Backup Documents 10/10/2017 Item #16F11 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 6 i
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 to 1.01 1--1
4. BCC Office Board of County 7:7AD
Commissioners ‘EN / 1p\\1,,\
5. Minutes and Records Clerk of Court's Office
r 101LS) (? 3.44544k-
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 ,$Pnte-mbeF-4.27-2613 Agenda Item Number 14E" 1
Approved by the BCC - R�`p� 1� l ,-F-
Type of Document Executive Summary,Permit,VIN list,and Number of Original 2
Attached 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) Applicable)
1. Does the document require the chairman's original signature? O =q
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 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
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 Sept 12,2017 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. this line.
9. Initials of attorney verifying that the attached document is the version approved by the - N/A is not
BCC,all changes directed by the BCC have been made,and the document is ready for th an option for
Chairman's signature. !this line.
PLEASE RETURN ALL DOCUMENTS TO KATHY HEINRICHSBERG I1 MEI G.MNGMNT
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WINS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
16F11
MEMORANDUM
Date: October 19, 2017
To: Kathy Heinrichsberg, Executive Secretary
Bureau of Emergency Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: COPCN w/Just Like Family Concierge Medical Transport
Services, LLC
Attached is the original document as referenced above, (Item #16F11) approved
by the Board of County Commissioners on Tuesday, October 10, 2017.
If you have any questions, please contact me at 252-8411.
Thank you.
Attachment
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16F11
COLLIER COUNTY FLORIDA
Class "2" COPCN
Name of Service: Just Like Family Concierge Medical Transport, Inc.
Name of Owner: Jacob Nassberg
Principle Address of Service: 3200 Bailey Lane
Suite 117
Naples, , FL 34105
Business Telephone: (239) 682-8907
Description of Service: Inter-facility for Collier County
Number of Ambulances: (3) Three
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.
Issued and approved this 1 Q day of Q*`C?J-0 .. , 2017
ATTEST: BOA' I O -•LINTY COMMISSIONERS
DWIGHT E.BRICK, CLE' COLLI C• d TY, FLORID
4N-
•S ,Deputy Clerk Penny Taylor airman
fi nature only.
Approved as to form and legality:
Nh. N. A
Jennifer A. Belped% C).5 aa�
Assistant County Attorney $\
16F11
EXHIBIT ._..,
Page of�.�,.�..
JUST LIKE FAMILY, LLC
LIST OF VEHICLES IN FLEET—2017-18
MERCEDES WD3PE7CD8FP118959 ALS PERMIT#019703 2015
SPRINTER
MERCEDES WD3PE7CD9FP121112 ALS PERMIT#019641 2015
SPRINTER
FORD TRANSIT 1FDYR2CM1HKA15492 ALS PERMIT#020462 2017