Backup Documents 02/08/2022 Item #16F1 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP j 6 F l
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
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 cue I I a I l d a,
4. BCC Office Board of County 49i hj ,, /
Commissioners itY /S, 02,�Vad-
5. Minutes and Records Clerk of Court's Office err af 8 r7e- az
sP —
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 February 8,2022 '- Agenda Item Number 16 F I
Approved by the BCC MinuteTraq 21046
Type of Document i.rPjJ5't'V' C4r LN Number of Original 2
Attached Permit and Certificate 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? � J"-- �l/
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 ��u"� ) 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 is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on February 8,2022 and all changes made
during the meeting have been incorporated in the attached document. The County _n /(�
Attorney's Office has reviewed the changes,if applicable. �
9. Initials of attorney verifying that the attached document is the version approved by the t"i
BCC,all changes directed by the BCC have been made,and the document is ready for the
Chairman's signature. ��
1: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
16 F 1
MEMORANDUM
Date: February 8, 2022
To: Kathy Heinrichsberg, Executive Secretary
Bureau of Emergency Services
From: Arm Jennejohn, Deputy Clerk
Minutes & Records Department
Re: Certificate of Public Convenience and Necessity for a Class 2
ALS non-emergency inter-facility ambulance transports to Just
Like Family Concierge Medical Transport Services
Attached is the original COPCN referenced above (Item #16F1) and certified copy
of the associated document, approved by the Board of County Commissioners on
February 8, 2022.
A copy of the COPCN and the original accompanying document will be held in
the Minutes and Records Department for the Board's Official Record.
If you have any questions, please call me at 252-8406.
Thank you.
Attachment
16F1
COLLIER COUNTY FLORIDA
Class "2" COPCN
ALS Transfer Services
Effective Date: March 7, 2022
Expiration Date: March 7,2023
Name of Service: Just Like Family Concierge Medical Transport Services L.,LC
D.B.A. Brewster Ambulance Service
Name of Owner: Paul Hobaica
Brewster Ambulance
Jeffery Panozzo
Chris Dibona
Yohandy Machin
Mark Brewster
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: (12) Twelve (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 for the term set
forth herein, 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.
Issued and approved this 1 4-h day of FLO'/(�ly.. , 2022
yam..,.,) .` d �1
A I f, : - -.ERK' ' , BOARD OF ' ►. ' COMMISSIONERS
CR I' v1,-10.1 (r COLLIE �j, TY, FL 'ID
Apo
:),..44 i
1,0 1444:, .. N o /gr..,
Allet V... or
•Aft as Kt A U LE. y Clerk hairman
Siflliafure 4niy. /
Approved as to form and legality:
IeJ`-J10 'a a
Je r A. Belpedi % ,\a
Assistant County Attorney '
CA4
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