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Sasha Boulanger 12/31/2011 m► M IAMIBEACH Cit of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: 305) 673 -741 1, Fax: (305) 673 -7254 01 -10 - Sasha Boulanger 826 Raymond Street Miami Beach, Florida 33141 WB EC Marine Authority Congratulations! You have been appointed by Commissioner Ed Tobin 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, ithi2, Robert Parcher City Clerk cc: Saul Frances, Parking Director Jose Alberto ATTACHMENTS: Letter of Appointment Oath City 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. MIAMIBEACH Cit of Miami Beach, 1700 Convention Center Drive, Miami Beach, Fbrida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673 -7411, Fax: (305) 673 -7254 TO Sasha Boulanger RE: Marine Authority 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 theFlorida Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees, and understand that as a member of a City of Miami Beach Board and /or Committee, I must comply with the financial disclosure* require- ments of Miami -Dade County or the State of Florida (depending on the board or committee on which I serve) on July 1st, following the closing of the calendar year on which 1 have served. (/ C asha Boulanger Sworn to and subscribed before me this day of FMS 11. 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. 1 m►, miAm1 BEACH CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM NAME: Boulanger Sasha A Last Name First Name Middle Initial HOME ADDRESS: 826 Raymond St Miami Beach FL 33141 Apt No. House No. /Street City State Zip Code PHONE: 305 389 9333 305 531 6110 305 531 0511 sasha@southbeachdivers.com Home Work Fax Email Address Business Name: South Beach Dive And Surf Position: Owner Address: 850 Washington Ave Miami Beach FL 33139 No. Street City State Zip Code Professional License (describe): Expires: Attach a copy of the license Pursuant to City Code section 2 -22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; this requirement shall be fulfilled in the following ways: a) an individual shall have been a resident of the city for a minimum of six months; or b) an individual shall demonstrate ownership /interest for a minimum of six months in a business established in the city. • Resident of Miami Beach for a minimum of six (6) months: Yes • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes • Are you a registered voter in Miami Beach: Yes • (Please circle one): I am now a resident of: North Beach • I am applying for an appointment because I have special abilities, knowledge and experience. Please list below: I am a local business owner with 15 years experience in the diving community and feel my knowlege could be of service to the marine authority board. • Are you presently a registered lobbyist with the City of Miami Beach? No Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three (3) choices will be observed by the City Clerk's Office. (Regular Boards of City) L ____, Af uldolAc Huuainy Adviav,y Cl.+nnniticc Hvuainy Authv,il Art in Public Places Committee Loan Review Committee 1 Beautification Committee [1] Marine Authority l __ Board of Adjustment* Miami Beach Commission for Women Budget Advisory Committee Miami Beach Cultural Arts Council Capital Improvements Projects Oversight Committee Miami Beach Sister Cities Program Committee on the Homeless Normandy Shores Local Gov't Neigh. Improvement Committee for Quality Education in MB Parks and Recreation Facilities Board Community Development Advisory Personnel Board Community Relations Board Planning Board* Convention Center Advisory Board Police Citizens Relations Committee __ Debarment Committee Production Industry Council Design Review Board* Public Safety Advisory Committee Disability Access Committee Safety Committee Fine Arts Board Single Family Residential Review Panel Gay, Lesbian, Bisexual and Transqender (GLBT) Sustainability Committee Golf Advisory Committee [2] Transportation and Parking Committee Health Advisory Committee Visitor and Convention Authority Health Facilities Authority Board Waterfront Protection Committee _ Hispanic Affairs Committee Youth Center Advisory Board Historic Preservation Board * Board Required to File State Disclosure form Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center: 1. Past service on the Youth Center Advisory Board: Years of Service: 2. Present participation in Youth Center activities by your children If yes, please list the names of your children, their ages, and which programs. List below: Child's name: Age: Program: y 1 t Child's name: Age: Program: 1 !, A • Have you ever been convicted of a felony: No If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: No If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: No If yes, explain in detail • Are you currently serving on any City Boards or Committees: No If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: Title: Name: Title: • List all properties owned or have an interest in, which are located within the City of Miami Beach: • I am now employed by the City of Miami Beach: No Which department? • Pursuant to City Code Section 2 -25 (b): Do you have a Parent who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): None. Could not uncheck box. The following information is voluntary and is neither part of your application nor has any bearing on your consideration for appointment. It is being asked to comply with federal equal opportunity reporting requirements. Gender: