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Sasha Boulanger 12.31.2016 /vUAiv\ IBEACH 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)673-7411,Fax:(305)673-7254 January 06, 2016 • Mr. Sasha Boulanger 826 Raymond Street Miami Beach, Florida 33141 SUBJECT: Marine and Waterfront Protection Authority Dear Mr. Sasha Boulanger: Congratulations!You have been reappointed by Commissioner John Aleman to the above referenced, board or committee named above, for a term ending: 12/31/2016. Pursuant to City of Miami Beach Code Section 2-22 (5) a, "Notwithstanding any other provision of the City Code or of any resolution, commencing with terms beginning on or after January 1, 2007, the term of every board member who is directly appointed by a member of the City Commission shall automatically expire upon the latter of: December 31 of the year the appointing City Commissioner leaves office or p p Y upon the appointment/election of the successor City Commission member." If you are unable to accept this appointment, or have any questions, please call the Office of the City Clerk at 305.673.7411. Please read the enclosed materials carefully. Congratulations and good luck. Regards, Rafael Granado City Clerk cc: Saul Frances, Parking Director Mercedes Carcasses, 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 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. MIAMI BEACH 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)673-7411,Fax:(305)673-7254 TO: Mr. Sasha Boulanger RE: Marine and Waterfront Protection 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: 12/31/2016. I have been issued a copy of section 2-11.1 of the Miami-Dade County Code (Conflict of Interest and pY Y Code of Ethics Ordinance), as well as Florida Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Public Officers 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 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 I have served. kasha Boulanger Sworn to and subscribed before me this g/4 U0'day of , 2014. -Tay\ -a) )6 Deputy lerk *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. MI.A IDADE SOURCE OF INCOME STATEMENT Disclosure for Tax Year Ending Last Name First Name r Middle Name/Initial 2014 OD0()/ E-I_r . Sa+ tz A. 1 Mailing Address-Street Number,Street Name,or P.O.B c g -o w s1C(1 c- ft/ A V R City,State,Zip ID Number r)i A/11 r 1 i ec> F 3.?(-7 If your home address is your mailing address, and your home address is exempt from public records pursuant to Fla.Stat.§119.07,read instructions on the following page and check here.