Backup Documents 01/28/2025 Item #16F 3 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP c
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 46
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE � i"
/
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 ff
JAk/mh II 30
4. BCC Office Board of County
Commissioners 1r IS/ )f/p
5. Minutes and Records Clerk of Court's Office
j
(3+6
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 Cherie DuBock/EMS Phone Number 239-252-3756
Contact/ Department
Agenda Date Item was 1/28/2025 Agenda Item Number 16.F.3
Approved by the BCC
Type of Document COPCN CERTIFICATE&PERMIT Number of Original 2
Attached Documents Attached
PO number or account PLEASE EMAIL TO
number if document is BRUCE.GASTINEAU@
to be recorded COLLIERCOUNTYFL.GOV
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? CD
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
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
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
document or the foal negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip
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 !!MOS and all changes made N/A is not
during the meeting have been incorporated in the attached document. The County -Ak inJ an option for
Attorney's Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the nnk tya. N/A is not
BCC, all changes directed by the BCC have been made,and the document is ready for the P an option for
Chairman's signature. this line.
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
16F3
COLLIER COUNTY FLORIDA
Renewal of Class "2" COPCN
Name of Service: Just like Family Concierge Medical Transport Services LLC, DBA
Brewster Ambulance Service.
Name of Owners: Paul Hobaica, Brewster Ambulance, Jeffery Panozzo, Chris Dibona, &
Yohandy Machin.
Principle Address of Service: 11820 Lacy Lane, Fort Myers, FL 33966
Business Telephone: (239)-682-8907
Description of Service: Inter-facility and out of county transport for Collier County
Number of Ambulances: 22 Ground Units available.
See attachment"A" for description of vehicles.
This permit, as provided by Ordinance No. 24-25, as amended, shall allow the above
named Ambulance Service to operate inter-facility and out of county transports for a fee
or charge for the following area(s): Collier County for one year from the date executed
hereon, 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 2$ih day of 5a.r,,,4Lry , 2025.
Effective Date: March 7, 2025
EcpfMtiSn bate: March 7, 2026
ATTESTD'° BOARD OF COUNTY COMMISSIONERS
Crystal K. frize4, Clerk COLLI COUNTY, FLORIDA
s
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476Q.'.(i110406-
as ctQPINtr3's
Clerk Burt L. Saunders, Chairman
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signature only
Appro .. 3 form and legality:
1'
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Jeffrey ' Klatzkow, County Attorney
[25-EMS-01254/1915346/1]
16F3
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