Baruch Jacobs, M.D.m MIP,MIB~AC~
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
• OFFICE OF THE CITY CLERK, Robert Parcher, Ciry Clerk
Tel: (305) 673-741 1, Fax: (305) 673-7254
04-01-2010
Baruch Jacobs M.D.
3.605 Flamingo Dr
Miami Beach, Florida 33.140
~}U,BJ~ECT~ Health Advisory Committee
Congratulations! You have been appointed by the City Commission to the agency,
board or committee named .above for a term ending: 12/31/2011.
Pursuant.to Ordinance No. 2006-3543, commencing with terms beginning on or after
January 1st, 2007, the -term of board members who are directly appointed by a member of
the City Commission shall automatically expire on December 31 of the year the appointing
elected official leaves office.
If you are unable to accept this appointment or have any questions, please call the City
Clerk's Office at 305-673-7411.. Please read the enclosed materials carefully.
Congratulations again. and good luck.
Sincerely,
,~ ~'~
Robert Parcher ,
City Clerk _ . ~ '
cc: ,Saul Frances, Parking. Director
Cliff Leonard
ATTACHMENTS:
Letter of Appointment
Oath
Gity Code Ordinance section, applicable to agency, board or committee
City Code Section 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
Ordinance No. 2006-3543 -Amendment to City Code Section 2-22
Miami-Dade County Code Section 2-11.1 -Conflict of Interest and Code of .Ethics Ordinance
City Wide Permit Application'- (Parking Department Form)
.Booklet -Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employee
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
m MIAMIC ~~z~~l
q., . ... .. .. .
City o M~am~ Beach, 1700 Convention Center Drive;.'Miami`.Beach.;Floridan33.fi>39, www:iniarnibeachfl:gov ~ ~,~~~, ' ` `''
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OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk ';:= ° '~ " "' "` • ` ' •- " ~ • ~ • ~ -''~
Tel: (305) 673-74.1 1, Fax: (305) 673-7254 ~ t~: ~ . ,.. . ; :. .. ` ... ~ '_ _ .. , -. ..
~,
TO Dr. Baruch Jacobs •
RE: Health Advisory Committee
I do solemnly swear or affirm to bear true faith., loyalty and allegiance to the Government of the '
United States, the State of .Florida, and the City of Miami Beach, and to perform all the duties of
a member of the above-mentioned board or committee of the City of Miami Beach to which I have
been appointed for a term ending: 12/31,/2011.
I have been issued a copy of Section 2-11.1 ~of the Miami-Dade County Code (Conflict of Interest
and Code of Ethics Ordinance), as well as theF/orida Commission on Ethics Guide to the Sunshine
Amendment and Code of Ethics for Public Officers and Emp/ogees, and understand that as a member
of a City of Miami .Beach Board and/or.Committee, I must comply with the financial disclosure require-
rnents of .Miami-Dade County orthe-State of Florida (depending o board or committee on which
I serve) on July 1st, following the closing of the calendar year ich I have s
~"J Dr. B~ J" _acobs
Sworn to and subscribed before me this ~ day of ~'~- • , 2010.:.
,_
Silvia Prieto
.Deputy Clerk
*Please visit the City of Miami Beach website at: www.miamibeachfl.gov under City Clerk/Board and Committees
for additional information regarding the Financial. Disclosure Requirements.
We are committed to providing excellent public service and safety to all who live, work and. play in our vibrant, tropical, historic community.
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.. ~ Business Name: >lr/~-~' ~ rya „~ /`~.7 ~~ r Position: ~.~~~%•--~ _
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' Address: G~C.7 /"~~ ~G~~ ~ ~36~1`~ r-~r~~ ., ..~.. y ~
. ~ ~ No.. .~- ~ Street.. .. _ City ~ State Zip Code
' Professional License,(describe ~ ~'~ ~ _ - Expires: "`~~1~ ~L9/~ Attach'~a copy of .the license
.. ~ , .
. Pursuant ta.City Cotle sectipn 2-22(x) a and b: Members.of agencies, boards, and committees shall be affiliated with the city; this-
. .. . .
