies. I seek approval of the arrangement from the agency for which I serve as a state employee and from the state agency above that made the contract. FINANCIAL INTEREST IN A CONTRACT WITH A STATE AGENCY PLEASE CHECK OFF ONE OF THE THREE STATEMENTS BELOW AND PROVIDE THE REQUESTED INFORMATION. 1) Service to a state agency I will provide personal or educational services to a state agency listed above Please identify the state agency and also the Executive Office it is in, if applicable. 2) Service to a provider or I will provide personal or educational services to a provider or organization funded by a state organization agency listed above. Please provide the name and address of the provider or organization. Shriver Clinical Services 541 North Ave 1ST Floor Door #2 WakeFleld, MA 01880 Please identify the state agency that funds the provider or organization, and also the Executive Office it is in, if applicable. DDS 3) Service to a person or persons I will provide personal services directly to a person or persons who receive services from, or have services paid for by, a state agency listed above. Please identify the state agency that provides services to, or pays for services for, the person or persons, and also the Executive Office it is in, if applicable. Please describe the Please provide information about the type of personal or educational services you will provide. services you will Please do not include the name of any individual who receives services. provide. Medical on-call coverage after office hours What will you be Please include a dollar amount, if possible. paid, or what other I will be paid $ 160.00 for each on call your. I work financial interest will you have? approximately 12- on call tours per month. On call tours occur after normal office hours of 8A to up Mon. through Friday aswell as 74 hars each weekend day. Employee signature Rand Ent par Date: 11-27-18 APPROVAL BY AGENCY YOU SERVE AS A STATE EMPLOYEE Name and title of appointing authority Patricia Lyons Central west State op. Community Services Director Office phone 978 - 652 - 4048 Office e-mail Patriea.Lyons@StateMA.US Signature by By signing here, I indicate that I have reviewed the facts that the state employee has appointing authority disclosed above and approve the arrangement proposed by the state employee. Date: 11-27-18 |