❑ Filing a�an Frpioyee County Employee ❑Municipal Employee, Name of Municipality: Position held or sought Department where employed Work address Work telephone Term began on Filing as a Board Member ❑ County Board Member Municipal Board Member, Name of Nlunicipa[ity: (4�,I,t,c,e 6 Board where serving Pa yt vie, A 1,1 3 bur h,pf( i3ø/eeIaiáo/LJ Work address Work telephone !Term began on ( 2 So �� 13A. A-02_ _30xx-7 o/ d I List below every source of income you received,along with the address and the principal activity of each source. Include your public salary.Place the sources of income in descending order,with the largest source first.Also, include any source of income received by another person for your . benefit. However,the income of your spouse or any business partner need not be disclosed.If continued on a separate sheet,check here.7 Name of Source of Income Address I Description of the Principal Business Activity sou.-It e a c 4 D, v12_rf R-11 wet n. ti 114ll Jess f?.&.4---e.,'\ 6 vs( A 0 ESA Ar c. I hereby swear(or affirm)that the information above is a true and correct statement. (RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardcopy ❑ Electronic Copy S'. - of p- an disclosing SCt---c 4 0v an sZ1 ' / 6 Print name v /� /Date signed OFFICE USE ONLY Accented: Y i N Deficiency: Processed Datellnitials: Scanned Date/Initials: 138 sP-,a 2h3 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 P rofessional 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) Affordable Housing Advisory Committee Housing Authority Art in Public Places Committee Loan Review Committee Beautification Committee [1] Marine Authority 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 Transgender (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: Child’s name: Age: Program: ● 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? ● Parent who is employed by the Pursuant to City Code Section 2 - 25 (b): Do you have a 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: P rohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2 - 459). o P rohibition from contracting with the city (Miami - Dade County Code section 2 - 11.1). o P rohibition from lobbying be fore board/committee you have served on for period of one year after leaving office (Miami o Beach City Code section 2 - 26). R equirement to disclose certain financial interests and gifts (Miami - Dade County Code section 2 - 11.1). o (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 w hom 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 NOTE: Applications will remain on file for a period of one (1) calendar year. Received in the City Clerk’s Office by: __________________ ______ _______ Date: _ _ _/ __/____ Control No. __________ Date: _ __/__/_____ Name of Deputy Clerk é Û É Ô Û ú Í Ç Ð Û Î Õ × Ê êÛÃÏÍÎØéÈïÓÛÏÓú×ÛÙÔöð ÉÛÉÔÛüÉÍÇÈÔÚ×ÛÙÔØÓÆ×ÊÉÙÍÏ å Í Ê Ñ ÷ Ä Ì × Ê Ó × Î Ù × ïÓÛÏÓú×ÛÙÔöð ÅÅÅÉÍÇÈÔÚ×ÛÙÔØÓÆ×ÊÉÙ ÍÏ y ùÇÊÊ×ÎÈ íÊÓÕÓÎÛÐÍÅÎ×ÊÍÖéÍÇÈÔú×ÛÙÔøÓÆ×ÊÉÎÍÅéÍÇÈÔú×ÛÙÔøÓÆ×ÛÎØéÇÊÖ óÎÈÔ×ÖÓÊÉÈÖÓÆ×Ã×ÛÊÉ×ÄÌÛÎØ×ØÖÊÍÏÛÎ×ÏÌÈÃ ÉËÖÈÐÍÙÛÈÓÍÎÈÍ ÉËÖÈ å×ÛÊ×ÈÔ×ÐÛÊÕ×ÉÈÛÎØÏÍÉÈÉÇÙÙ×ÉÉÖÇÐÖÇÐÐÉ×ÊÆÓÙ×ØÓÆ×ÛÎØÉÇÊÖÉÔÍÌÓÎ È Ô×ïÓÛÏÓÛÊ×Û ÷ÏÌÐÍÃÖÇÐÐÈÓÏ×ÛÎØÌÛÊÈÈÓÏ×ÉÈÛÖÖ ù×ÊÈÓÖÓ×ØÍÆ×Ê ÉÈÇØ×ÎÈÉÖÊÍÏíÌ×ÎåÛÈ×ÊÈÍøÓÆ×ÏÛÉÈ×Ê è×ÛÙÔùìêÛÎØöÓÊÉÈûÓØÈÍÐÍÙÛÐÉÙÔÍÍÐÉÛÎØÈÔ×ÙÍÏÏÇÎÓÈÃ ôÛÆ×ÍÆ×Ê ØÓÆ×ÉÔ×Ê×ÓÎïÓÛÏÓú×ÛÙÔ ïÓÛÏÓú×ÛÙÔöð ÅÅÅê××ÖõÇÛÊØÍÊÕ y ùÇÊÊ×ÎÈ öÍÇÎØÓÎÕÏ×ÏÚ×ÊÛÎØèÊÇÉÈ××ÍÖê××ÖõÇÛÊØÛÎÍÎÌÊÍÖÓÈÍÊÕÛÎÓÂÛÈÓÍÎ ÈÔÛÈ ìÊÍÆÓØ×ÉÙÍÐÐ×ÙÈÓÆ×ÛÉÉÓÉÈÛÎÙ×ÓÎÈÔ×ÌÊÍÏÍÈÓÍÎÖÇÎØÓÎÕÛÎØ ÍÊÕÛÎÓÂÓÎÕÍÖÊ×ÉÍÇÊÙ×ÉÖÍÊÈÔ×ÓÎÉÈÛÐÐÛÈÓÍ ÎÛÎØÏÛÓÎÈ×ÎÛÎÙ×ÍÖ ÏÍÍÊÓÎÕÚÇÍÃÉÍÎÈÔ×Ê××ÖÉÛØÒÛÙ×ÎÈÈÍïÓÛÏÓ øÛØ×ùÍÇÎÈÃ ìÊÍÏÍÈ×ÉÛÎØÉÇÌÌÍÊÈÉÚÍÈÔÛÊÈÓÖÓÙÓÛÐÊ××ÖØ×ÌÐÍÃÏ×ÎÈÛÎØÎÛÈÇÊÛÐ Ê××ÖÙÍÎÉ×ÊÆÛÈÓÍÎÓÎÉ×ÛÛÊ×ÛÉÛØÒÛÙ×ÎÈÈÍïÓÛÏÓ øÛØ×ùÍÇÎÈÃ ìÊÍÆÓØ×ØÈÔ×ÉÍÇÊÙ×ÖÍÊÈÔ×ØÍÎÛÈÓÍÎÍÖÖÇÎØÉÈÍÉÓ ÎÑÛ tÅÊ×ÙÑÍÖÖ ÈÔ ïÓÛÏÓú×ÛÙÔø×Ù×ÏÚ×Ê ïÓÛÏÓú×ÛÙÔöð y ì Ê Í Ö × É É Ó Í Î Û Ð ù × Ê È Ó Ö Ó Ù Û È Ó Í Î É ìûøóïÛÉÈ×ÊéÙÇÚÛøÓÆÓÎÕóÎÉÈÊÇÙÈÍÊ ÷Ï×ÊÕ×ÎÙÃöÓÊÉÈê×ÉÌÍÎÉ×óÎÉÈÊÇÙÈÍÊ ûÏ×ÊÓÙÛÎê×ØùÊÍÉÉùìêöÓÊÉÈûÓØû÷øóÎÉÈÊÇÙÈÍÊ ' ' I t\ lk A F,... r... A, ,,,,,, ai, i IS 1 i t f d '�a �?C�� City of Miami Beach 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachEl.gov CITY CLERK'S OFFICE CityClerk@miamibeachfl.gov Telephone: 305.673.7411 Fax: 305.673.7254 Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with Miami- Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2) Board Member's Name: a 6()a, - 6 0 0(a-fr7 ate- I 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 Financial 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 they may have been recently appointed. One of the following forms must be filed with the City Clerk of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida, no later than 12:00 noon of July 1, of each year. 1. A "Source of Income Statement" For your convenience, the form is-attached. The form can also be downloaded at: htto://www.miamidade.gov/elections/Library/source of income statement.pdf 2. A "Statement of Financial Interests (Form 1)" For your convenience, the form is attached. The form can also be downloaded at: http://www.ethics.state.fl.us/ethics/forms.html 3:A Copy of your 2013 Federal Income Tax Return Failure to file one of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine of no more than$500, 60 days in jail or both. , /// // , Sig .t. e Date Updated:Wednesday,April 09,2014 Page 4of4 F:\CLER\SALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx , ,, AA I Am 1 -it; E A, - i, • ., • DIVERSITY STATISTICS REPORTING Name: O (,c too 0 If at.6 c . Wnb u Board / Committee: 4..t—u � ex'vkd o rc Appointment Date: / V/ _ Pursuant to City of Miami Beach Ordinance 2009-3632, the City is required to annually prepare and present a report to the City Commission identifying the City's diversity statistics. This form allows board and committee applicants and members to voluntarily self-identify their race, ethnicity, disabled .status and gender. Please check the appropriate box for each category: Gen• : Male [mil Female Z' Race/Ethnic - -gories What is your race? La African-American/Black Caucasian/White • Asian or Pacific Islander Native-American/American Indian Other— Print Race: Do you consider yourself to be Spanish, Hispanic or Latino/a. 'lark the "No"box if not Spanish, Hispanic, Latino/a. U No D Yes Do you consider yourself Physically Disabled? 0 No D Yes C:\Users\CENTFraN\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\NP4J9CNX\BC minority information form 05-20-13 FINAL.doc Updated: Monday,January 26,2015