' requirement shall 6e fulfilled in theefaligwirig ways: a} an -ndividual ahall have been a ,.resident'of the city"`for a minimum of six
. months; or b) an individual shall demorastrate ownership/interest for a minimum of six .months in a business~~esta~li~hed ih the city:
~' ~
• Resident of Miami.8each for a minimum of ix {6) months: Yes ~;or:No ^ ~ =-~ ~,
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' • .Demonstrate an ownershi /interest in a business in Miami Beach for a minimum of six (6) months.: Yes rr Nc
• Are you a registered voter. in Miami Beach: Yes of Na: 0' ~ = ~ ~~ ,
• (Please :circle one); I am nowYa resident of: ~ orth Beach , South Beach ~ Middle Bs h~ .~- `
. ~.
• I ;am. applying for. an appointment because l.have special abilities, knowledge and ~exper nce. P - e (ist ~ieiow~ - 3
. ..~.
- • -Are yvu presently a registered lobbyist. with the' City of Miami Beach? Yes ^ or No~ ~ ~ c.)'~
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., P-lease, list your preferences in order of ranking [1] first choice (2]; second choice, .and ~3] third'choice. Piease~ote that oniy three s•31 .
,~ choices will be observed by the City Clerk's Office. (Regular Boards of City) ~'f `,
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^ Affordable Housir Adviso Committee ^ Housin Autho ' °`
., _ .
0 Arvin Public Places .Committee • ~ • ~
^ Laan Review. Committee
:
.
^: Beautification`Commi ee ~ ~ ` ~ .
O Marine Autho ' ".
^ Board of Ad~ustment* ~ ~ ~ Miami Beach Commission for 1Nomen •
D Bud et Adviso Committee ~~ "' ~' '^ Miami Beach~Cuitural Arts .Council
D Ca ital Im rovements Pro~ects Oversi ht Committee `D Miami -Beach .Sister Cities .Pro ram `
~^ Committee on the Homeless- ~ `' ~ ^ Nomtiandy Shores Local Government Nei h. im rvvemertt
Committee for Qualit Education~in MB ~ ^ Parks and Recreatioh F,acifities Board
Corimmuni `Develo ment Adviso '0 Personnel Board
~^ Communit .Relations Board ~ ~. D Plannin' Board*'' ~ ,
Convention Center Adviso Board ~ . C1 Police Citizens Relations Committee
Debarment Committee' ~ ` ~ _ ~ ,Production Indus Council
Desi n Review.l3oard* ~ ~ Public-Safe Adviso Committee
Disabilit Access Committee . ~ - . - , 1]wSafe Committee '
Fine Arts Board "~ ~ - 0 Sin le famii Residential Review Panel '
D Ga` ,Lesbian; Bisexual and Trans ender GLBT - ~ ~ ~ ' ^ Sustainabil' Committee
~~ Golf Adviso Committee ~ ~ ~ ^ Trans arenc Refiabii' 8~ Accountabifit Committee "TRAC'
Health. Adviso'Committee. ~ ~ ^ Trans ortation and Parkin Committee
D Health Facilities Autho ' Board ~ ~ ^.Visitor and Convention P.utho ~ ~ `
His anic Affairs .Committee ~ ~ ~ ~ ~ ~ ^ Waterfront Protection Committee
Historic: Preservation Board O Youth- Center Adviso Board
*Board Required to. Fiie'State. Disclosure Form
~iote:~. ff applying `for Youth Advisory Board; please indicates your affiliation. with the Scott Rakow~Youth Center: -~. '
_. - -
' . Past service on th'e Youth Center Advi;>ory' I3aard: -Yes p No ~ Years of Service': ~ ~ ~ ~~ ~ ••~ ~
:2~ Present 'participation in Youth Center activities by your ~ehiidreri Yes~_ No -. If yes, pieas~ fit to es of your children, their
ages, and which programs. List below:.. ~ ~ -~ ~ •~ ~~ ~ ~ ~~'~~
Chitd~s ...Warne
. ~ ~ ~ Hge: ..Program: ~'
....
