Dominique Bailleul 12/31/2014 City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Rafael Granado,City Clerk
Tel: (305)673-741 1, Fax: (305)673-7254
November 21, 2013
Dominique Bailleul
2808 Jefferson Avenue, #116
Miami Beach, Florida 33139
SUBJECT: HISTORIC PRESERVATION BOARD
Congratulations! You have been reappointed by the City Commission to the above
referenced agency, board or committee for a term ending: 12/31/2014.
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,
Ra ael Granado
City Clerk
cc: Saul Frances, Parking Director
Thomas Mooney, City Liaison
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
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
Employees
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
I
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk
Tel: (305)673-7411,Fax: (305)673-7254
TO Dominique Bailleul
RE: Historic Preservation Board
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: 12/31/2014.
1 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 the Florida Commission on Ethics Guide to the Sunshine Amend-
ment 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*requirements of
Miami-Dade County or ithe State of Florida (depending on the board or committee on which I serve)on
July 1, following the closing of the calendar year on which I have served.
Dominique Bailleul
Sworn to and subscribed before me this 2 4 a of 1Uex&vtocrz., 201
Silvia Prieto
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfi.gov under City Clerk/Board and Comm
for additional information regarding the Financial Disclosure Requirement
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
CITY OF MIAMI BEACH
$ NA I A&� F BOARD AND COMFIT T EE APPLICATION FORM
Last Name First Name Middle Initial
208 3�f s c�ry -A ya-ry 0e-4 et-A ,1� , 3 S 13 at
Home Addr ss City State Zip Code
$ -5 2 6q:0310-377.0
Home Telephone Work elephone Cellular Telephone Email address
'"BLve5 Position: (Z
Business Name
It
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Business Address City State Zip Code
Professional License(describe) G •4 e�..�ti c.�+��-°�CbCc coy WNw* Expires: ®Q 1'5o /?mot L,
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
for a minimum of six months.
• Resident of Miami Beach for a minimum of six (6) months: Yes Q& or No ED
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six months: Yes or No
• Are you a registered voter in Miami Beach: Yes§U or No
• I am now a resident of: North Beach U South Beach M Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
22 S/ 1&) $Z i an t
• Are you presently a registered lobbyist with the City of Miami Beach?Yes or 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)
❑Affordable Housing Advisory Committee ❑ Fine Arts Board ❑ Normandy Shores Local Government
Neighborhood Improvement
❑Art in Public Places Committee ❑ Gay, Lesbian, Bisexual and Transgender ❑ Parks and Recreation Facilities Board
Enhancement Committee GLBT
❑Beautification Committee ❑Golf Advisory Committee ❑ Personnel Board
❑Board of Adjustment* * ❑ Health Advisory Committee JK Planning Board* 2
❑ Budget Advisory Committee ❑ Health Facilities Authority Board ❑ Police Citizens Relations Committee
!St Capital Improvements Projects ❑ Hispanic Affairs Committee ❑ Production Industry Council
Oversight Committee .3
❑Committee on the Homeless Historic Preservation Board 1 ❑Safety Committee
❑Committee for Quality Education in MB ❑Housing Authority ❑Single Family Residential Review Panel
❑Community Development Advisory ❑ Loan Review Committee ❑Sustainabilit Committee
❑Community Relations Board ❑ Marine Authority ❑Tennis Advisory Committee
❑Convention Center Advisory Board ❑ Miami Beach Commission for Women ❑Transportation and Parking Committee
❑ Debarment Committee ❑ Miami Beach Cultural Arts Council ❑Visitor and Convention Authority
❑ Design Review Board* ❑ Miami Beach Human Rights Committee ❑Youth Center Advisory Board
❑ Disability Access Committee ❑ Miami Beach Sister Cities Program ❑Waterfront Protection Committee
* Board Required to File State Disclosure Form
If you seek appointment to a professional seat(e.g., lawyer, architect)on the Board of Adjustment, Design Review Board,
Historic Preservation Board,or Planning Board,attach a copy of your currently-effectively license,and furnish the
following information:
Type of Professional License If A R. Ucoq JNumber-�
L
License Issuance Date and Licen r n 71e I
;
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
DEC 2 812012
a
0
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center: ` A-
l. Past service on the Youth Center Advisory Board:Yes I.J No LJ Years of Service:
2. Present participation in Youth Center activities by your children Yes ZI No . If-yes, please list the names of your children,
their ages and which programs. List below:
Child's name: . Age: Program:
Child's name: Age: Program:
*Have you ever been convicted of a felony:Yes or No If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes:Yes ED or No'& If yes, please explain in detail:
iV-I
• Do you currently owe the City of Miami Beach any money:Yes I or No If yes, explain in detail
Al
•Are you currently serving on any City Boards or Committees:Yes or No If yes;which board?
•Whet organizations in the City of Miami Beach do you currently hold membership in?
All/a
Name Title
Name Title
• List all properties owned or have an interest in,which are located within the City of Miami Beach:
2c3S S $�. /4✓a�yy c� � 1 t� ,��t`��-f[� q=tr; � °'3,� 1��
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• I am now employed by the City of Miami Beach:Yes or No .Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ID, spouse E--3-,, child brother , or sister who is
employed by the City of Miami Beach? Check all that apply. Identify the department(s):
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.
Ethnic Origin: Check one only 1)
Gender: Male 0 Female
White (Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
African-American/Black (Not of Hispanic Origin):All persons having origins in any of the Black racial groups of Africa.
Hispanic: All persons of Mexican, Puerto Rican,Cuban,Central or South American,or other Spanish culture or origin,regardless of race.
