Backup Documents 01/14/2020 Item #16E2 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 6 E i
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1.
2.
3. County Attorney Office County Attorney Office JAB 1/14/20
4. BCC Office Board of County
Commissioners
5. Minutes and Records Clerk of Court's Office
� � ()-`1)"� ;r()-`1)"PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the addressees
above,may need to contact staff for additional or missing information.
Name of Primary Staff Kathy Heinrichsberg Phone Number 252-3622
Contact/ Department /
Agenda Date Item was January 14,2020 / Agenda Item Number 16E2 - /
Approved by the BCC v✓
Type of Document / Number of Original �3
Attached Permit, Certificate,VIN l/ Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature? KH
2. Does the document need to be sent to another agency for additional signatures? If yes, N/A
provide the Contact Information(Name;Agency;Address; Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be KH
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's NA
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the KH
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's KH
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip NA
should be provided to the County Attorney Office at the time the item ' input into SIRE.
Some documents are time sensitive and require forwarding to Tallah see within a certain
time frame or the BCC's actions are nullified. Be aware of your eadlines!
8. The document was approved by the BCC on January 14,203 and all changes made KH IA is not
during the meeting have been incorporated in the attached document. The County option for
Attorney's Office has reviewed the changes,if applicable. s line.
9. Initials of attorney verifying that the attached document is the version approved by the A is not
BCC, all changes directed by the BCC have been made,and the document is ready for the C1 option for
Chairman's signature. ?�' s line.
Please return original documents to Kathy Heinrichsberg in Emergency Ma em t
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
1 6 E2
MEMORANDUM
Date: January 15, 2020
To: Kathy Heinrichsberg, Executive Secretary
Bureau of Emergency Services
From: Teresa Cannon, Sr. Deputy Clerk
Minutes & Records Department
Re: COPCN w/Just Like Family Concierge Medical Transport
Attached is an original of the documents as referenced above, (Item #16E2) as
approved by the Board of County Commissioners on Tuesday, January 14, 2020.
The Board's Minutes & Records Department has kept a copy as part of the Board's
Official Records.
If you have any questions, please contact me at 252-8411.
Thank you.
Attachment
16E2
COLLIER COUNTY FLORIDA
Class "2" COPCN
ALS Transfer Services
Name of Service: Just Like Family Concierge Medical Transport
D.B.A. Brewster Ambulance Service
Name of Owner: Paul H o b a i c a
Brewster Ambulance
Jeffery Panozzo
Mark Brewster
Bradford Cohen
Principle Address of Service: 1061 Collier Center Way
Suite # 1
Naples, Fl 34110
Business Telephone: (239) 682-8907
Description of Service: Inter-facility for Collier County
Number of Ambulances: (8) Eight (As referenced in the application)
This permit, as provided by Ordinance No. 2004-12, as amended, shall allow the above
named Ambulance Service to operate intra-facility, inter-facility and out of county
transports for a fee or charge for the following area(s): Collier County until March 6,
2020, except that this permit may be revoked by the Board of County Commissioners of
Collier County at any time the service named herein shall fail to comply with any local,
state or federal laws or regulation application to the provisions of Emergency Medical
Services.
Approved this
-- - y of .. 04u_QCY 2020
ATTEST: CLERK BOARD OF COUNTY COMMISSIONERS
CRYSTAL K. KINZEL COLLIER "iti; , ORIDA
.&&&04cc •
`.: t as to.Chill l�ltty Clerk Wi, .m L. McDaniel,Jr. Chairman
Approved as to form and legality:
Je ),CX J(-)3
er A. Belpe �� \NG
Assistant County Attorney p\
\�
ti
1 6 E2
,�, I,.k,
cJ
`Iiti
HEALTH ,'�
STATE OF FLORIDA
DEPARTMENT OF HEALTH
EMERGENCY MEDICAL SERVICES
AMBULANCE/VEHICLE PERMITS
V.I.N. MAKE MODEL YEAR PERMIT#(s)
1FDBW2XM7KKA63062 FORD TRANSIT 2019 A-22581 B-5965
1FDYR2XM2KKA63049 FORD TRANSIT 2019 A-22582 B-5966
IFDYR2XM6KKA21192 FORD TRANSIT 2019 A-22583 B-5967
IFDYR2CM1HKA15492 FORD TRANSIT 2017 A-21470 B-5678
WD3PE7CD9FP121112 MERCEDES SPRINTER 2015 A-21469 B-5677
WD3PE7CD8FP118959 MERCEDES SPRINTER 2015 A-21809 B-5679
1FDYR2CMXJKA87880 FORD TRANSIT 2018 A-21899
1 FDYR2CM2JKA81006 FORD TRANSIT 2018 A-21900
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