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,Child's .name ,,, .. ~ .,t ~' ,~~ ~ u
.Age: . Program:,
F '\ LER".$AU;\aF~RM~'\&~ARC~ .AND COMAhITT~ES\&~. ApPit~ation06260~' I~l~Vv'.doc -
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r-,---_._-.. -- _ _ .- _ _ . _ -- . __. _ .. ~. _____ ., ,__ _._ _ .___- .__ ____r_.._ __..._.~___. . ____.___ -- _-____ ..._ _.__ ._ .__ _ _ _ __ _-
o!-lave you ever been convicteb telony: Yes : '~~ No 1= ~~es. please exgla~~ detail.
,,~ __
Do you currently have a violation(s) of Ciiy;,of ~iarn,i: Beach codes: Yes ~ o., No =:. f yes, prase explain in detail:
• Do you currently owe the City of Miami Beach any rrioney~. Yes _: or o~~. if yes: explain in detail
k + Are you currently serving on ny Cit.y Ba rds o Committees: Yes~ar No ".. If yes', which 5aard?
INhaf organizations in the City of Miami Beach do you currei-itJ.y hold membership in?
Name: Title:
Name: Title:
~. ~ + List a(I roperties owned or have .an interest in, which are located within the City of Miami Beach:
~~ r
. ~ __
• I am now employed by the City of Miami Beach: Yes ~~ ar t~~lhich department?
' • Pursuant toCity Code Section 2-25 (b): Do you have a parent ~, spouse G, child L; brother D, `or.sister C~ who is employed by the
City of Miami Beach? Check alt that apply. Identify the~department(s):~
The folfowing information is voluntary and is neither part of your application nor has any bsaring on your consideration for appointment. ft is
.being asked to comply with federal aqua( opportunity reporting requfremer-ts.
Gender: ~ fi/iate 0 Female
Ethnic Origin: Check one only (1)
~Whfte (Nat o` Hispanic Origin): All persons having origins in any of the .original peoples of curope, North Africa or the Nfictdle past.
African-AmericanlBfack (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of,Africa.
hispanic: Fill persons of Mexican, Puerto Rican, Cuban, Central ~or South American, or other Spanish culture or origir-, regardless of .race. `
^ Aston or Pacific islander: Al! persons having origins in any of the original peoples of the Far ast, Southeast Asia, the. Indian Subcontinent, on
the Pacific !stands. This area includes, for example; China, India, .tapan, Korea,.the Philippine islands and Somas.
U Cuttura$~der-tiftc~tio ~hroue h trlbavafftiiat! fo o~ commun' o reco hition. of the original peoples of North America, and.-who maintain
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~ Physically Cttatienged: Yes ~~ or f~to~' '
'~ Employment Status: Employed Retired 0 Homemaker ~ Jther ^ ~ ,
NC3TE: tf appointed, you w[t( bedrequired to follow certain tav~rs which apply to city board~committee members. E
,These taws include, but are not limited to, the following:
' c Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2-459).
o Prohibition from contracting with the city (Miami-Dade County Code section 2-11.1).
o Prohibition from lobbying. before board/committee you have served an for period of one year after leaving office lNliami
Beach City Code section 2-26).
o Re4uirement to disclose certain financial interests and gifts (Nfiami-Dade County Code section 2-11..1):
(re: CNEB Community Development Advisory Committee}: prohibition, during tenure and for one yearafter leaving office,
from having any interest in or .receiving any benefit from Community Development Block Grant funds for either yourself ,
or those with whom you have business or immediate family ties (CFR 57Q.611 }. ~ _.,,
i
Ctpon request, copies of these taws may be obtained from the City Ctert:.
"i hereb fleet to the curacy and truthfulness of the application and have received, read .and will abide by Chapter 2,
Article of the C e "Standards of Co uc for City Officers, ~ ployees and Agency Members."
~ ~ ~~U~
Ap ' '~ is Signfaf Date Name of Applicant PLERSE P NT)
t
Please attach a copy of your resume to this application
NdTE: Applications will remain on fHe for a period of one (1) calendar year.
ReceiveC in the City Clerk's Office by
Date~~ ~j>'!~ ontrol No ,~_~~~ Date: ~' 121
Name of Deputy Clerk
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