Male Race: White Ethnic Origin: Check one only (1) White Physically Challenged: No Employment Status: Employed Other: NOTE: If appointed, you will be required to follow certain laws which apply to city board /committee members. These laws include, but are not limited to, the following: o 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 on for period of one year after leaving office (Miami Beach City Code section 2 -26). o Requirement to disclose certain financial interests and gifts (Miami -Dade County Code section 2- 11.1). (re: CMB Community Development Advisory Committee): prohibition, during tenure and for one year after 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 570.611). Upon request, copies of these laws may be obtained from the City Clerk. "I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2, Article VII — of the City Code "Standards of Conduct for City Officers, Employees and Agency Members." I Sasha Boulanger agreed to the following terms on 11/10/2010 11:54:21 AM Please attach a copy of your resume to this application 01-C- NOTE: Applications will remain on file for a period of one (1) d GGG / �j Received in the City Clerk's Office by: 174 ,, Date` ` 9 / 0 / Control No Y?" Date: ( /� a "/v Name of Depu Clerk A Sasha Boulanger 826 Raymond St., Miami Beach, FL 33141 sasha @southbeachdivers.com • 305 - 531 -6110 Work Experience Miami Beach, FL www.southbeachdivers.com 1995 - Current Owner • Original owner of South Beach Divers (now South Beach Dive and Surf) • In the first five years, expanded from an empty 800 sq ft location to 2500 sq ft. • We are the largest and most successful full service dive and surf shop in the Miami area • Employ 5 full time and 7 part time staff instructor • Certified over 600 students from Open Water to Divemaster • Teach CPR and First Aid to local schools and the community • Have over 2500 dives here in Miami Beach Reef Guard Miami Beach, FL www.ReefGuard.org 2009 - Current • Founding member and Trustee of Reef Guard, a non profit organization that: • Provides collective assistance in the promotion, funding and organizing of resources for the installation and maintenance of mooring buoys on the reefs adjacent to Miami -Dade County • Promotes and supports both artificial reef deployment and natural reef conservation in sea areas adjacent to Miami -Dade County • Provided the source for the donation of funds to sink a 210' wreck off Miami Beach December 30 2009 Team Divers Miami Beach, FL Manager 1992 - 1994 Professional Certifications • PADI Master Scuba Diving Instructor • Emergency First Response Instructor • American Red Cross CPR, First Aid, AED Instructor in MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfLgov CITY CLERK Office CityClerk@miamibeochfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 Acknowledgement of fines /suspension for Board Members for failure to comply with Miami -Dade County Financial Disclosure Code Provision Code Section 2 -1 1.1 (i) (2) Board Member name: `��s' h g am afl Q r understand that no later than July 1, of each year all members of Boards and Committees of the City of Miami Beach, including those of a purely advisory nature, are required to comply with Miami -Dade County Disclosure Requirements. This means that the members of City Advisory Boards, whose sole or primary responsibility is to recommend legislation or give advice to the City Commission, must file, even though you may have been recently appointed. You must file one of the following with the City Clerk of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida, by July 1 each year. 1. A "Source of income Statement" (attached) or 2. A "Financial Statement" (attached( or] 3. A Copy of the person's current Federal Income Tax Return Failure to file, according to the Miami -Dade County Code Chapter 1, General Provision, Section 1 -5 may subject the person or firm to a fine not to exceed $500.00 or by imprisonment in the county jail for a period not to exceed sixty days, or both. ,92A/ / Signa Date: MIAMFDADE SOURCE OF INCOME STATEMENT Please Print or Type First Name Middle Name /Initial Last Name Disclosure 1 /� For Tax Year D Name: S A S h c∎ A l� 00. 0,/1 oo�� .J -� Ending: �� / Mailing Address: SO W ot r ; n 5 � ON Ave_ City /State /zip: /✓)i aM ; AQ re- 3 3 (3 Social Security Number: Filing as a: 0 County Employee: Municipal Employee of: Position held or sought: I Board where serving: a rr` a A �. r �� Term or Employment / Began on: Department where employed: n �✓1 Work Address: 250 ltJash 4 5oAv Ht/e, / lie ii( e.e If your hone address is exempt from public records pursuant to Florida Statutes § 119.07 please died( here (read instructs): / 0 Work Telephone: 36 S S 3 l p I l o Home Address: gZ G R a y/ii Cil o f ..r Street a : i3 e a C Add (Y) L- 3 3/ yr City State Zip Code Please list below in descending order with the largest source first, the name, address and prindpal business activity of every source of your income induding public salary you received or any person received for your benefit or use during the disdosure period. The income of your spcase or any business partner need not be disclosed. If continued on a separate sheet, check here: [� Description of the Prindpal Name of Source of Income Address Business Activity Sou_U- &eget, Dove_C1' yeso I4 44:4 Di1r2 '4d / - L .1 Gla.rle_J-A I hereby swear (. affirm) that the aforesaid information is a true and correct statement. e.2/-/( Sig re of ''" % disclosing Date signed