Backup Documents 10/27/2015 Item #11F ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO F
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. 1 he completed routing slip and original documents are to be anted to the Count}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
2a.)(1 lo)i, l►S
4. BCC Office Board of County
Commissioners ,J kAzsc
5. Minutes and Records Clerk of Court's Office "P(r1 iot�2 t iJ 9�
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,B eau of Emergency Phone Number 239-252-3622
Contact/ Department Services
Agenda Date Item was October 27,2015 Agenda Item Number 16E6 \`—'F
Approved by the BCC
Type of Document Original Certificate Number of Original rA of
Attached Original Permit 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) A.pli..ble)
1. Does the document require the chairman's original signature? KI I l
2. Does the document need to be sent to another agency for additional signatures? If yes, KH
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 KH
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's KH
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chaittnan'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 KI-1
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip KH
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 October 27,2015 and all changes made KH N/A is not
during the meeting have been incorporated in the attached document. The County - an option for
Attorney's Office has reviewed the changes,if applicable. ��` t ' line.
9. Initials of attorney verifying that the attached document is the version approved by the KH l/ is not
BCC,all changes directed by the BCC have been made,and the document is ready for e 05' an o tion for
Chairman's signature. this e.
Please route back to Kathy Heinrichsberg in Emergency Management
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
MEMORANDUM
Date: October 29, 2015
To: Kathy Heinrichsberg, Executive Secretary
Bureau of Emergency Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: COCPN & Permit w/Just Like Family Concierge Medical
Transport Service, LLC
Attached is the original COCPN and an original permit as referenced above, (Item
#11F) approved by the Board of County Commissioners on Tuesday, October 27,
2015.
If you have any questions, please contact me at 252-8411..
Thank you.
Attachments
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COLLIER COUNTY FLORIDA
Class "2" COPCN
Name of Service: Just Like Family Concierge Medical Transport Services, LLC
Name of Owner: Elisabeth Nassberg
Principle Address of Service: 4500 Executive Drive
Suite #205
Naples, FL 34119
Business Telephone: (239) 682-8907
Description of Service: Inter-facility for Collier County
Number of Ambulances: 1 Ground Unit available*
See attachment: See attached document(s) for Vehicle Identification Number
This permit, as provided by Ordinance No. 2004-12, as amended, shall allow the above
named Ambulance Service to operate intra-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_"14k day of Q a -- , 2015
ATTEST: BOARD OF COUNTY COMMISSIONERS
DWIGHT E. BROCK, CLERK COLLIER COUNTY, FLORIDA
•
- e -
E. w.. ko Chairman, eputy Clerk Tim Nance, Chairman
Approved as to form and legality:
Jennifer A. Belpedio
Assistant County Attorney
*The maximum vehicles authorized is three (3). Ambulance VIN's to be reported to the
County for permit modification prior to being placed in operation.
October 28,2015
Dan E.Summers,CEM,FPEM, Director
Collier County Bureau of Emergency Services
8075 Lely Cultural Parkway
Suite 445
Naples, FL 34113
Dear Mr.Summers,
In accordance with the approval of the COPCN application submitted for our company,Just Like
Family Concierge Medical Transport, LLC.,on Tuesday October 27th, 2015 we request that the VIN number
of our recently acquired vehicle be included on the COPCN permit.
The VIN number for the 2015 Mercedes Benz is W03PE7CD8FP118959.
Thank you for your assistance.
in erely,
-4101
is. •eth 'assberg
Owner
Concierge Medical Transport
4500 Executive Drive Suite#205 Naples, Florida 34110 Phone 239.682.8907
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