Backup Documents 10/11/2016 Item #16E 6 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO lua
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNA
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 5,0.537
gyp ) I kW
4. BCC Office Board of County -pF �
Commissioners l ta`kZllb
5. Minutes and Records Clerk of Court's Office 7)0\ to(I3h6 9694m
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 Phone Number 252-3622
Contact/ Department Kathy Heinrichsberg,E ecutive Secretary
Agenda Date Item was October 11,2016 Agenda Item Number
Approved by the BCC 16E6
Type of Document COCPN Permit and Certificate Number of Original 2- 1 Permit
Attached Documents Attached 1 Certificate
PO number or account N/A
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 sign re? STAMP OK KH
2. Does the document need to be sent to another agency fora ' ional signat ? If yes, KH 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 KH 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 1444"----
should
(Wshould 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 11,2016 and all changes made KH
during the meeting have been incorporated in the attached document. The County
Attorney's Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the l •
BCC,all changes directed by the BCC have been made,and the document is ready for the cx, •
Chairman's signature.
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
16E6
MEMORANDUM
Date: October 14, 2016
To: KathyHeinrichsberg, Secretary
g�
Bureau of Emergency Services
From: Ann Jennejohn, Deputy Clerk
Minutes & Records Department
Re: Annual Certificate of Public Convenience and Necessity (COPCN)
Permit and Certificate for Just Like Family Concierge Medical
Transport Services, LLC., D/B/A Concierge Medical Transport
Please find the original copies of the documents referenced above (Item #16E6)
approved by the Board of County Commissioners on Tuesday, October 11, 2016.
Copies of the permit and certificate will be held in the Minutes and Records
Department for the Board's Official Record.
If ou have anyquestions, please contact me at 252-8406.
Y
Thank you.
Attachment
1 6E 6 ____
COLLIER COUNTY FLORIDA
Class"2"COPCN
Name of Service: Just Like Family Concierge Medical Transport, Inc.
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: (2)Two
See attachment: "A"for description of vehicles
This permit,as provided by Ordinance No. 2004-12,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.
ItO
Issued and approved this '1 ; day of Q c kdaeQ ,2016
ATTEST: BOARD OF COUNTY COMMISSIONERS
DWIGHT E.BROCK,CLERK COLL ' COUNTY, LORIDA
•
es as o � ''."!t.:. Clerk Donna iala, Chairman
signature on y.
Approved as to form and legality:
%LCL-A
CO
Jennifer A. Belpedio
Assistant County Attorney �ry Item#
Agenda lV 1,1-ve,
Date ----
Date 1 'lCo
Reeed,.
Deputy
Off,
1 6E6
Attachment A
JUST LIKE FAMILY, LLC
LIST OF VEHICLES IN FLEET—2016-17
VIN Type of License Permit Number Effective Date
1. WD3PE7CD8FP118959 ALS Permit*019703 2015
2. W03PE7CD9FP121112 ALS Permit#019641 2015
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