EDAsian or Pacific Islander:All persons having origins in any of the original peoples of the Far East,Southeast Asia,the Indian Subcontinent,or
the Pacific Islands. This area includes,for example,China, India,Japan, Korea,the Philippine Islands and Somoa.
ID American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America,and who maintain
Cultural identification throw h tribal affiliation or community recognition.
Physically Challenged: Yes or No
Employment Status: Employed IN Retired ID HomemakerU Other ID
Please remember to attach a current resume and a copy of any applicable
professional license.
Attach additional sheets, if necessary, to provide required information.
F:\CLER\$ALL\a FORM S\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
r
NOTE: IF APPOINTED,YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARD/COMMITTEE
MEMBERS. THESE LAWS INCLUDE, BUT ARE NOT LIMITED TO,THE FOLLOWING:
• Prohibition from directly or indirectly lobbying city personnel(Miami Beach City Code section 2-459).
• Prohibition from contracting with the city(Miami-Dade County Code section 2-11.1).
• 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).
• Requirement to disclose certain financial interests and gifts(Miami-Dade County Code section 2-11.1).
• 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 I 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."
-- P // 2a1Z
App icant's Signature Date Name of Applicant(PLEASE PRINT)
� L l Z
Received in the City Clerk's Office by
PY i
Name of Deputy Clerk Control No. Date
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
Dominique Bailleul
208 Jefferson Avenue#116 (305)538-9317
Miami Beach FL 33139 dlbailleul(a-the-beach.net
RESUME
PROFILE A seasoned professional and effectual leader with a proven ability to manage businesses:
• Twenty years of strong inside/outside leadership experience
• Passion for gaining personal relationships with clients
EMPLOYMENT
2000—Present Owner—President Blue Leaf LLC
A local company based in Miami Beach, managing Condominium and Homeowners Associations. A
local market organization, Blue Leaf LLC employs 15 people locally.
• Administration of buildings and associations
• Organization of meetings and necessary requirements for Board of Directors
• Physical management of buildings
• Financial management of Associations
1995—2000 Sales Representative MetLife
One of the leaders in insurance and financial products company. Performed sales presentations and
conducted financial reviews for clients. Followed up with clients to answer questions and generate
referrals.
Key Achievements
• Awarded top sales representative eight times in first year
• Million dollar round table achievement
• LUTCF Graduate
1990- 1995 Senior Vice President Gabelli US INC
• Development of North American Subsidiary for French Company
• Creation of sales forces and development of distribution networks
• Marketing development
1989- 1990 Military Service
French Navy military service
1987-1989 Cultural Representative-Buyer Walt Disney World
Cultural representative in EPCOT Center French Pavilion; Merchandising buyer for the French stores
EDUCATION
Studied International Business Chamber of Commerce of Paris
Studied Agribusiness, Superior Technician in Food Productions, Lycee d'Arras
STATIE.,Qf FLORIDA
DE -- PROF $ N TIO�ENTSBUSTNESS AND PARTM
b: COMMUNITY ASSOCIATION_ MANAGERS SEQ#L12092003528
. . LICENSE NBR�, I
09. .20 128057.190 CAM23�522:
The: COMMUNITY ASS,OCATION MANAGE,_ _
Named below IS LIGENS'ED - -
Under the. ;provisions of Chapt `r _
Expiration date: SE 30, 2014
BAILLEUL, DOMINIQUE. F >
I
t>
2 0 8 JEFFERSON: AVENUE
# 116 i
MIAMI BEACH FL, a-313 9 ,-$,�w_
RICK:.SCOTT.
.; ., `...:..< KEN LAWSON
GOVERNOR .' SECRETARY j
.;..• DISPLAY AS REQUIRED:BY LAW
i
A1\A I BEACH
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach,Florida 33139,
www.miamibeachfLQov
CITY CLERK Office CityClerkCmiamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
Acknowledgement of fines/.suspension for Board Members far.failure
to comply with Miami-Dade County Financial.Disclosure Code Provision
Code section 2-11.1(i) .(2)
L
Board Member.name: ?1 W1 Al
I understand that no :later than July 1, of .each year all members of.Boards and
Committees of the .City .of Miami Beach, includin-g 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 ofthe-following with the.City Clerk of Miami Beach, 17.00 Convention
-center.Drive, Miami Beach, Florida,.by July 1 each:year.
-I. 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 I, General
Provision, Section 1-5 may subject the person or firm to a f ne not-to exceed
.$500.00 or by imprisonment'in the county.jail for-a period not to exceed sixty
clays, or both.
Signature: .Date:
M I A M I•DADE
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name/Initial Last Name
Disclosure
For Tax Year
Name: n,. :�;7 <q2ey::-, Ending: Z
Mailing Address:
City/State/Zip:
er:
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought:
Board where serving: Term or Employment
Began on:
Department where employed:
Work Address:
If your home address is exempt from public records pursuant to
Florida Statutes§119.07 please check here(read instructions): ® Work Telephone:
Home Address:
Street Address
City State Zip Code
Please list below in descending order with the largest source first, the name, address and
principal business activity of every source of your income including public salary you
received or any person received for your benefit or use during the disclosure period. The
income of your spouse or any business partner need not be disclosed. If continued on a
separate sheet,check here: El
Description of the Principal
Name of Source of Income Address Business Adivity
e;le�)Q5 Aut A&�L-�
I hereby swear(or affirm)that the aforesaid information is a true and correct statement.
Si on disclosing Date signed
i